The clinical nurse leader: a response from practice.

PubMed

Drenkard, Karen Neil

2004-01-01

In October 2003, over 200 nurse leaders from education and practice met at the invitation of the American Association of Colleges of Nursing. A newly released white paper, describing the role of the clinical nurse leader, was discussed at the conference. This article outlines a response to that white paper from one practice setting. The article shares information about another role, that of team coordinator, that is similar to clinical nurse leader and has been implemented at an integrated not-for-profit health care system in 5 hospitals. The comparison of the team coordinator role to the clinical nurse leader role might assist in visualizing such a role in practice. Although the roles are not identical, many of the driving forces for change were similar; these included the need to meet the changing demands for improved patient outcomes and nurse retention. The team coordinator role has 4 domains of practice that are crosswalked against the clinical nurse leader 15 core competencies. An evaluation of the team coordinator role showed changes that need to be made, such as placing more emphasis on clinical progression of patients. Lessons learned are shared, including keeping the scope of the role manageable, providing documentation standards for new roles, and the leadership required of the nursing executive to implement change.

Organisational support for evidence-based practice: occupational therapists perceptions.

PubMed

Bennett, Sally; Allen, Shelley; Caldwell, Elizabeth; Whitehead, Mary; Turpin, Merrill; Fleming, Jennifer; Cox, Ruth

2016-02-01

Barriers to the use of evidence-based practice extend beyond the individual clinician and often include organisational barriers. Adoption of systematic organisational support for evidence-based practice in health care is integral to its use. This study aimed to explore the perceptions of occupational therapy staff regarding the influence of organisational initiatives to support evidence-based practice on workplace culture and clinical practice. This study used semi-structured interviews with 30 occupational therapists working in a major metropolitan hospital in Brisbane, Australia regarding their perceptions of organisational initiatives designed to support evidence-based practice. Four themes emerged from the data: (i) firmly embedding a culture valuing research and EBP, (ii) aligning professional identity with the Research and Evidence in Practice model, (iii) experiences of change: pride, confidence and pressure and (iv) making evidence-based changes to clinical practices. Organisational initiatives for evidence-based practice were perceived as influencing the culture of the workplace, therapists' sense of identity as clinicians, and as contributing to changes in clinical practice. It is therefore important to consider organisational factors when attempting to increase the use of evidence in practice. © 2016 Occupational Therapy Australia.

Pediatric providers' attitudes toward retail clinics.

PubMed

Garbutt, Jane M; Mandrell, Kathy M; Sterkel, Randall; Epstein, Jay; Stahl, Kristin; Kreusser, Katherine; Sitrin, Harold; Ariza, Adolfo; Reis, Evelyn Cohen; Siegel, Robert; Pascoe, John; Strunk, Robert C

2013-11-01

To describe pediatric primary care providers' attitudes toward retail clinics and their experiences of retail clinics use by their patients. A 51-item, self-administered survey from 4 pediatric practice-based research networks from the midwestern US, which gauged providers' attitudes toward and perceptions of their patients' interactions with retail clinics, and changes to office practice to better compete. A total of 226 providers participated (50% response). Providers believed that retail clinics were a business threat (80%) and disrupted continuity of chronic disease management (54%). Few (20%) agreed that retail clinics provided care within recommended clinical guidelines. Most (91%) reported that they provided additional care after a retail clinic visit (median 1-2 times per week), and 37% felt this resulted from suboptimal care at retail clinics "most or all of the time." Few (15%) reported being notified by the retail clinic within 24 hours of a patient visit. Those reporting prompt communication were less likely to report suboptimal retail clinic care (OR 0.20, 95% CI 0.10-0.42) or disruption in continuity of care (OR 0.32, 95% CI 0.15-0.71). Thirty-six percent reported changes to office practice to compete with retail clinics (most commonly adjusting or extending office hours), and change was more likely if retail clinics were perceived as a threat (OR 3.70, 95% CI 1.56-8.76); 30% planned to make changes in the near future. Based on the perceived business threat, pediatric providers are making changes to their practice to compete with retail clinics. Improved communication between the clinic and providers may improve collaboration. Copyright © 2013 Mosby, Inc. All rights reserved.

PEDIATRIC PROVIDERS’ ATTITUDES TOWARD RETAIL CLINICS

PubMed Central

Garbutt, Jane M.; Mandrell, Kathy M.; Sterkel, Randall; Epstein, Jay; Stahl, Kristin; Kreusser, Katherine; O’Neil, Jerome; Sitrin, Harold; Ariza, Adolfo; Reis, Evelyn Cohen; Siegel, Robert; Pascoe, John; Strunk, Robert C.

2013-01-01

Objective To describe pediatric primary care providers’ attitudes toward retail clinics and their experiences of retail clinics use by their patients. Study design A 51-item, self-administered survey from four pediatric practice-based research networks from the Midwestern United States, which gauged providers’ attitudes toward and perceptions of their patients’ interactions with retail clinics, and changes to office practice to better compete. Results A total of 226 providers participated (50% response). Providers believed that retail clinics were a business threat (80%) and disrupted continuity of chronic disease management (54%). Few (20%) agreed that retail clinics provided care within recommended clinical guidelines. Most (91%) reported that they provided additional care after a retail clinic visit (median 1–2 times per week) and 37% felt this resulted from suboptimal care at retail clinics “most or all of the time.” Few (15%) reported being notified by the retail clinic within 24 hours of a patient visit. Those reporting prompt communication were less likely to report suboptimal retail clinic care (OR 0.20, 95%CI 0.10 to 0.42) or disruption in continuity of care (OR 0.32, 95%CI 0.15 to 0.71). Thirty-six percent reported changes to office practice to compete with retail clinics (most commonly adjusting or extending office hours) and change was more likely if retail clinics were perceived as a threat (OR 3.70, 95%CI 1.56 to 8.76); 30% planned to make changes in the near future. Conclusions Based on the perceived business threat, pediatric providers are making changes to their practice to compete with retail clinics. Improved communication between the clinic and providers may improve collaboration. PMID:23810720

Impact of Clinical Practice Guidelines on Use of Intra-Articular Hyaluronic Acid and Corticosteroid Injections for Knee Osteoarthritis.

PubMed

Bedard, Nicholas A; DeMik, David E; Glass, Natalie A; Burnett, Robert A; Bozic, Kevin J; Callaghan, John J

2018-05-16

The efficacy of corticosteroid and hyaluronic acid injections for knee osteoarthritis has been questioned. The purpose of this study was to determine the impact of the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines on the use of these injections in the United States and determine if utilization differed by provider specialty. Patients with knee osteoarthritis were identified within the Humana database from 2007 to 2015, and the percentage of patients receiving a knee injection relative to the number of patients having an encounter for knee osteoarthritis was calculated and was trended for the study period. The impact of each edition of the AAOS clinical practice guidelines on injection use was evaluated with segmented regression analysis. Injection trends were also analyzed relative to the specialty of the provider performing the injection. Of 1,065,175 patients with knee osteoarthritis, 405,101 (38.0%) received a corticosteroid injection and 137,005 (12.9%) received a hyaluronic acid injection. The rate of increase in hyaluronic acid use, per 100 patients with knee osteoarthritis, decreased from 0.15 to 0.07 injection per quarter year (p = 0.02) after the first clinical practice guideline, and the increase changed to a decrease at a rate of -0.12 injection per quarter (p < 0.001) after the second clinical practice guideline. After the first clinical practice guideline, the rate of increase in utilization of corticosteroids, per 100 patients with knee osteoarthritis, significantly lessened to 0.12 injection per quarter (p < 0.001), and after the second clinical practice guideline, corticosteroid injection use plateaued (p = 0.72). The trend in use of hyaluronic acid injections by orthopaedic surgeons and pain specialists decreased with time following the second-edition clinical practice guideline but did not change for primary care physicians or nonoperative musculoskeletal providers. Subtle but significant changes in hyaluronic acid and corticosteroid injections occurred following the publication of both clinical practice guidelines. Although the clinical practice guidelines did impact injection use, given the high costs of these injections and their questionable clinical efficacy, further interventions beyond publishing clinical practice guidelines are needed to encourage higher-value care for patients with knee osteoarthritis.

Clinical Nurse Specialists Guide Staff Nurses to Promote Practice Accountability Through Peer Review.

PubMed

Semper, Julie; Halvorson, Betty; Hersh, Mary; Torres, Clare; Lillington, Linda

2016-01-01

The aim of the study was to describe the clinical nurse specialist role in developing and implementing a staff nurse education program to promote practice accountability using peer review principles. Peer review is essential for professional nursing practice demanding a significant culture change. Clinical nurse specialists in a Magnet-designated community hospital were charged with developing a staff nurse peer review education program. Peer review is a recognized mechanism of professional self-regulation to ensure delivery of quality care. The American Nurses Association strongly urges incorporating peer review in professional nursing practice models. Clinical nurse specialists play a critical role in educating staff nurses about practice accountability. Clinical nurse specialists developed an education program guided by the American Nurses Association's principles of peer review. A baseline needs assessment identified potential barriers and learning needs. Content incorporated tools and strategies to build communication skills, collaboration, practice change, and peer accountability. The education program resulted in increased staff nurse knowledge about peer review and application of peer review principles in practice. Clinical nurse specialists played a critical role in helping staff nurses understand peer review and its application to practice. The clinical nurse specialist role will continue to be important in sustaining the application of peer review principles in practice.

Successful clinical and organisational change in endodontic practice: a qualitative study.

PubMed

Koch, M; Englander, M; Tegelberg, Å; Wolf, E

2014-08-01

The aim of this study was to explicate and describe the qualitative meaning of successful clinical and organizational change in endodontic practice, following a comprehensive implementation program, including the integration of the nickel-titanium-rotary-technique. After an educational intervention in the Public Dental Service in a Swedish county, thematic in-depth interviews were conducted, with special reference to the participants' experience of the successful change. Interviews with four participants, were purposively selected on the basis of occupation (dentist, dental assistant, receptionist, clinical manager), for a phenomenological human scientific analysis. Four constituents were identified as necessary for the invariant, general structure of the phenomenon: 1) disclosed motivation, 2) allowance for individual learning processes, 3) continuous professional collaboration, and 4) a facilitating educator. The perceived requirements for achieving successful clinical and organizational change in endodontic practice were clinical relevance, an atmosphere which facilitated discussion and allowance for individual learning patterns. The qualities required in the educator were acknowledged competence with respect to scientific knowledge and clinical expertise, as well as familiarity with conditions at the dental clinics. The results indicate a complex interelationship among various aspects of the successful change process. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Media Reporting of Practice-Changing Clinical Trials in Oncology: A North American Perspective.

PubMed

Andrew, Peter; Vickers, Michael M; O'Connor, Stephen; Valdes, Mario; Tang, Patricia A

2016-03-01

Media reporting of clinical trials impacts patient-oncologist interactions. We sought to characterize the accuracy of media and Internet reporting of practice-changing clinical trials in oncology. The first media articles referencing 17 practice-changing clinical trials were collected from 4 media outlets: newspapers, cable news, cancer websites, and industry websites. Measured outcomes were media reporting score, social media score, and academic citation score. The media reporting score was a measure of completeness of information detailed in media articles as scored by a 15-point scoring instrument. The social media score represented the ubiquity of social media presence referencing 17 practice-changing clinical trials in cancer as determined by the American Society of Clinical Oncology in its annual report, entitled Clinical Cancer Advances 2012; social media score was calculated from Twitter, Facebook, and Google searches. The academic citation score comprised total citations from Google Scholar plus the Scopus database, which represented the academic impact per clinical cancer advance. From 170 media articles, 107 (63%) had sufficient data for analysis. Cohen's κ coefficient demonstrated reliability of the media reporting score instrument with a coefficient of determination of 94%. Per the media reporting score, information was most complete from industry, followed by cancer websites, newspapers, and cable news. The most commonly omitted items, in descending order, were study limitations, exclusion criteria, conflict of interest, and other. The social media score was weakly correlated with academic citation score. Media outlets appear to have set a low bar for coverage of many practice-changing advances in oncology, with reports of scientific breakthroughs often omitting basic study facts and cautions, which may mislead the public. The media should be encouraged to use a standardized reporting template and provide accessible references to original source information whenever feasible. ©AlphaMed Press.

[Quality assurance and quality improvement in medical practice. Part 3: Clinical audit in medical practice].

PubMed

Godény, Sándor

2012-02-05

The first two articles in the series were about the definition of quality in healthcare, the quality approach, the importance of quality assurance, the advantages of quality management systems and the basic concepts and necessity of evidence based medicine. In the third article the importance and basic steps of clinical audit are summarised. Clinical audit is an integral part of quality assurance and quality improvement in healthcare, that is the responsibility of any practitioner involved in medical practice. Clinical audit principally measures the clinical practice against clinical guidelines, protocols and other professional standards, and sometimes induces changes to ensure that all patients receive care according to principles of the best practice. The clinical audit can be defined also as a quality improvement process that seeks to identify areas for service improvement, develop and carry out plans and actions to improve medical activity and then by re-audit to ensure that these changes have an effect. Therefore, its aims are both to stimulate quality improvement interventions and to assess their impact in order to develop clinical effectiveness. At the end of the article key points of quality assurance and improvement in medical practice are summarised.

Integrating patient-centered care and clinical ethics into nutrition practice.

PubMed

Schwartz, Denise Baird

2013-10-01

The purpose of this article is to present the application of patient-centered care and clinical ethics into nutrition practice, illustrate the process in a case study, and promote change in the current healthcare clinical ethics model. Nutrition support clinicians have an opportunity to add another dimension to their practice with the incorporation of patient-centered care and clinical ethics. This represents a culture change for healthcare professionals, including nutrition support clinicians, patients and their family. All of these individuals are stakeholders in the process and have the ability to modify the current healthcare system to improve communication and facilitate a change by humanizing nutrition support practice. Nutrition support is a medical, life-sustaining treatment, and the use of this therapy requires knowledge by the nutrition support clinician of patient-centered care concepts, preventive clinical ethics, religion/spirituality and cultural diversity, palliative care team role, and advance care planning. Integrating these into the practice of nutrition support is an innovative approach and results in new knowledge that requires a change in the culture of care and engagement and empowerment of the patient and their family in the process. This is more than a healthcare issue; it involves a social/family conversation movement that will be enhanced by the nutrition support clinician's participation.

Translating evidence to practice in the health professions: a randomized trial of Twitter vs Facebook.

PubMed

Tunnecliff, Jacqueline; Weiner, John; Gaida, James E; Keating, Jennifer L; Morgan, Prue; Ilic, Dragan; Clearihan, Lyn; Davies, David; Sadasivan, Sivalal; Mohanty, Patitapaban; Ganesh, Shankar; Reynolds, John; Maloney, Stephen

2017-03-01

Our objective was to compare the change in research informed knowledge of health professionals and their intended practice following exposure to research information delivered by either Twitter or Facebook. This open label comparative design study randomized health professional clinicians to receive "practice points" on tendinopathy management via Twitter or Facebook. Evaluated outcomes included knowledge change and self-reported changes to clinical practice. Four hundred and ninety-four participants were randomized to 1 of 2 groups and 317 responders analyzed. Both groups demonstrated improvements in knowledge and reported changes to clinical practice. There was no statistical difference between groups for the outcomes of knowledge change (P = .728), changes to clinical practice (P = .11) or the increased use of research information (P = .89). Practice points were shared more by the Twitter group (P < .001); attrition was lower in the Facebook group (P < .001). Research information delivered by either Twitter or Facebook can improve clinician knowledge and promote behavior change. No differences in these outcomes were observed between the Twitter and Facebook groups. Brief social media posts are as effective as longer posts for improving knowledge and promoting behavior change. Twitter may be more useful in publicizing information and Facebook for encouraging course completion. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com

A clinical education and practice placements in the allied health professions: an international perspective.

PubMed

Rodger, Sylvia; Webb, Gillian; Devitt, Lorraine; Gilbert, John; Wrightson, Pat; McMeeken, Joan

2008-01-01

This report describes the outcomes of extensive discussions surrounding clinical education and practice placement issues undertaken by an international group of allied health educators (in audiology, occupational therapy, physiotherapy, and speech pathology) who have met since 2001 as part of Universitas 21 Health Sciences annual meetings. The report outlines key issues associated with clinical education and practice placements from an international perspective and across these four allied health professions. The allied health practice context is described in terms of the range of allied health educational programs in Universitas 21 and recent changes in health and tertiary education sectors in represented countries. Some issues and benefits related to supervision during allied health students' practice placements are addressed. A new approach is proposed through partnership such that frameworks for the provision of practice placements can be created to facilitate student learning and educate and support clinical educators. A set of guidelines that can enhance partnerships and collaborative practice for the benefit of clinical education within complex and changing health/human service and educational environments is proposed.

Facilitators of transforming primary care: a look under the hood at practice leadership.

PubMed

Donahue, Katrina E; Halladay, Jacqueline R; Wise, Alison; Reiter, Kristin; Lee, Shoou-Yih Daniel; Ward, Kimberly; Mitchell, Madeline; Qaqish, Bahjat

2013-01-01

This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care. We used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach. Of the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the first year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41-4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of performing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08-1.74); no significant associations were seen for the intermediate outcome measures of hemoglobin A1c, blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff. In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.

Facilitators of Transforming Primary Care: A Look Under the Hood at Practice Leadership

PubMed Central

Donahue, Katrina E.; Halladay, Jacqueline R.; Wise, Alison; Reiter, Kristin; Lee, Shoou-Yih Daniel; Ward, Kimberly; Mitchell, Madeline; Qaqish, Bahjat

2013-01-01

PURPOSE This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care. METHODS We used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach. RESULTS Of the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the first year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41–4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of performing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08–1.74); no significant associations were seen for the intermediate outcome measures of hemoglobin A1c, blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff. CONCLUSIONS In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement. PMID:23690383

Translating research findings to clinical nursing practice.

PubMed

Curtis, Kate; Fry, Margaret; Shaban, Ramon Z; Considine, Julie

2017-03-01

To describe the importance of, and methods for, successfully conducting and translating research into clinical practice. There is universal acknowledgement that the clinical care provided to individuals should be informed on the best available evidence. Knowledge and evidence derived from robust scholarly methods should drive our clinical practice, decisions and change to improve the way we deliver care. Translating research evidence to clinical practice is essential to safe, transparent, effective and efficient healthcare provision and meeting the expectations of patients, families and society. Despite its importance, translating research into clinical practice is challenging. There are more nurses in the frontline of health care than any other healthcare profession. As such, nurse-led research is increasingly recognised as a critical pathway to practical and effective ways of improving patient outcomes. However, there are well-established barriers to the conduct and translation of research evidence into practice. This clinical practice discussion paper interprets the knowledge translation literature for clinicians interested in translating research into practice. This paper is informed by the scientific literature around knowledge translation, implementation science and clinician behaviour change, and presented from the nurse clinician perspective. We provide practical, evidence-informed suggestions to overcome the barriers and facilitate enablers of knowledge translation. Examples of nurse-led research incorporating the principles of knowledge translation in their study design that have resulted in improvements in patient outcomes are presented in conjunction with supporting evidence. Translation should be considered in research design, including the end users and an evaluation of the research implementation. The success of research implementation in health care is dependent on clinician/consumer behaviour change and it is critical that implementation strategy includes this. Translating best research evidence can make for a more transparent and sustainable healthcare service, to which nurses are central. © 2016 The Authors. Journal of Clinical Nursing Published by John Wiley & Sons Ltd.

Implications of workforce and financing changes for primary care practice utilization, revenue, and cost: a generalizable mathematical model for practice management.

PubMed

Basu, Sanjay; Landon, Bruce E; Song, Zirui; Bitton, Asaf; Phillips, Russell S

2015-02-01

Primary care practice transformations require tools for policymakers and practice managers to understand the financial implications of workforce and reimbursement changes. To create a simulation model to understand how practice utilization, revenues, and expenses may change in the context of workforce and financing changes. We created a simulation model estimating clinic-level utilization, revenues, and expenses using user-specified or public input data detailing practice staffing levels, salaries and overhead expenditures, patient characteristics, clinic workload, and reimbursements. We assessed whether the model could accurately estimate clinic utilization, revenues, and expenses across the nation using labor compensation, medical expenditure, and reimbursements databases, as well as cost and revenue data from independent practices of varying size. We demonstrated the model's utility in a simulation of how utilization, revenue, and expenses would change after hiring a nurse practitioner (NP) compared with hiring a part-time physician. Modeled practice utilization and revenue closely matched independent national utilization and reimbursement data, disaggregated by patient age, sex, race/ethnicity, insurance status, and ICD diagnostic group; the model was able to estimate independent revenue and cost estimates, with highest accuracy among larger practices. A demonstration analysis revealed that hiring an NP to work independently with a subset of patients diagnosed with diabetes or hypertension could increase net revenues, if NP visits involve limited MD consultation or if NP reimbursement rates increase. A model of utilization, revenue, and expenses in primary care practices may help policymakers and managers understand the implications of workforce and financing changes.

The Pursuit of a Collegial Model of Clinical Practice: The Story of One University

ERIC Educational Resources Information Center

Strieker, Toni S.; Lim, Woong; Hubbard, Daphne; Crovitz, Darren; Gray, Kimberly C.; Holbien, Marie; Steffen, Cherry

2017-01-01

This study addresses the urgent need for change in clinical experiences that better prepare teacher candidates to negotiate the changing landscape of educational and accreditation policies and practices affecting P-12 classrooms. Specifically, the article examines the impact of a comprehensive 4-year initiative to transform traditional student…

Maintenance of Certification: How Performance in Practice Changes Improve Tobacco Cessation in Addiction Psychiatrists’ Practice

PubMed Central

Ford, James H.; Oliver, Karen A.; Giles, Miriam; Cates-Wessel, Kathryn; Krahn, Dean; Levin, Frances R.

2017-01-01

Background and Objectives In 2000, the American Board of Medical Specialties implemented the Maintenance of Certification (MOC), a structured process to help physicians identify and implement a quality improvement project to improve patient care. This study reports on findings from an MOC Performance in Practice (PIP) module designed and evaluated by addiction psychiatrists who are members of the American Academy of Addiction Psychiatry (AAAP). Method A 3-phase process was utilized to recruit AAAP members to participate in the study. The current study utilized data from 154 self-selected AAAP members who evaluated the effectiveness of the MOC Tobacco Cessation PIP. Results Of the physicians participating, 76% (n 120) completed the Tobacco PIP. A paired t-test analysis revealed that reported changes in clinical measure documentation were significant across all six measures. Targeted improvement efforts focused on a single clinical measure. Results found that simple change projects designed to improve clinical practice led to substantial changes in self-reported chart documentation for the selected measure. Conclusions The current findings suggest that addiction psychiatrists can leverage the MOC process to improve clinical care. PMID:27973746

Identifying and applying psychological theory to setting and achieving rehabilitation goals.

PubMed

Scobbie, Lesley; Wyke, Sally; Dixon, Diane

2009-04-01

Goal setting is considered to be a fundamental part of rehabilitation; however, theories of behaviour change relevant to goal-setting practice have not been comprehensively reviewed. (i) To identify and discuss specific theories of behaviour change relevant to goal-setting practice in the rehabilitation setting. (ii) To identify 'candidate' theories that that offer most potential to inform clinical practice. The rehabilitation and self-management literature was systematically searched to identify review papers or empirical studies that proposed a specific theory of behaviour change relevant to setting and/or achieving goals in a clinical context. Data from included papers were extracted under the headings of: key constructs, clinical application and empirical support. Twenty-four papers were included in the review which proposed a total of five theories: (i) social cognitive theory, (ii) goal setting theory, (iii) health action process approach, (iv) proactive coping theory, and (v) the self-regulatory model of illness behaviour. The first three of these theories demonstrated most potential to inform clinical practice, on the basis of their capacity to inform interventions that resulted in improved patient outcomes. Social cognitive theory, goal setting theory and the health action process approach are theories of behaviour change that can inform clinicians in the process of setting and achieving goals in the rehabilitation setting. Overlapping constructs within these theories have been identified, and can be applied in clinical practice through the development and evaluation of a goal-setting practice framework.

Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting.

PubMed

Clarke, Christina M; Persaud, Drepaul David

2011-03-01

Many contemporary acute care facilities lack safe and effective clinical handover practices resulting in patient transitions that are vulnerable to discontinuities in care, medical errors, and adverse patient safety events. This article is intended to supplement existing handover improvement literature by providing practical guidance for leaders and managers who are seeking to improve the safety and the effectiveness of clinical handovers in the acute care setting. A 4-stage change model has been applied to guide the application of strategies for handover improvement. Change management and quality improvement principles, as well as concepts drawn from safety science and high-reliability organizations, were applied to inform strategies. A model for handover improvement respecting handover complexity is presented. Strategies targeted to stages of change include the following: 1. Enhancing awareness of handover problems and opportunities with the support of strategic directions, accountability, end user involvement, and problem complexity recognition. 2. Identifying solutions by applying and adapting best practices in local contexts. 3. Implementing locally adapted best practices supported by communication, documentation, and training. 4. Institutionalizing practice changes through integration, monitoring, and active dissemination. Finally, continued evaluation at every stage is essential. Although gaps in handover process and function knowledge remain, efforts to improve handover safety and effectiveness are still possible. Continued evaluation is critical in building this understanding and to ensure that practice changes lead to improvements in patient safety, organizational effectiveness, and patient and provider satisfaction. Through handover knowledge building, fundamental changes in handover policies and practices may be possible.

Quality improvement activities associated with organisational capacity in general practice.

PubMed

Amoroso, Cheryl; Proudfoot, Judy; Bubner, Tanya; Swan, Edward; Espinel, Paola; Barton, Christopher; Beilby, Justin; Harris, Mark

2007-01-01

Clinical audit is recognised worldwide as a useful tool for quality improvement. A feedback report profiling capacity for chronic disease care was sent to 97 general practices. These practices were invited to complete a clinical audit activity based on that feedback. Data were analysed quantitatively and case studies were developed based on the free text responses. Eighty-two (33%) of 247 general practitioners participated in the clinical audit process, representing 57 (59%) of 97 general practices. From the data in their feedback report, 37 (65%) of the 57 practices recognised the area most in need of improvement. This was most likely where the need related to clinical practice or teamwork, and least likely where the need related to linkages with other services, and business and finance. Only 25 practices (46%) developed an action plan related to their recognised area for improvement, and 22 (39%) practices implemented their chosen activity. Participating GPs judged that change activity focused on teamwork was most successful. The clinical audit process offered participating GPs and practices an opportunity to reflect on their performance across a number of key areas and to implement change to enhance the practice's capacity for quality chronic disease care. The relationship between need and action was weak, suggesting a need for greater support to overcome barriers.

Clinical audit of leg ulceration prevalence in a community area: a case study of good practice.

PubMed

Hindley, Jenny

2014-09-01

This article presents the findings of an audit on venous leg ulceration prevalence in a community area as a framework for discussing the concept and importance of audit as a tool to inform practice and as a means to benchmark care against national or international standards. It is hoped that the discussed audit will practically demonstrate how such procedures can be implemented in practice for those who have not yet undertaken it, as well as highlighting the unexpected extra benefits of this type of qualitative data collection that can often unexpectedly inform practice and influence change. Audit can be used to measure, monitor and disseminate evidence-based practice across community localities, facilitating the identification of learning needs and the instigation of clinical change, thereby prioritising patient needs by ensuring safety through the benchmarking of clinical practice.

Teaching and evaluating point of care learning with an Internet-based clinical-question portfolio.

PubMed

Green, Michael L; Reddy, Siddharta G; Holmboe, Eric

2009-01-01

Diplomates in the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program satisfy the self-evaluation of medical knowledge requirement by completing open-book multiple-choice exams. However, this method remains unlikely to affect practice change and often covers content areas not relevant to diplomates' practices. We developed and evaluated an Internet-based point of care (POC) learning portfolio to serve as an alternative. Participants enter information about their clinical questions, including characteristics, information pursuit, application, and practice change. After documenting 20 questions, they reflect upon a summary report and write commitment-to-change statements about their learning strategies. They can link to help screens and medical information resources. We report on the beta test evaluation of the module, completed by 23 internists and 4 internal medicine residents. Participants found the instructions clear and navigated the module without difficulty. The majority preferred the POC portfolio to multiple-choice examinations, citing greater relevance to their practice, guidance in expanding their palette of information resources, opportunity to reflect on their learning needs, and "credit" for self-directed learning related to their patients. Participants entered a total of 543 clinical questions, of which 250 (46%) resulted in a planned practice change. After completing the module, 14 of 27 (52%) participants committed to at least 1 change in their POC learning strategies. Internists found the portfolio valuable, preferred it to multiple-choice examinations, often changed their practice after pursuing clinical questions, and productively reflected on their learning strategies. The ABIM will offer this portfolio as an elective option in MOC.

Implementing Quality Improvement in Small, Autonomous Primary Care Practices: Implications for the Patient Centered Medical Home

PubMed Central

Arar, Nedal H.; Noel, Polly H.; Leykum, Luci; Zeber, John E.; Romero, Raquel; Parchman, Michael L.

2012-01-01

Background Implementing improvement programs to enhance quality of care within primary care clinics is complex, with limited practical guidance available to help practices during the process. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient-centered medical homes (PCMH). This study examined practice members’ perceptions of the opportunities and challenges associated with implementing changes in their practice. Methods Semi-structured interviews were conducted with a purposive sample of 56 individuals working in 16 small, community-based primary care practices. The interview consisted of open-ended questions focused on participants’ perceptions of: (1) practice vision, (2) perceived need for practice improvement, and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analyzed. Results Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients’ involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking/follow-up system, standardization of processes of care, and overall clinic documentations. Changes related to the patients’ involvement in their care included improving (a) health education, and (b) self care management. Among the internal barriers were: staff readiness for change, poor communication, and relationship difficulties among team members. External barriers were: insurance regulations, finances and patient health literacy. Practice Implications Transforming their practices to more patient-centered models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programs. Successful strategy for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members’ perceived needs and planned improvement efforts. PMID:22186171

Assessing the quality of radiographic processing in general dental practice.

PubMed

Thornley, P H; Stewardson, D A; Rout, P G J; Burke, F J T

2006-05-13

To determine if a commercial device (Vischeck) for monitoring film processing quality was a practical option in general dental practice, and to assess processing quality among a group of GDPs in the West Midlands with this device. Clinical evaluation. General dental practice, UK, 2004. Ten GDP volunteers from a practice based research group processed Vischeck strips (a) when chemicals were changed, (b) one week later, and (c) immediately before the next change of chemicals. These were compared with strips processed under ideal conditions. Additionally, a series of duplicate radiographs were produced and processed together with Vischeck strips in progressively more dilute developer solutions to compare the change in radiograph quality assessed clinically with that derived from the Vischeck. The Vischeck strips suggested that at the time chosen for change of processing chemicals, eight dentists had been processing films well beyond the point indicated for replacement. Solutions were changed after a wide range of time periods and number of films processed. The calibration of the Vischeck strip correlated closely to a clinical assessment of acceptable film quality. Vischeck strips are a useful aid to monitoring processing quality in automatic developers in general dental practice. Most of this group of GDPs were using chemicals beyond the point at which diagnostic yield would be affected.

Translating Evidence Into Practice via Social Media: A Mixed-Methods Study.

PubMed

Maloney, Stephen; Tunnecliff, Jacqueline; Morgan, Prue; Gaida, Jamie E; Clearihan, Lyn; Sadasivan, Sivalal; Davies, David; Ganesh, Shankar; Mohanty, Patitapaban; Weiner, John; Reynolds, John; Ilic, Dragan

2015-10-26

Approximately 80% of research evidence relevant to clinical practice never reaches the clinicians delivering patient care. A key barrier for the translation of evidence into practice is the limited time and skills clinicians have to find and appraise emerging evidence. Social media may provide a bridge between health researchers and health service providers. The aim of this study was to determine the efficacy of social media as an educational medium to effectively translate emerging research evidence into clinical practice. The study used a mixed-methods approach. Evidence-based practice points were delivered via social media platforms. The primary outcomes of attitude, knowledge, and behavior change were assessed using a preintervention/postintervention evaluation, with qualitative data gathered to contextualize the findings. Data were obtained from 317 clinicians from multiple health disciplines, predominantly from the United Kingdom, Australia, the United States, India, and Malaysia. The participants reported an overall improvement in attitudes toward social media for professional development (P<.001). The knowledge evaluation demonstrated a significant increase in knowledge after the training (P<.001). The majority of respondents (136/194, 70.1%) indicated that the education they had received via social media had changed the way they practice, or intended to practice. Similarly, a large proportion of respondents (135/193, 69.9%) indicated that the education they had received via social media had increased their use of research evidence within their clinical practice. Social media may be an effective educational medium for improving knowledge of health professionals, fostering their use of research evidence, and changing their clinical behaviors by translating new research evidence into clinical practice.

The Working Practices and Clinical Experiences of Paediatric Speech and Language Therapists: A National UK Survey

ERIC Educational Resources Information Center

Pring, Tim; Flood, Emma; Dodd, Barbara; Joffe, Victoria

2012-01-01

Background: The majority of speech and language therapists (SLTs) work with children who have speech, language and communication needs. There is limited information about their working practices and clinical experience and their views of how changes to healthcare may impact upon their practice. Aims: To investigate the working practices and…

Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery.

PubMed

Mahle, William T; Nicolson, Susan C; Hollenbeck-Pringle, Danielle; Gaies, Michael G; Witte, Madolin K; Lee, Eva K; Goldsworthy, Michelle; Stark, Paul C; Burns, Kristin M; Scheurer, Mark A; Cooper, David S; Thiagarajan, Ravi; Sivarajan, V Ben; Colan, Steven D; Schamberger, Marcus S; Shekerdemian, Lara S

2016-10-01

To determine whether a collaborative learning strategy-derived clinical practice guideline can reduce the duration of endotracheal intubation following infant heart surgery. Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre- and post-clinical practice guideline implementation at the four sites participating in the collaborative (active sites) compared with data from five Pediatric Heart Network centers not participating in collaborative learning (control sites). Ten children's hospitals. Data were collected for infants following two-index operations: 1) repair of isolated coarctation of the aorta (birth to 365 d) and 2) repair of tetralogy of Fallot (29-365 d). There were 240 subjects eligible for the clinical practice guideline at active sites and 259 subjects at control sites. Development and application of early extubation clinical practice guideline. After clinical practice guideline implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p < 0.001) with no increase in reintubation rate. The median duration of postoperative intubation among active sites decreased from 21.2 to 4.5 hours (p < 0.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p = 0.63). At active sites, clinical practice guideline implementation had no statistically significant impact on median ICU length of stay (71.9 hr pre- vs 69.2 hr postimplementation; p = 0.29) for the entire cohort. There was a trend toward shorter ICU length of stay in the tetralogy of Fallot subgroup (71.6 hr pre- vs 54.2 hr postimplementation, p = 0.068). A collaborative learning strategy designed clinical practice guideline significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation clinical practice guideline did not significantly change postoperative ICU length of stay.

Effectiveness of a clinical practice change intervention in increasing the provision of nicotine dependence treatment in inpatient psychiatric facilities: an implementation trial.

PubMed

Wye, Paula M; Stockings, Emily A; Bowman, Jenny A; Oldmeadow, Chris; Wiggers, John H

2017-02-07

Despite clinical practice guidelines recommending the routine provision of nicotine dependence treatment to smokers in inpatient psychiatric facilities, the prevalence of such treatment provision is low. The aim of this study was to examine the effectiveness of a clinical practice change intervention in increasing clinician recorded provision of nicotine dependence treatment to patients in inpatient psychiatric facilities. We undertook an interrupted time series analysis of nicotine dependence treatment provision before, during and after a clinical practice change intervention to increase clinician recorded provision of nicotine dependence treatment for all hospital discharges (aged >18 years, N = 4175) over a 19 month period in two inpatient adult psychiatric facilities in New South Wales, Australia. The clinical practice change intervention comprised six key strategies: leadership and consensus, enabling systems and procedures, training and education, information and resources, audit and feedback and an on-site practice change support officer. Systematic medical record audit and segmented logistic regression was used to determine differences in proportions for each nicotine dependence treatment outcome measure between the 'pre', 'during' and 'post-intervention' periods. The prevalence of all five outcome measures increased significantly between the pre and post-intervention periods, including clinician recorded: assessment of patient smoking status (36.43 to 51.95%; adjusted odds ratio [AOR] = 2.39, 99% Confidence Interval [CI]: 1.23 to 4.66); assessment of patient nicotine dependence status (4.74 to 11.04%; AOR = 109.67, 99% CI: 35.35 to 340.22); provision of brief advice to quit (0.85 to 8.81%; AOR = 97.43, 99% CI: 31.03 to 306.30); provision of nicotine replacement therapy (8.06 to 26.25%; AOR = 19.59, 99% CI: 8.17 to 46.94); and provision of nicotine dependence treatment on discharge (8.82 to 13.45%, AOR = 12.36; 99% CI: 6.08 to 25.14). This is the first study to provide evidence that a clinical practice change intervention may increase clinician recorded provision of nicotine dependence treatment in inpatient psychiatric settings. The intervention offers a mechanism for psychiatric facilities to increase the provision of nicotine dependence treatment in accordance with clinical guidelines.

Deployment of Military Mothers during Wartime

DTIC Science & Technology

2012-11-12

Changes in Clinical Practice, Leadership, Management , Education, Policy, and/or Military Doctrine that Resulted from Study or Project 26...excellence Knowledge management Education and training Leadership, Ethics, and Mentoring: Health policy Recruitment and retention...research into practice/evidence-based practice Clinical excellence Knowledge management Education and training Leadership, Ethics, and Mentoring

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY PROTOCOL FOR STANDARDIZED PRODUCTION OF CLINICAL PRACTICE GUIDELINES, ALGORITHMS, AND CHECKLISTS - 2017 UPDATE.

PubMed

Mechanick, Jeffrey I; Pessah-Pollack, Rachel; Camacho, Pauline; Correa, Ricardo; Figaro, M Kathleen; Garber, Jeffrey R; Jasim, Sina; Pantalone, Kevin M; Trence, Dace; Upala, Sikarin

2017-08-01

Clinical practice guideline (CPG), clinical practice algorithm (CPA), and clinical checklist (CC, collectively CPGAC) development is a high priority of the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE). This 2017 update in CPG development consists of (1) a paradigm change wherein first, environmental scans identify important clinical issues and needs, second, CPA construction focuses on these clinical issues and needs, and third, CPG provide CPA node/edge-specific scientific substantiation and appended CC; (2) inclusion of new technical semantic and numerical descriptors for evidence types, subjective factors, and qualifiers; and (3) incorporation of patient-centered care components such as economics and transcultural adaptations, as well as implementation, validation, and evaluation strategies. This third point highlights the dominating factors of personal finances, governmental influences, and third-party payer dictates on CPGAC implementation, which ultimately impact CPGAC development. The AACE/ACE guidelines for the CPGAC program is a successful and ongoing iterative exercise to optimize endocrine care in a changing and challenging healthcare environment. AACE = American Association of Clinical Endocrinologists ACC = American College of Cardiology ACE = American College of Endocrinology ASeRT = ACE Scientific Referencing Team BEL = best evidence level CC = clinical checklist CPA = clinical practice algorithm CPG = clinical practice guideline CPGAC = clinical practice guideline, algorithm, and checklist EBM = evidence-based medicine EHR = electronic health record EL = evidence level G4GAC = Guidelines for Guidelines, Algorithms, and Checklists GAC = guidelines, algorithms, and checklists HCP = healthcare professional(s) POEMS = patient-oriented evidence that matters PRCT = prospective randomized controlled trial.

Translating Evidence Into Practice via Social Media: A Mixed-Methods Study

PubMed Central

Tunnecliff, Jacqueline; Morgan, Prue; Gaida, Jamie E; Clearihan, Lyn; Sadasivan, Sivalal; Davies, David; Ganesh, Shankar; Mohanty, Patitapaban; Weiner, John; Reynolds, John; Ilic, Dragan

2015-01-01

Background Approximately 80% of research evidence relevant to clinical practice never reaches the clinicians delivering patient care. A key barrier for the translation of evidence into practice is the limited time and skills clinicians have to find and appraise emerging evidence. Social media may provide a bridge between health researchers and health service providers. Objective The aim of this study was to determine the efficacy of social media as an educational medium to effectively translate emerging research evidence into clinical practice. Methods The study used a mixed-methods approach. Evidence-based practice points were delivered via social media platforms. The primary outcomes of attitude, knowledge, and behavior change were assessed using a preintervention/postintervention evaluation, with qualitative data gathered to contextualize the findings. Results Data were obtained from 317 clinicians from multiple health disciplines, predominantly from the United Kingdom, Australia, the United States, India, and Malaysia. The participants reported an overall improvement in attitudes toward social media for professional development (P<.001). The knowledge evaluation demonstrated a significant increase in knowledge after the training (P<.001). The majority of respondents (136/194, 70.1%) indicated that the education they had received via social media had changed the way they practice, or intended to practice. Similarly, a large proportion of respondents (135/193, 69.9%) indicated that the education they had received via social media had increased their use of research evidence within their clinical practice. Conclusions Social media may be an effective educational medium for improving knowledge of health professionals, fostering their use of research evidence, and changing their clinical behaviors by translating new research evidence into clinical practice. PMID:26503129

Using scenario-based training to promote information literacy among on-call consultant pediatricians

PubMed Central

Pettersson, Jonas; Bjorkander, Emil; Bark, Sirpa; Holmgren, Daniel; Wekell, Per

2017-01-01

Background Traditionally, teaching hospital staff to search for medical information relies heavily on educator-defined search methods. In contrast, the authors describe our experiences using real-time scenarios to teach on-call consultant pediatricians information literacy skills as part of a two-year continuing professional development program. Case Presentation Two information-searching workshops were held at Sahlgrenska University Hospital in Gothenburg, Sweden. During the workshops, pediatricians were presented with medical scenarios that were closely related to their clinical practice. Participants were initially encouraged to solve the problems using their own preferred search methods, followed by group discussions led by clinical educators and a medical librarian in which search problems were identified and overcome. The workshops were evaluated using questionnaires to assess participant satisfaction and the extent to which participants intended to implement changes in their clinical practice and reported actual change. Conclusions A scenario-based approach to teaching clinicians how to search for medical information is an attractive alternative to traditional lectures. The relevance of such an approach was supported by a high level of participant engagement during the workshops and high scores for participant satisfaction, intended changes to clinical practice, and reported benefits in actual clinical practice. PMID:28670215

Using scenario-based training to promote information literacy among on-call consultant pediatricians.

PubMed

Pettersson, Jonas; Bjorkander, Emil; Bark, Sirpa; Holmgren, Daniel; Wekell, Per

2017-07-01

Traditionally, teaching hospital staff to search for medical information relies heavily on educator-defined search methods. In contrast, the authors describe our experiences using real-time scenarios to teach on-call consultant pediatricians information literacy skills as part of a two-year continuing professional development program. Two information-searching workshops were held at Sahlgrenska University Hospital in Gothenburg, Sweden. During the workshops, pediatricians were presented with medical scenarios that were closely related to their clinical practice. Participants were initially encouraged to solve the problems using their own preferred search methods, followed by group discussions led by clinical educators and a medical librarian in which search problems were identified and overcome. The workshops were evaluated using questionnaires to assess participant satisfaction and the extent to which participants intended to implement changes in their clinical practice and reported actual change. A scenario-based approach to teaching clinicians how to search for medical information is an attractive alternative to traditional lectures. The relevance of such an approach was supported by a high level of participant engagement during the workshops and high scores for participant satisfaction, intended changes to clinical practice, and reported benefits in actual clinical practice.

Changing Provider Behavior in the Context of Chronic Disease Management: Focus on Clinical Inertia.

PubMed

Lavoie, Kim L; Rash, Joshua A; Campbell, Tavis S

2017-01-06

Widespread acceptance of evidence-based medicine has led to the proliferation of clinical practice guidelines as the primary mode of communicating current best practices across a range of chronic diseases. Despite overwhelming evidence supporting the benefits of their use, there is a long history of poor uptake by providers. Nonadherence to clinical practice guidelines is referred to as clinical inertia and represents provider failure to initiate or intensify treatment despite a clear indication to do so. Here we review evidence for the ubiquity of clinical inertia across a variety of chronic health conditions, as well as the organizational and system, patient, and provider factors that serve to maintain it. Limitations are highlighted in the emerging literature examining interventions to reduce clinical inertia. An evidence-based framework to address these limitations is proposed that uses behavior change theory and advocates for shared decision making and enhanced guideline development and dissemination.

Inter-radiologist agreement for CT scoring of pediatric splenic injuries and effect on an established clinical practice guideline.

PubMed

Leschied, Jessica R; Mazza, Michael B; Davenport, Matthew; Chong, Suzanne T; Smith, Ethan A; Hoff, Carrie N; Ladino-Torres, Maria F; Khalatbari, Shokoufeh; Ehrlich, Peter F; Dillman, Jonathan R

2016-02-01

The American Pediatric Surgical Association (APSA) advocates for the use of a clinical practice guideline to direct management of hemodynamically stable pediatric spleen injuries. The clinical practice guideline is based on the CT score of the spleen injury according to the American Association for the Surgery of Trauma (AAST) CT scoring system. To determine the potential effect of radiologist agreement for CT scoring of pediatric spleen injuries on an established APSA clinical practice guideline. We retrospectively analyzed blunt splenic injuries occurring in children from January 2007 to January 2012 at a single level 1 trauma center (n = 90). Abdominal CT exams performed at clinical presentation were reviewed by four radiologists who documented the following: (1) splenic injury grade (AAST system), (2) arterial extravasation and (3) pseudoaneurysm. Inter-rater agreement for AAST injury grade was assessed using the multi-rater Fleiss kappa and Kendall coefficient of concordance. Inter-rater agreement was assessed using weighted (AAST injury grade) or prevalence-adjusted bias-adjusted (binary measures) kappa statistics; 95% confidence intervals were calculated. We evaluated the hypothetical effect of radiologist disagreement on an established APSA clinical practice guideline. Inter-rater agreement was good for absolute AAST injury grade (kappa: 0.64 [0.59–0.69]) and excellent for relative AAST injury grade (Kendall w: 0.90). All radiologists agreed on the AAST grade in 52% of cases. Based on an established clinical practice guideline, radiologist disagreement could have changed the decision for intensive care management in 11% (10/90) of children, changed the length of hospital stay in 44% (40/90), and changed the time to return to normal activity in 44% (40/90). Radiologist agreement when assigning splenic AAST injury grades is less than perfect, and disagreements have the potential to change management in a substantial number of pediatric patients.

Update in outpatient general internal medicine: practice-changing evidence published in 2014.

PubMed

Sundsted, Karna K; Wieland, Mark L; Szostek, Jason H; Post, Jason A; Mauck, Karen F

2015-10-01

The practice of outpatient general internal medicine requires a diverse and evolving knowledge base. General internists must identify practice-changing shifts in the literature and reflect on their impact. Accordingly, we conducted a review of practice-changing articles published in outpatient general internal medicine in 2014. To identify high-quality, clinically relevant publications, we reviewed all titles and abstracts published in the following primary data sources in 2014: New England Journal of Medicine, Journal of the American Medical Association (JAMA), Annals of Internal Medicine, JAMA Internal Medicine, and the Cochrane Database of Systematic Reviews. All 2014 primary data summaries from Journal Watch-General Internal Medicine and ACP JournalWise also were reviewed. The authors used a modified Delphi method to reach consensus on inclusion of 8 articles using the following criteria: clinical relevance to outpatient internal medicine, potential for practice change, and strength of evidence. Clusters of important articles around one clinical question were considered as a single-candidate series. The article merits were debated until consensus was reached on the final 8, spanning a variety of topics commonly encountered in outpatient general internal medicine. Copyright © 2015 Elsevier Inc. All rights reserved.

Translating learning into practice

PubMed Central

Armson, Heather; Kinzie, Sarah; Hawes, Dawnelle; Roder, Stefanie; Wakefield, Jacqueline; Elmslie, Tom

2007-01-01

PROBLEM ADDRESSED The need for effective and accessible educational approaches by which family physicians can maintain practice competence in the face of an overwhelming amount of medical information. OBJECTIVE OF PROGRAM The practice-based small group (PBSG) learning program encourages practice changes through a process of small-group peer discussion—identifying practice gaps and reviewing clinical approaches in light of evidence. PROGRAM DESCRIPTION The PBSG uses an interactive educational approach to continuing professional development. In small, self-formed groups within their local communities, family physicians discuss clinical topics using prepared modules that provide sample patient cases and accompanying information that distils the best evidence. Participants are guided by peer facilitators to reflect on the discussion and commit to appropriate practice changes. CONCLUSION The PBSG has evolved over the past 15 years in response to feedback from members and reflections of the developers. The success of the program is evidenced in effect on clinical practice, a large and increasing number of members, and the growth of interest internationally. PMID:17872876

The impact of training and working conditions on junior doctors’ intention to leave clinical practice

PubMed Central

2014-01-01

Background The shortage of physicians is an evolving problem throughout the world. In this study we aimed to identify to what extent junior doctors’ training and working conditions determine their intention to leave clinical practice after residency training. Methods A prospective cohort study was conducted in 557 junior doctors undergoing residency training in German hospitals. Self-reported specialty training conditions, working conditions and intention to leave clinical practice were measured over three time points. Scales covering training conditions were assessed by structured residency training, professional support, and dealing with lack of knowledge; working conditions were evaluated by work overload, job autonomy and social support, based on the Demand–Control–Support model. Multivariate ordinal logistic regression analyses with random intercept for longitudinal data were applied to determine the odds ratio of having a higher level of intention to leave clinical practice. Results In the models that considered training and working conditions separately to predict intention to leave clinical practice we found significant baseline effects and change effects. After modelling training and working conditions simultaneously, we found evidence that the change effect of job autonomy (OR 0.77, p = .005) was associated with intention to leave clinical practice, whereas for the training conditions, only the baseline effects of structured residency training (OR 0.74, p = .017) and dealing with lack of knowledge (OR 0.74, p = .026) predicted intention to leave clinical practice. Conclusions Junior doctors undergoing specialty training experience high workload in hospital practice and intense requirements in terms of specialty training. Our study indicates that simultaneously improving working conditions over time and establishing a high standard of specialty training conditions may prevent junior doctors from considering leaving clinical practice after residency training. PMID:24942360

Towards multidisciplinary assessment of older people: exploring the change process.

PubMed

Ross, Fiona; O'Tuathail, Claire; Stubberfield, Debbie

2005-04-01

This paper discusses the process of change that took place in an intervention study of standardized multidisciplinary assessment guidelines implemented in a female ward for older people in a District General Hospital in South London. This study was one of nine implementation projects in the South Thames Evidence-Based Practice Project. The relationship between the worlds of research and healthcare practice is uneasy and contested and, as such, is a breeding ground for challenging questions about how evidence can be used to foment change in clinical practice. Recent literature on change highlights the importance of understanding complexity, which informed our approach and analysis. A multifaceted approach to change that comprised evidence-based guidelines, leadership (project leader) and change management was evaluated before and after the implementation by telephone interviews with patients, a postal survey of community staff and interviews with ward staff. A diagnostic analysis of current assessment practice informed the change process. The project leader collected data on adherence. This paper draws on descriptive and qualitative data and addresses the links between contextual issues and the processes and pathways of change, informed by theoretical ideas from the change literature. Key themes emerged: working through others and across boundaries, managing uncertainty and unanticipated challenges. Adherence of ward staff to using the multidisciplinary assessment guidelines was high, with evidence of some dissemination to community staff at follow-up. Three years after the project finished the multidisciplinary assessment is still part of routine clinical practice. The analysis contributes to understanding about the nursing leadership of change within an interprofessional arena of practice. It highlights the importance of understanding the context in relation to the impact and sustainability of change and thus the utility of conducting a diagnostic analysis in the early stages of implementation. This has implications for developing approaches to change in nursing and interprofessional practice in other settings. Using research to change practice needs clinical leaders who are supported by the organization and have the skills to implement research evidence, manage uncertainty and build trust with a range of other professionals.

Integrated Theory of Health Behavior Change

PubMed Central

RYAN, POLLY

2009-01-01

An essential characteristic of advanced practice nurses is the use of theory in practice. Clinical nurse specialists apply theory in providing or directing patient care, in their work as consultants to staff nurses, and as leaders influencing and facilitating system change. Knowledge of technology and pharmacology has far outpaced knowledge of how to facilitate health behavior change, and new theories are needed to better understand how practitioners can facilitate health behavior change. In this article, the Integrated Theory of Health Behavior Change is described, and an example of its use as foundation to intervention development is presented. The Integrated Theory of Health Behavior Change suggests that health behavior change can be enhanced by fostering knowledge and beliefs, increasing self-regulation skills and abilities, and enhancing social facilitation. Engagement in self-management behaviors is seen as the proximal outcome influencing the long-term distal outcome of improved health status. Person-centered interventions are directed to increasing knowledge and beliefs, self-regulation skills and abilities, and social facilitation. Using a theoretical framework improves clinical nurse specialist practice by focusing assessments, directing the use of best-practice interventions, and improving patient outcomes. Using theory fosters improved communication with other disciplines and enhances the management of complex clinical conditions by providing holistic, comprehensive care. PMID:19395894

Examining clinical supervision as a mechanism for changes in practice: a research protocol.

PubMed

Dilworth, Sophie; Higgins, Isabel; Parker, Vicki; Kelly, Brian; Turner, Jane

2014-02-01

This paper describes the research protocol for a study exploring if and how clinical supervision facilitates change in practice relating to psychosocial aspects of care for Health Professionals, who have been trained to deliver a psychosocial intervention to adults with cancer. There is a recognized need to implement care that is in line with clinical practice guidelines for the psychosocial care of adults with cancer. Clinical supervision is recommended as a means to support Health Professionals in providing the recommended psychosocial care. A qualitative design embedded within an experimental, stepped wedge randomized control trial. The study will use discourse analysis to analyse audio-recorded data collected in clinical supervision sessions that are being delivered as one element of a large randomized control trial. The sessions will be attended primarily by nurses, but including physiotherapists, radiation therapists, occupational therapists. The Health Professionals are participants in a randomized control trial designed to reduce anxiety and depression of distressed adults with cancer. The sessions will be facilitated by psychiatrists experienced in psycho-oncology and the provision of clinical supervision. The proposed research is designed specifically to facilitate exploration of the mechanisms by which clinical supervision enables Health Professionals to deliver a brief, tailored psychosocial intervention in the context of their everyday practice. This is the first study to use discourse analysis embedded within an experimental randomized control trial to explore the mechanisms of change generated within clinical supervision by analysing the discourse within the clinical supervision sessions. © 2013 John Wiley & Sons Ltd.

Physician perspectives on a tailored multifaceted primary care practice facilitation intervention for improvement of cardiovascular care.

PubMed

Liddy, Clare; Singh, Jatinderpreet; Guo, Merry; Hogg, William

2016-02-01

Practice facilitation is an effective way to help physicians implement change in their clinics, but little is known about physicians' perspectives on this service. To examine physicians' responses to a practice facilitation program, focussing on their overall satisfaction, perceived most significant clinical changes, and interactions with the facilitator. The Improved Delivery of Cardiovascular Care program investigated the impact of practice facilitation on improving the quality of cardiovascular primary care in Eastern Ontario, Canada, from 2007 to 2011. We conducted a qualitative content analysis of post-intervention surveys completed by participating physicians, using a constant comparison approach framed around the Chronic Care Model. Ninety-five physicians completed the survey. Physicians overwhelmingly viewed the program positively, though descriptions of its benefits and impact varied widely. Facilitators filled three key roles for physicians, acting as a resource centre, motivator and outside perspective. Physicians adopted a number of changes in their practices. These changes include adoption of clinical information systems (diabetes registries), decision support tools (chart audits, guideline documents, flow sheets) and delivery system design (community resources). Most physicians appreciated having access to a practice facilitator and viewed the intervention positively. Insight into physicians' perspectives on practice facilitation provides a valuable counterpoint to outcomes-based evaluations of such services. Further research should investigate potential obstacles in the group of physicians who make fewer practice changes, as well as the sustainability of this type of facilitation intervention. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Ethical preferences for the clinical practice of empowerment social work.

PubMed

Miley, Karla; DuBois, Brenda

2007-01-01

Social workers in health care and mental health benefit from interventions that integrate principles of contextual social work practice with standards for clinical practice. The authors articulate a conceptual framework for the ethical practice of social work that complements the social justice purpose. The sixteen ethical preferences in this framework are the ethics of care, autonomy, power, change, respect, critical thinking, praxis, discourse, critique, justice, contextual practice, inclusion, anti-oppression, advocacy, collaboration, and politicized practice.

Connecting the dots and merging meaning: using mixed methods to study primary care delivery transformation.

PubMed

Scammon, Debra L; Tomoaia-Cotisel, Andrada; Day, Rachel L; Day, Julie; Kim, Jaewhan; Waitzman, Norman J; Farrell, Timothy W; Magill, Michael K

2013-12-01

To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. Convergent case study mixed methods design. Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence. © Health Research and Educational Trust.

Connecting the Dots and Merging Meaning: Using Mixed Methods to Study Primary Care Delivery Transformation

PubMed Central

Scammon, Debra L; Tomoaia-Cotisel, Andrada; Day, Rachel L; Day, Julie; Kim, Jaewhan; Waitzman, Norman J; Farrell, Timothy W; Magill, Michael K

2013-01-01

Objective. To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. Data Source/Study Setting. An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. Study Design. Convergent case study mixed methods design. Data Collection/Extraction Methods. Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. Principal Findings. Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. Conclusions. Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence. PMID:24279836

[Science and ethics, therapeutic misconception and mirage].

PubMed

Raymond, J; Long, H

2008-12-01

Medical practice changes constantly. Ethical imperatives are however incorrigible. How can we reconcile ethics, practice and progress? Some bioethicians argue that research and care should be disentangled to minimize the 'therapeutic misconception', a clinical propensity to believe that patients are the object of medical care, while in fact they are the subjects of a scientific experiment. On the contrary, we believe that clinical research should be an integral part of the good practice. A divorce between research and clinical practice leads to an incorrigible medicine, liable to the therapeutic mirage, that is the false belief that everything modern medicine can offer has been proved beneficial. But both therapeutic misconception and mirage are possible because of a misunderstanding of either research or clinical practice. In this essay we review ethical principles behind clinical trial methodology and attempt to reconcile ethics, science and clinical practice. Not only should clinical research be integrated to the good practice of medicine, it should also be part of training in our specialty.

Breaking up is hard to do: lessons learned from a pharma-free practice transformation.

PubMed

Evans, David; Hartung, Daniel M; Beasley, Denise; Fagnan, Lyle J

2013-01-01

Academic medical centers are examining relationships with the pharmaceutical industry and making changes to limit interactions. Most doctors, however, practice outside of academic institutions and see pharmaceutical detailers and accept drug samples and gifts. Little guidance for practicing physicians exists about transforming practices to become pharma-free. Consideration must be given to the impact on practice culture, staff views, and patient needs. A small private practice, setting out to transform into a pharma-free clinic, used a practice transformation process that examined the industry presence in the clinic, educated the doctors on potential conflicts of interest, and improved practice flow. Staff were given the opportunity to share concerns, and their issues were acknowledged. Educational interventions were developed to help providers keep current. Finally, efforts were made to educate patients about the policy. The clinic recorded the degree to which it was detailed. Loss of gifts, keeping current with new drugs, and managing without samples were noted concerns. Policy change champions developed strategies to address concerns. A shift in practice culture to a pharma-free clinic is achievable and maintainable over time. Barriers to success can be identified and overcome with attention given to careful gathering of information, staff input, and stakeholder education.

Nursing journal clubs and the clinical nurse specialist.

PubMed

Westlake, Cheryl; Albert, Nancy M; Rice, Karen L; Bautista, Cynthia; Close, Jackie; Foster, Jan; Timmerman, Gayle M

2015-01-01

The purpose of this article was to describe the clinical nurse specialist's role in developing and implementing a journal club. Tools for critiquing clinical and research articles with an application of each are provided. The journal club provides a forum through which nurses maintain their knowledge base about clinically relevant topics and developments in their specific clinical discipline, analyze and synthesize the relevant scientific literature as evidence, and engage in informal discussions about evidence-based and best practices. The value of journal clubs includes nursing staff education, review of and support for evidence-based practice, promotion of nursing research, and fostering of organization-wide nursing practice changes. The process for establishing a journal club and suggested appraisal tools are discussed. In addition, strategies for overcoming barriers to the implementation of a journal club are outlined. Suggested article review questions and a reporting format for clinical and research articles are provided with examples from 2 articles. Finally, a glossary of terms commonly used by research scientists and manuscript writers are listed and additional resources provided. The clinical nurse specialist's role in developing and implementing a journal club will be facilitated through the use of this article. Enhanced nursing staff education, evidence-based practice, organization-wide nursing practice changes, and nursing research may be conducted following the implementation of a nursing journal club.

The relationship between baseline Organizational Readiness to Change Assessment subscale scores and implementation of hepatitis prevention services in substance use disorders treatment clinics: a case study

PubMed Central

2010-01-01

Background The Organizational Readiness to Change Assessment (ORCA) is a measure of organizational readiness for implementing practice change in healthcare settings that is organized based on the core elements and sub-elements of the Promoting Action on Research Implementation in Health Services (PARIHS) framework. General support for the reliability and factor structure of the ORCA has been reported. However, no published study has examined the utility of the ORCA in a clinical setting. The purpose of the current study was to examine the relationship between baseline ORCA scores and implementation of hepatitis prevention services in substance use disorders (SUD) clinics. Methods Nine clinic teams from Veterans Health Administration SUD clinics across the United States participated in a six-month training program to promote evidence-based practices for hepatitis prevention. A representative from each team completed the ORCA evidence and context subscales at baseline. Results Eight of nine clinics reported implementation of at least one new hepatitis prevention practice after completing the six-month training program. Clinic teams were categorized by level of implementation-high (n = 4) versus low (n = 5)-based on how many hepatitis prevention practices were integrated into their clinics after completing the training program. High implementation teams had significantly higher scores on the patient experience and leadership culture subscales of the ORCA compared to low implementation teams. While not reaching significance in this small sample, high implementation clinics also had higher scores on the research, clinical experience, staff culture, leadership behavior, and measurement subscales as compared to low implementation clinics. Conclusions The results of this study suggest that the ORCA was able to measure differences in organizational factors at baseline between clinics that reported high and low implementation of practice recommendations at follow-up. This supports the use of the ORCA to describe factors related to implementing practice recommendations in clinical settings. Future research utilizing larger sample sizes will be essential to support these preliminary findings. PMID:20546584

The Effect of a Self-Reflection and Insight Program on the Nursing Competence of Nursing Students: A Longitudinal Study.

PubMed

Pai, Hsiang-Chu

2015-01-01

Nurses have to solve complex problems for their patients and their families, and as such, nursing care capability has become a focus of attention. The aim of this longitudinal study was to develop a self-reflection practice exercise program for nursing students to be used during clinical practice and to evaluate the effects of this program empirically and longitudinally on change in students' clinical competence, self-reflection, stress, and perceived teaching quality. An additional aim was to determine the predictors important to nursing competence. We sampled 260 nursing students from a total of 377 practicum students to participate in this study. A total of 245 students nurse completed 4 questionnaires, Holistic Nursing Competence Scale, Self-Reflection and Insight Scale, Perceived Stress Scale, and Clinical Teaching Quality Scale, at 2, 4, and 6 months after clinical practice experience. Generalized estimating equation models were used to examine the change in scores on each of the questionnaires. The findings showed that, at 6 months after clinical practice, nursing competence was significantly higher than at 2 and 4 months, was positively related to self-reflection and insight, and was negatively related to practice stress. Nursing students' competence at each time period was positively related to clinical teachers' instructional quality at 4 and 6 months. These results indicate that a clinical practice program with self-reflection learning exercise improves nursing students' clinical competence and that nursing students' self-reflection and perceived practice stress affect their nursing competence. Nursing core competencies are enhanced with a self-reflection program, which helps nursing students to improve self-awareness and decrease stress that may interfere with learning. Further, clinical practice experience, self-reflection and insight, and practice stress are predictors of nursing students' clinical competence. Copyright © 2015 Elsevier Inc. All rights reserved.

Gaps between Knowing and Doing: Understanding and Assessing the Barriers to Optimal Health Care

ERIC Educational Resources Information Center

Cochrane, Lorna J.; Olson, Curtis A.; Murray, Suzanne; Dupuis, Martin; Tooman, Tricia; Hayes, Sean

2007-01-01

Introduction: A significant gap exists between science and clinical practice guidelines, on the one hand, and actual clinical practice, on the other. An in-depth understanding of the barriers and incentives contributing to the gap can lead to interventions that effect change toward optimal practice and thus to better care. Methods: A systematic…

Practical considerations in clinical strategy to support the development of injectable drug-device combination products for biologics.

PubMed

Li, Zhaoyang; Easton, Rachael

2018-01-01

The development of an injectable drug-device combination (DDC) product for biologics is an intricate and evolving process that requires substantial investments of time and money. Consequently, the commercial dosage form(s) or presentation(s) are often not ready when pivotal trials commence, and it is common to have drug product changes (manufacturing process or presentation) during clinical development. A scientifically sound and robust bridging strategy is required in order to introduce these changes into the clinic safely. There is currently no single developmental paradigm, but a risk-based hierarchical approach has been well accepted. The rigor required of a bridging package depends on the level of risk associated with the changes. Clinical pharmacokinetic/pharmacodynamic comparability or outcome studies are only required when important changes occur at a late stage. Moreover, an injectable DDC needs to be user-centric, and usability assessment in real-world clinical settings may be required to support the approval of a DDC. In this review, we discuss the common issues during the manufacturing process and presentation development of an injectable DDC and practical considerations in establishing a clinical strategy to address these issues, including key elements of clinical studies. We also analyze the current practice in the industry and review relevant and status of regulatory guidance in the DDC field.

Practical considerations in clinical strategy to support the development of injectable drug-device combination products for biologics

PubMed Central

Easton, Rachael

2018-01-01

ABSTRACT The development of an injectable drug-device combination (DDC) product for biologics is an intricate and evolving process that requires substantial investments of time and money. Consequently, the commercial dosage form(s) or presentation(s) are often not ready when pivotal trials commence, and it is common to have drug product changes (manufacturing process or presentation) during clinical development. A scientifically sound and robust bridging strategy is required in order to introduce these changes into the clinic safely. There is currently no single developmental paradigm, but a risk-based hierarchical approach has been well accepted. The rigor required of a bridging package depends on the level of risk associated with the changes. Clinical pharmacokinetic/pharmacodynamic comparability or outcome studies are only required when important changes occur at a late stage. Moreover, an injectable DDC needs to be user-centric, and usability assessment in real-world clinical settings may be required to support the approval of a DDC. In this review, we discuss the common issues during the manufacturing process and presentation development of an injectable DDC and practical considerations in establishing a clinical strategy to address these issues, including key elements of clinical studies. We also analyze the current practice in the industry and review relevant and status of regulatory guidance in the DDC field. PMID:29035675

Recommendations for the Integration of Genomics into Clinical Practice

PubMed Central

Bowdin, Sarah; Gilbert, Adel; Bedoukian, Emma; Carew, Christopher; Adam, Margaret P; Belmont, John; Bernhardt, Barbara; Biesecker, Leslie; Bjornsson, Hans T.; Blitzer, Miriam; D’Alessandro, Lisa C. A.; Deardorff, Matthew A.; Demmer, Laurie; Elliott, Alison; Feldman, Gerald L.; Glass, Ian A.; Herman, Gail; Hindorff, Lucia; Hisama, Fuki; Hudgins, Louanne; Innes, A. Micheil; Jackson, Laird; Jarvik, Gail; Kim, Raymond; Korf, Bruce; Ledbetter, David H.; Li, Mindy; Liston, Eriskay; Marshall, Christian; Medne, Livija; Meyn, M. Stephen; Monfared, Nasim; Morton, Cynthia; Mulvihill, John J.; Plon, Sharon E.; Rehm, Heidi; Roberts, Amy; Shuman, Cheryl; Spinner, Nancy B.; Stavropoulos, D. James; Valverde, Kathleen; Waggoner, Darrel J.; Wilkens, Alisha; Cohn, Ronald D.; Krantz, Ian D.

2017-01-01

The introduction of diagnostic clinical genome and exome sequencing (CGES) is changing the scope of practice for clinical geneticists. Many large institutions are making a significant investment in infrastructure and technology, allowing clinicians to access CGES especially as health care coverage begins to extend to clinically indicated genomic sequencing-based tests. Translating and realizing the comprehensive clinical benefits of genomic medicine remains a key challenge for the current and future care of patients. With the increasing application of CGES, it is necessary for geneticists and other health care providers to understand its benefits and limitations, in order to interpret the clinical relevance of genomic variants identified in the context of health and disease. Establishing new, collaborative working relationships with specialists across diverse disciplines (e.g., clinicians, laboratorians, bioinformaticians) will undoubtedly be key attributes of the future practice of clinical genetics and may serve as an example for other specialties in medicine. These new skills and relationships will also inform the development of the future model of clinical genetics training curricula. To address the evolving role of the clinical geneticist in the rapidly changing climate of genomic medicine, two Clinical Genetics Think Tank meetings were held which brought together physicians, laboratorians, scientists, genetic counselors, trainees and patients with experience in clinical genetics, genetic diagnostics, and genetics education. This paper provides recommendations that will guide the integration of genomics into clinical practice. PMID:27171546

The minimally important difference for the health assessment questionnaire in rheumatoid arthritis clinical practice is smaller than in randomized controlled trials.

PubMed

Pope, Janet E; Khanna, Dinesh; Norrie, Deborah; Ouimet, Janine M

2009-02-01

Patient-reported outcomes are used in clinical practice and trials. We studied a large clinical practice to determine the minimally important difference (MID) estimates for (1) the Health Assessment Questionnaire-Damage Index (HAQ-DI): improvement and worsening using patient global assessment anchor; and (2) pain using a patient-reported pain anchor. Patients with rheumatoid arthritis (RA; N = 225) had clinic visits at 2 timepoints within 1 year, completed the HAQ-DI and pain visual analog scale (VAS; 0-100 mm), and answered the question, "How would you describe your overall status/overall pain since the last visit?", as much worsened, somewhat worsened, the same, somewhat improved, or much improved. If rated as somewhat improved or worsened, they were defined as the minimally changed subgroups. Eighty-three percent were women, mean age 60 years, with disease duration 11.7 +/- 10.7 years. The baseline HAQ-DI was 0.97 +/- SD 0.76, and at followup 1.0 +/- 0.77 (mean change +0.03 +/- 0.40). The baseline pain VAS was 42.3 +/- 28.8, and at followup 38.5 +/- 27.9 (mean change -2.8 +/- 25.9). The mean (SD) HAQ-DI change score was -0.09 (0.42) for somewhat improved and 0.15 (0.33) for somewhat worsened. The HAQ-DI change for somewhat/much better was -0.20 +/- 0.52, and for somewhat/much worse +0.21 +/- 0.33. For pain, somewhat improved changed by -11.9 mm on the VAS, and somewhat worsened by 6.8 mm. Estimates for HAQ-DI and pain were larger than the for no-change group, 0.03 (0.32) and -3.2 (20.9). The MID for HAQ-DI in clinical practice is smaller than it is in trials. This may have implications for observational studies and clinical care.

How are evidence and knowledge used in orthopaedic decision-making? Three comparative case studies of different approaches to implementation of clinical guidance in practice.

PubMed

Grove, Amy; Clarke, Aileen; Currie, Graeme

2018-05-31

The uptake and use of clinical guidelines is often insufficient to change clinical behaviour and reduce variation in practice. As a consequence of diverse organisational contexts, the simple provision of guidelines cannot ensure fidelity or guarantee their use when making decisions. Implementation research in surgery has focused on understanding what evidence exists for clinical practice decisions but limits understanding to the technical, educational and accessibility issues. This research aims to identify where, when and how evidence and knowledge are used in orthopaedic decision-making and how variation in these factors contributes to different approaches to implementation of clinical guidance in practice. We used in-depth case studies to examine guideline implementation in real-life surgical practice. We conducted comparative case studies in three English National Health Service hospitals over a 12-month period. Each in-depth case study consisted of a mix of qualitative methods including interviews, observations and document analysis. Data included field notes from observations of day-to-day practice, 64 interviews with NHS surgeons and staff and the collection of 121 supplementary documents. Case studies identified 17 sources of knowledge and evidence which influenced clinical decisions in elective orthopaedic surgery. A comparative analysis across cases revealed that each hospital had distinct approaches to decision-making. Decision-making is described as occurring as a result of how 17 types of knowledge and evidence were privileged and of how they interacted and changed in context. Guideline implementation was contingent and mediated through four distinct contextual levels. Implementation could be assessed for individual surgeons, groups of surgeons or the organisation as a whole, but it could also differ between these levels. Differences in how evidence and knowledge were used contributed to variations in practice from guidelines. A range of complex and competing sources of evidence and knowledge exists which influence the working practices of healthcare professionals. The dynamic selection, combination and use of each type of knowledge and evidence influence the implementation and use of clinical guidance in practice. Clinical guidelines are a fundamental part of practice, but represent only one type of evidence influencing clinical decisions. In the orthopaedic speciality, other distinct sources of evidence and knowledge are selected and used which impact on how guidelines are implemented. New approaches to guideline implementation need to appreciate and incorporate this diverse range of knowledge and evidence which influences clinical decisions and to take account of the changing contexts in which decisions are made.

Creating a halo traction wheelchair resource manual: using the EBP approach.

PubMed

Difazio, Rachel

2003-04-01

This article describes a clinically based project that used evidence-based practice (EBP). It follows the EBP process of: (1) identifying a clinical problem and stating a clinical question that focuses the process; (2) doing a literature search for best research evidence; (3) using query techniques, such as phone calls and e-mails, to determine best clinical practice among similar institutions; and (4) drawing a practice conclusion-to accept the status quo, to instigate change of practice, or to do more research. This project was an interdisciplinary effort orchestrated by the surgical programs nurses at Boston Children's Hospital. Copyright 2003, Elsevier Inc. All rights reserved.

The use of neuroimaging in the management of chronic headache in children in clinical practice versus clinical practice guidelines.

PubMed

Prpić, Igor; Ahel, Tea; Rotim, Krešimir; Gajski, Domagoj; Vukelić, Petar; Sasso, Antun

2014-12-01

In daily practice, neuroimaging studies are frequently performed for the management of childhood headache. The aim of this study was to determine whether there is significant discrepancy between clinical practice and clinical practice guidelines on the indications for neuroimaging studies. Medical records of children with chronic headache, aged 2 to 18 years and treated at Rijeka University Hospital Center, Kantrida Department of Pediatrics, were retrospectively reviewed. Indications for brain magnetic resonance imaging and computed tomography (MRI/CT) scanning were reviewed and compared with clinical practice guidelines. Brain imaging was performed in 164 (76.3%) of 215 children, MRI in 93 (56.7%) and CT in 71 (43.3%) children. Indications for brain MRI/CT were as follows: anxiety and/or insistence by the child's family (71.3%), presence of associated features suggesting neurologic dysfunction (13.4%), age under 5 years (12.8%) and abnormal neurologic examination (2.4%). The majority of children (71.4%) had normal neuroimaging findings. In the rest of imaging studies (28.1%), MRI/CT revealed different intracerebral/extracerebral findings not influencing changes in headache management. Only one (0.60%) patient required change in headache management after MRI/CT. Study results proved that, despite available evidence-based clinical guidelines, brain imaging in children with chronic headaches is overused, mostly in order to decrease anxiety of the family/patient.

Recent Innovations in the Changing Criterion Design: Implications for Research and Practice in Special Education

ERIC Educational Resources Information Center

McDougall, Dennis; Hawkins, Jacqueline; Brady, Michael; Jenkins, Amelia

2006-01-01

This article illustrates (a) 2 recent innovations in the changing criterion research design, (b) how these innovations apply to research and practice in special education, and (c) how clinical needs influence design features of the changing criterion design. The first innovation, the range-bound changing criterion, is a very simple variation of…

Impact of the 5As Team study on clinical practice in primary care obesity management: a qualitative study

PubMed Central

Asselin, Jodie; Salami, Eniola; Osunlana, Adedayo M.; Ogunleye, Ayodele A.; Cave, Andrew; Johnson, Jeffrey A.; Sharma, Arya M.; Campbell-Scherer, Denise L.

2017-01-01

Background: The 5As [Ask, Assess, Advise, Agree, Assist] of Obesity Management Team study was a randomized controlled trial of an intervention that was implemented and evaluated to help primary care providers improve clinical practice for obesity management. This paper presents health care provider perspectives of the impacts of the intervention on individual provider and team practices. Methods: This study reports a thematic network analysis of qualitative data collected during the 5As Team study, which involved 24 chronic disease teams affiliated with family practices in a Primary Care Network in Alberta. Qualitative data from 28 primary care providers (registered nurses/nurse practitioners [n = 14], dietitians [n = 7] and mental health workers [n = 7]) in the intervention arm were collected through semistructured interviews, field notes, practice facilitator diaries and 2 evaluation workshop questionnaires. Results: Providers internalized 5As Team intervention concepts, deepening self-evaluation and changing clinical reasoning around obesity. Providers perceived that this internalization changed the provider-patient relationship positively. The intervention changed relations between providers, increasing interdisciplinary understanding, collaboration and discovery of areas for improvement. This personal and interpersonal evolution effected change to the entire Primary Care Network. Interpretation: The 5As Team intervention had multiple impacts on providers and teams to improve obesity management in primary care. Improved provider confidence and capability is a precondition of developing effective patient interventions. Trial registration: ClinicalTrials.gov, no.: NCT01967797. PMID:28450428

Questioning diagnoses in clinical practice: a thematic analysis of clinical psychologists' accounts of working beyond diagnosis in the United Kingdom.

PubMed

Randall-James, James; Coles, Steven

2018-02-08

The British Psychological Society proposes that clinical psychologists are well placed to move beyond psychiatric diagnoses and develop alternative practices. This study sought to explore what the application of these guiding principles looks like in clinical practice, the challenges faced and possible routes forward. A purpose-designed survey was completed by 305 respondents and a thematic analysis completed. Thematic analysis was used to identify five superordinate themes relating to individuals, relational, others, structures and society, comprising of a total of 21 group themes. The presented group themes highlight an array of approaches to practicing beyond diagnosis and factors that help and hinder such action; from scaffolding change, becoming leaders, relating to the multi-disciplinary team, restructuring services and the processes of change. A key concept was "playing the diagnostic game". "Playing the diagnostic game" enables psychologists to manage an array of tensions and anxieties: conflicts between belief and practice, relationships with colleagues, and dilemmas of position and power. It also potentially limits a concerted questioning of diagnosis and consideration of alternatives. An alternative conceptual framework for non-diagnostic practice is needed to aid the collective efforts of clinical psychologists developing their practice beyond diagnosis, some of which have been highlighted in this study. Until then, ways of mitigating the perceived threats to questioning diagnosis need further exploration, theorising and backing.

Facilitating Lewin's change model with collaborative evaluation in promoting evidence based practices of health professionals.

PubMed

Manchester, Julianne; Gray-Miceli, Deanna L; Metcalf, Judith A; Paolini, Charlotte A; Napier, Anne H; Coogle, Constance L; Owens, Myra G

2014-12-01

Evidence based practices (EBPs) in clinical settings interact with and adapt to host organizational characteristics. The contextual factors themselves, surrounding health professions' practices, also adapt as practices become sustained. The authors assert the need for better planning models toward these contextual factors, the influence of which undergird a well-documented science to practice gap in literature on EBPs. The mechanism for EBP planners to anticipate contextual effects as programs Unfreeze their host settings, create Movement, and become Refrozen (Lewin, 1951) is present in Lewin's 3-step change model. Planning for contextual change appears equally important as planning for the actual practice outcomes among providers and patients. Two case studies from a Geriatric Education Center network will illustrate the synthesis of Lewin's three steps with collaborative evaluation principles. The use of the model may become an important tool for continuing education evaluators or organizations beginning a journey toward EBP demonstration projects in clinical settings. Copyright © 2014 Elsevier Ltd. All rights reserved.

Adopting Health Behavior Change Theory throughout the Clinical Practice Guideline Process

ERIC Educational Resources Information Center

Ceccato, Natalie E.; Ferris, Lorraine E.; Manuel, Douglas; Grimshaw, Jeremy M.

2007-01-01

Adopting a theoretical framework throughout the clinical practice guideline (CPG) process (development, dissemination, implementation, and evaluation) can be useful in systematically identifying, addressing, and explaining behavioral influences impacting CPG uptake and effectiveness. This article argues that using a theoretical framework should…

Theoretical Issues in Clinical Social Group Work.

ERIC Educational Resources Information Center

Randall, Elizabeth; Wodarski, John S.

1989-01-01

Reviews relevant issues in clinical social group practice including group versus individual treatment, group work advantages, approach rationale, group conditions for change, worker role in group, group composition, group practice technique and method, time as group work dimension, pretherapy training, group therapy precautions, and group work…

Transformation of the Air Force Medical Service -The Right Medicine

DTIC Science & Technology

2003-04-17

to clinical practice guidelines (CPGs)/ evidence - based medicine . These areas have been transformed using this technology combined with a changing...and the central databases can e-mail the answers. Clinical Practice Guidelines (CPGs) and Evidence Based Medicine have been derived from expert

The impact of pay-for-performance on professional boundaries in UK general practice: an ethnographic study.

PubMed

Grant, Suzanne; Huby, Guro; Watkins, Francis; Checkland, Kath; McDonald, Ruth; Davies, Huw; Guthrie, Bruce

2009-03-01

The 2004 new General Medical Services (nGMS) contract exemplifies trends across the public services towards increased definition, measurement and regulation of professional work, with general practice income now largely dependent on the quality of care provided across a range of clinical and organisational indicators known collectively as the 'Quality and Outcomes Framework' (QOF). This paper reports an ethnographically based study of the impact of the new contract and the financial incentives contained within it on professional boundaries in UK general practice. The distribution of clinical and administrative work has changed significantly and there has been a new concentration of authority, with QOF decision making and monitoring being led by an internal QOF team of clinical and managerial staff who make the major practice-level decisions about QOF, monitor progress against targets, and intervene to resolve areas or indicators at risk of missing targets. General practitioners and nurses, however, appear to have accommodated these changes by re-creating long established narratives on professional boundaries and clinical hierarchies. This paper is concerned with the impact of these new arrangements on existing clinical hierarchies.

Use of evidence in the process of practice change in a clinical team: a study-forming part of the Autocontrol Project.

PubMed

Mehta, V; Kushniruk, A; Gauthier, S; Richard, Y; Deland, E; Veilleux, M; Grant, A

1998-01-01

The Autocontrol Project is concerned with the accessing, processing and communication of high quality information so that a clinical team can make and implement decisions for practice change, and then evaluate if improvement has been achieved. High quality information is used as evidence for change. In this study, we have evaluated how evidence is used by a clinical team to explain an identified problem of inappropriate use of blood gas tests. In an experimental study of the Surgical Intensive Care Unit, video recordings of team meetings of nurses and doctors were undertaken, structured according to a problem-based format. Evidence of current practice patterns derived from the hospital information system, as well as the results of a questionnaire to the unit's staff about knowledge and use of blood gas measurements, were supplied to the participants beforehand. At the second meeting, the output of the first meetings and a summarised analysis of pertinent literature were made available. This second meeting was required to finalise the list of causes of inappropriate blood gas use and propose pragmatic strategies for practice change. The video data of the meetings were coded to analyse the use of evidence, the categories of causes, issues and solutions proposed, and the quality of team interaction. The results indicate that in order to achieve consensus, the team used different types of evidence, including objective evidence of practice patterns, personal experience about direct and indirect organisational influences, and literature-based research evidence of best practice. Furthermore, group dynamics were favoured by the problem-based meeting structure, and a high level of cognitive critiquing between team members was observed. This research suggests that a combination of approaches involving identification of both operational factors (e.g. appropriate access to different types of evidence and meeting structure) and cognitive and behavioural approaches (e.g. ensuring expression of different viewpoints) is needed to support strategic decision-making for practice change in a clinical unit. This combined approach should favourably influence the provision of an effective and efficient evidence support environment for the clinical team.

A peer learning intervention for nursing students in clinical practice education: A quasi-experimental study.

PubMed

Pålsson, Ylva; Mårtensson, Gunilla; Swenne, Christine Leo; Ädel, Eva; Engström, Maria

2017-04-01

Studies of peer learning indicate that the model enables students to practice skills useful in their future profession, such as communication, cooperation, reflection and independence. However, so far most studies have used a qualitative approach and none have used a quasi-experimental design to study effects of nursing students' peer learning in clinical practice. To investigate the effects of peer learning in clinical practice education on nursing students' self-rated performance. Quasi-experimental. The study was conducted during nursing students' clinical practice. All undergraduate nursing students (n=87) attending their first clinical practice were approached. Seventy students out of 87 answered the questionnaires at both baseline and follow-up (42 of 46 in the intervention group and 28 of 39 in the comparison group). During the first two weeks of the clinical practice period, all students were supervised traditionally. Thereafter, the intervention group received peer learning the last two weeks, and the comparison group received traditional supervision. Questionnaire data were collected on nursing students' self-rated performance during the second (baseline) and last (follow-up) week of their clinical practice. Self-efficacy was improved in the intervention group and a significant interaction effect was found for changes over time between the two groups. For the other self-rated variables/tests, there were no differences in changes over time between the groups. Studying each group separately, the intervention group significantly improved on thirteen of the twenty variables/tests over time and the comparison group improved on four. The results indicate that peer learning is a useful method which improves nursing students' self-efficacy to a greater degree than traditional supervision does. Regarding the other self-rated performance variables, no interaction effects were found. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

The paediatric change laboratory: optimising postgraduate learning in the outpatient clinic.

PubMed

Skipper, Mads; Musaeus, Peter; Nøhr, Susanne Backman

2016-02-02

This study aimed to analyse and redesign the outpatient clinic in a paediatric department. The study was a joint collaboration with the doctors of the department (paediatric residents and specialists) using the Change Laboratory intervention method as a means to model and implement change in the outpatient clinic. This study was motivated by a perceived failure to integrate the activities of the outpatient clinic, patient care and training of residents. The ultimate goal of the intervention was to create improved care for patients through resident learning and development. We combined the Change Laboratory intervention with an already established innovative process for residents, 3-h meetings. The Change Laboratory intervention method consists of a well-defined theory (Cultural-historical activity theory) and concrete actions where participants construct a new theoretical model of the activity, which in this case was paediatric doctors' workplace learning modelled in order to improve medical social practice. The notion of expansive learning was used during the intervention in conjunction with thematic analysis of data in order to fuel the process of analysis and intervention. The activity system of the outpatient clinic can meaningfully be analysed in terms of the objects of patient care and training residents. The Change Laboratory sessions resulted in a joint action plan for the outpatient clinic structured around three themes: (1) Before: Preparation, expectations, and introduction; (2) During: Structural context and resources; (3) After: Follow-up and feedback. The participants found the Change Laboratory method to be a successful way of sharing reflections on how to optimise the organisation of work and training with patient care in mind. The Change Laboratory approach outlined in this study succeeded to change practices and to help medical doctors redesigning their work. Participating doctors must be motivated to uncover inherent contradictions in their medical activity systems of which care and learning are both part. Facilitators must be willing to spend time analysing both historical paediatric practice, current data on practice, and steer clear of organisational issues that might hamper a transformative learning environment. To ensure long-term success, economical and organisational resources, participant buy-in and department leadership support play a major role.

More than just teaching procedural skills: How RN clinical tutors perceive they contribute to medical students' professional identity development.

PubMed

McLean, Michelle; Johnson, Patricia; Sargeant, Sally; Green, Patricia

2015-01-01

On their journey to "becoming" doctors, medical students encounter a range of health professionals who contribute to their socialisation into clinical practice. Amongst these individuals are registered nurses (RNs) in clinical practice who are often employed by medical schools as clinical tutors. These RNs will encounter medical students on campus and later in the clinical setting. This qualitative study explored RNs' perceptions of their contribution to medical students' developing professional identities in order to provide a greater understanding of this process and ultimately inform future curriculum. This qualitative study took place in 2012 at one Australian medical school as part of a broader study exploring medical students' professional identity development from the perspectives of their teachers and trainers. Eight of the nine RNs involved in teaching procedural skills were interviewed. Recorded interviews were transcribed verbatim. Data were analysed inductively by the research team. Two major themes emerged: RNs as change agents and RNs as facilitators of medical students' transition to the clinical environment. RNs as change agents related to their role modelling good practice, being patient-centred, and by emphasising factors contributing to good teamwork such as recognising and respecting individual professional roles. They facilitated students' transition to the clinical environment often through personal narratives, by offering advice on how to behave and work with members of the healthcare team, and by being a point of contact in the hospital. Based on their descriptions of how they role modelled good practice and how they facilitated students' transition to clinical practice, we believe that RN clinical tutors do have the experience and expertise in clinical practice and a professional approach to patients to contribute to medical students' developing professional identities as future doctors.

Process evaluation of a multifaceted intervention to improve cardiovascular disease prevention in general practice.

PubMed

Lobo, Claudia M; Euser, Lya; Kamp, Jeanine; Frijling, Bernard D; Severens, Johan L; Hulscher, Marlies E J L; Grol, Richard P T M; Prins, Ad; van der Wouden, Johannes C

2003-09-01

To perform a process evaluation of a multifaceted intervention to improve cardiovascular and diabetes care in general practice. The feasibility of the intervention, carried out by outreach visitors in 62 practices, was addressed by evaluating whether the intervention programme was performed as planned and the extent to which it was accepted by the practice team. In addition, the costs of the programme were determined. The intervention was largely carried out as planned, although the intervention period had to be extended by three months. Of the 18 topics that could be addressed during the intervention period, 12 (mean) were addressed. The number of outreach visits per practice was 15.2 (mean), each visit lasted about one hour. Most practice members endorsed both the key recommendations for clinical decision-making and cardiovascular risk profiling. The majority of GPs (range 63-98%) agreed with the guidelines for clinical decision-making, and 29-97% had a positive opinion about the guidelines for practice organisation. According to practice staff members, the outreach visitor had sufficient knowledge and skills to support them in changing the practice organisation. GPs were less positive about the outreach visitor's knowledge and skills in optimising clinical decision-making; however 78% believed that the outreach visitor contributed to effecting change in their clinical decision-making. The total costs of the intervention per practice were Euro 4317. This process evaluation demonstrated that the intervention was usually carried out as planned and achieved a high satisfaction rating from the participating practice members.

Organizational Dimensions of Innovative Practice: A Qualitative Investigation of the Processes Supporting Innovation Adoption in Outpatient Physical Therapy Practice.

PubMed

Sabus, Carla; Spake, Ellen

2018-01-01

The ability to innovate and adapt practice is a requirement of the progressive healthcare provider. Innovative practice by rehabilitation providers has largely been approached as personal professional development; this study extends that perspective by examining innovation uptake from the organizational level. The varied professions can be expected to have distinct qualities of innovation adoption that reflect professional norms, values, and expectations. The purpose of this qualitative study was to describe the organizational processes of innovation uptake in outpatient physical therapy practice. Through nomination, two outpatient, privately owned physical therapy clinics were identified as innovation practices. Eighteen physical therapists, three owners, and a manager participated in the study. The two clinics served as case studies within a grounded theory approach. Data were collected through observation, unstructured questioning, work flow analysis, focus group sessions, and artifact analysis. Data were analyzed and coded among the investigators. A theoretical model of the innovation adoption process in outpatient physical therapy practice was developed. Elements of the model included (1) change grounded in relationship-centered care, (2) clinic readiness to accept change, and (3) clinic adaptability and resilience. A social paradigm of innovation adoption informed through this research complements the concentration on personal professional development.

To adopt, to adapt, or to contextualise? The big question in clinical practice guideline development.

PubMed

Dizon, Janine Margarita; Machingaidze, Shingai; Grimmer, Karen

2016-09-13

Developing new clinical practice guidelines (CPGs) can be time-consuming and expensive. A more efficient approach could be to adopt, adapt or contextualise recommendations from existing good quality CPGs so that the resultant guidance is tailored to the local context. The first steps are to search for international CPGs that have a similar purpose, end-users and patients to your situation. The second step is to critically appraise the methodological quality of the CPGs to ensure that your guidance is based on credible evidence. Then the decisions begin. Can you simply 'adopt' this (parent) clinical practice guidelines, and implement the recommendations in their entirety, without any changes, in your setting? If so, then no further work is required. However this situation is rare. What is more likely, is that even if recommendations from the parent clinical practice guidelines can be adopted, how they are implemented needs to address local issues. Thus you may need to 'contextualise' the guidance, by addressing implementation issues such as local workforce, training, health systems, equipment and/or access to services. Generally this means that additional information is required (Practice/Context Points) to support effective implementation of the clinical practice guidelines recommendations. In some cases, you may need to 'adapt' the guidance, where you will make changes to the recommendations so that care is relevant to your local environments. This may involve additional work to search for local research, or obtain local consensus, regarding how best to adapt recommendations. For example, adaptation might reflect substituting one drug for another (drugs have similar effects, but the alternative drug to the recommended one may be cheaper, more easily obtained or more culturally acceptable). There is lack of standardisation of clinical practice guidelines terminology, leading clinical practice guideline activities often being poorly conceptualised or reported. We provide an approach that would help improve efficiency and standardisation of clinical practice guidelines activities.

Using a community of practice to evaluate falls prevention activity in a residential aged care organisation: a clinical audit.

PubMed

Francis-Coad, Jacqueline; Etherton-Beer, Christopher; Bulsara, Caroline; Nobre, Debbie; Hill, Anne-Marie

2017-03-01

Objective This study evaluates whether a community of practice (CoP) could conduct a falls prevention clinical audit and identify gaps in falls prevention practice requiring action. Methods Cross-sectional falls prevention clinical audits were conducted in 13 residential aged care (RAC) sites of a not-for-profit organisation providing care to a total of 779 residents. The audits were led by an operationalised CoP assisted by site clinical staff. A CoP is a group of people with a shared interest who get together to innovate for change. The CoP was made up of self-nominated staff representing all RAC sites and comprised of staff from various disciplines with a shared interest in falls prevention. Results All 13 (100%) sites completed the audit. CoP conduct of the audit met identified criteria for an effective clinical audit. The priorities for improvement were identified as increasing the proportion of residents receiving vitamin D supplementation (mean 41.5%, s.d. 23.7) and development of mandatory falls prevention education for staff and a falls prevention policy, as neither was in place at any site. CoP actions undertaken included a letter to visiting GPs requesting support for vitamin D prescription, surveys of care staff and residents to inform falls education development, defining falls and writing a falls prevention policy. Conclusion A CoP was able to effectively conduct an evidence-based falls prevention activity audit and identify gaps in practice. CoP members were well positioned, as site staff, to overcome barriers and facilitate action in falls prevention practice. What is known about the topic? Audit and feedback is an effective way of measuring clinical quality and safety. CoPs have been established in healthcare using workplace staff to address clinical problems but little is known about their ability to audit and influence practice change. What does this paper add? This study contributes to the body of knowledge on CoPs in healthcare by evaluating the performance of one in the domain of falls prevention audit action. What are the implications for practitioners? A CoP is an effective model to engage staff in the clinical audit process. Clinical audits can raise staff awareness of gaps in practice and motivate staff to plan and action change as recommended in best practice guidelines.

Networking and training in palliative care: challenging values and changing practice.

PubMed

Leng, Mhoira Ef

2011-01-01

What make a good doctor is a question posed by the public and profession and is key when designing training programmes. The goal of training is to change practice not simply acquire knowledge yet too often curriculums and assessment focuses on knowledge and skills. Professional practice is underpinned by beliefs and values and therefore training may need to challenge deeply held values in order to result in a change in practice. Palliative care offers an opportunity to challenge values at a deeply personal level as it brings experiences of pain and suffering alongside clinical knowledge and skills. Palliative care is holistic and so real scenarios where physical, psychological, social and spiritual issues are evident can be presented in an interactive, learner centered environment. Training in ethics alongside clinical skills will assist the development of judgment which should also be assessed. Communication skills enable the clinician to hear and understand the needs and wishes of those facing life limiting illness. Training should include aspects of modeling and mentorship to demonstrate and integrate the learning with the realities of clinical practice and include those who lead and influence policy and advocacy.

Creatures of habit: accounting for the role of habit in implementation research on clinical behaviour change

PubMed Central

2012-01-01

Background Social cognitive theories on behaviour change are increasingly being used to understand and predict healthcare professionals’ intentions and clinical behaviours. Although these theories offer important insights into how new behaviours are initiated, they provide an incomplete account of how changes in clinical practice occur by failing to consider the role of cue-contingent habits. This article contributes to better understanding of the role of habits in clinical practice and how improved effectiveness of behavioural strategies in implementation research might be achieved. Discussion Habit is behaviour that has been repeated until it has become more or less automatic, enacted without purposeful thinking, largely without any sense of awareness. The process of forming habits occurs through a gradual shift in cognitive control from intentional to automatic processes. As behaviour is repeated in the same context, the control of behaviour gradually shifts from being internally guided (e.g., beliefs, attitudes, and intention) to being triggered by situational or contextual cues. Much clinical practice occurs in stable healthcare contexts and can be assumed to be habitual. Empirical findings in various fields suggest that behaviours that are repeated in constant contexts are difficult to change. Hence, interventions that focus on changing the context that maintains those habits have a greater probability of success. Some sort of contextual disturbance provides a window of opportunity in which a behaviour is more likely to be deliberately considered. Forming desired habits requires behaviour to be carried out repeatedly in the presence of the same contextual cues. Summary Social cognitive theories provide insight into how humans analytically process information and carefully plan actions, but their utility is more limited when it comes to explaining repeated behaviours that do not require such an ongoing contemplative decisional process. However, despite a growing interest in applying behavioural theory in interventions to change clinical practice, the potential importance of habit has not been explored in implementation research. PMID:22682656

Mapping new theoretical and methodological terrain for knowledge translation: contributions from critical realism and the arts

PubMed Central

Kontos, Pia C; Poland, Blake D

2009-01-01

Background Clinical practice guidelines have been a popular tool for the improvement of health care through the implementation of evidence from systematic research. Yet, it is increasingly clear that knowledge alone is insufficient to change practice. The social, cultural, and material contexts within which practice occurs may invite or reject innovation, complement or inhibit the activities required for success, and sustain or alter adherence to entrenched practices. However, knowledge translation (KT) models are limited in providing insight about how and why contextual contingencies interact, the causal mechanisms linking structural aspects of context and individual agency, and how these mechanisms influence KT. Another limitation of KT models is the neglect of methods to engage potential adopters of the innovation in critical reflection about aspects of context that influence practice, the relevance and meaning of innovation in the context of practice, and the identification of strategies for bringing about meaningful change. Discussion This paper presents a KT model, the Critical Realism and the Arts Research Utilization Model (CRARUM), that combines critical realism and arts-based methodologies. Critical realism facilitates understanding of clinical settings by providing insight into the interrelationship between its structures and potentials, and individual action. The arts nurture empathy, and can foster reflection on the ways in which contextual factors influence and shape clinical practice, and how they may facilitate or impede change. The combination of critical realism and the arts within the CRARUM model promotes the successful embedding of interventions, and greater impact and sustainability. Conclusion CRARUM has the potential to strengthen the science of implementation research by addressing the complexities of practice settings, and engaging potential adopters to critically reflect on existing and proposed practices and strategies for sustaining change. PMID:19123945

Leadership Practices of Clinical Trials Office Leaders in Academic Health Centers

ERIC Educational Resources Information Center

Naser, Diana D.

2012-01-01

In the ever-changing clinical research environment, academic health centers seek leaders who are visionary and innovative. Clinical trials offices across the country are led by individuals who are charged with promoting growth and change in order to maximize performance, develop unique research initiatives, and help institutions achieve a…

Implementation and Sequencing of Practice Transformation in Urban Practices with Underserved Patients.

PubMed

Quigley, Denise D; Predmore, Zachary S; Chen, Alex Y; Hays, Ron D

Patient-centered medical home (PCMH) has gained momentum as a model for primary-care health services reform. We conducted interviews at 14 primary care practices undergoing PCMH transformation in a large urban federally qualified health center in California and used grounded theory to identify common themes and patterns. We found clinics pursued a common sequence of changes in PCMH transformation: Clinics began with National Committee for Quality Assurance (NCQA) level 3 recognition, adding care coordination staff, reorganizing data flow among teams, and integrating with a centralized quality improvement and accountability infrastructure. Next, they realigned to support continuity of care. Then, clinics improved access by adding urgent care, patient portals, or extending hours. Most then improved planning and management of patient visits. Only a handful worked explicitly on improving access with same day slots, scheduling processes, and test result communication. The clinics' changes align with specific NCQA PCMH standards but also include adding physicians and services, culture changes, and improved communication with patients. NCQA PCMH level 3 recognition is only the beginning of a continuous improvement process to become patient centered. Full PCMH transformation took time and effort and relied on a sequential approach, with an early focus on foundational changes that included use of a robust quality improvement strategy before changes to delivery of and access to care.

Learning from a lifetime of leading effective change.

PubMed

Johnson, Claire; Clum, Gerard; Lassiter, Wright L; Phillips, Reed; Sportelli, Louis; Hunter, James C

2014-12-01

The purpose of this article is to report on the opening plenary session of the Association of Chiropractic Colleges Educational Conference-Research Agenda Conference (ACC-RAC) 2014, "Aiming for Effective Change: Leadership in Chiropractic Education, Research and Clinical Practice." Speakers with extensive backgrounds with implementing substantial change on a broad level shared personal examples from their experiences in education, research, political organizations, and clinical practice. They described efforts, challenges, and opportunities that are encountered in order to implement effective change and shared their personal thoughts on leadership. Each of the speakers shared their diverse, unique insights and personal experiences to convey the process and meaning of leadership.

Effective implementation of research into practice: an overview of systematic reviews of the health literature.

PubMed

Boaz, Annette; Baeza, Juan; Fraser, Alec

2011-06-22

The gap between research findings and clinical practice is well documented and a range of interventions has been developed to increase the implementation of research into clinical practice. A review of systematic reviews of the effectiveness of interventions designed to increase the use of research in clinical practice. A search for relevant systematic reviews was conducted of Medline and the Cochrane Database of Reviews 1998-2009. 13 systematic reviews containing 313 primary studies were included. Four strategy types are identified: audit and feedback; computerised decision support; opinion leaders; and multifaceted interventions. Nine of the reviews reported on multifaceted interventions. This review highlights the small effects of single interventions such as audit and feedback, computerised decision support and opinion leaders. Systematic reviews of multifaceted interventions claim an improvement in effectiveness over single interventions, with effect sizes ranging from small to moderate. This review found that a number of published systematic reviews fail to state whether the recommended practice change is based on the best available research evidence. This overview of systematic reviews updates the body of knowledge relating to the effectiveness of key mechanisms for improving clinical practice and service development. Multifaceted interventions are more likely to improve practice than single interventions such as audit and feedback. This review identified a small literature focusing explicitly on getting research evidence into clinical practice. It emphasizes the importance of ensuring that primary studies and systematic reviews are precise about the extent to which the reported interventions focus on changing practice based on research evidence (as opposed to other information codified in guidelines and education materials).

Group changes in cognitive performance after surgery mask changes in individual patients with Glioblastoma.

PubMed

van Loenen, Inge S; Rijnen, Sophie Jm; Bruijn, Jimme; Rutten, Geert-Jan M; Gehring, Karin; Sitskoorn, Margriet M

2018-06-07

There is a growing interest to include evaluations of cognitive performance in the clinical management of patients with Glioblastoma (GBM). However, as changes in cognitive performance of a group may mask changes in individual patients, study results are often difficult to transfer into clinical practice. We focused on the comparison of group versus individual changes in neuropsychological performance of GBM patients after initial surgical treatment. Patients underwent neuropsychological evaluation using CNS Vital Signs one day prior to, and three months after surgery. Two-tailed paired samples t-tests were conducted to assess changes on the group level. Reliable Change Indices (RCIs), that correct for practice effects and imperfect test-retest reliabilities, were used to examine change in individual patients. Cognitive dysfunction was common (>80%) both before and three months after surgery in this sample of 82 GBM patients. Whereas group analyses revealed minimal changes in performance over time, RCIs demonstrated that most patients (89%) showed changes in performance in at least one cognitive domain. Half of these individual patients solely showed improvements, a quarter solely showed declines, and another quarter showed both improvements and declines. This study clearly demonstrates that important individual changes in performance are masked when looking only at group results. Future studies should more often use an individual patient approach to enhance knowledge transfer into clinical practice. Copyright © 2018 The Author(s). Published by Elsevier Inc. All rights reserved.

Blending Western Biomedicine with Local Healing Practices.

PubMed

Chary, Anita; Sargent, Carolyn

2016-07-01

Western allopathic physicians working internationally might encounter allopathic colleagues who endorse local healing practices that are not scientifically supported and, hence, might pose harm to patients. Respect for the autonomy of local physicians and patients thus can conflict with the ethical principles of beneficence and nonmaleficence. In such a situation, it is advisable for Western allopathic physicians to communicate their concerns to local colleagues as equal partners. Making an effort to understand local meanings associated with a traditional therapy demonstrates one's respect for local cultural ideas and practices, even if one disagrees with that therapy, and is crucial to tailoring messages about clinical practice change. A realistic approach to cross-cultural clinical practice change seeks to reduce, rather than eliminate, harm. © 2016 American Medical Association. All Rights Reserved. ISSN 2376-6980.

Connecting pre-marketing clinical research and medical practice: opinion-based study of core issues and possible changes in drug regulation.

PubMed

Wieringa, Nicolien F; Peschar, Jules L; Denig, Petra; de Graeff, Pieter A; Vos, Rein

2003-01-01

To identify core issues that contribute to the gap between pre-marketing clinical research and practice as seen from the perspective of medical practice, as well as possible changes and potential barriers for dosing this gap. Interviews with 47 physicians and pharmacists who were liaised to drug regulation through their role in the pre- and post-marketing shaping of new cardiovascular drugs. Data were analyzed using methods of grounded theory and analytical evaluations. Six core issues were identified that referred to the standards in drug regulation, the organization of the regulatory system, and conflicting interests. Pre-marketing trials should focus more on populations and research questions relevant to medical practice. In particular, variability in drug responses between subgroups of patients and demonstration of effectiveness should become major principles in drug regulation. An interactive post-marketing process in which public interests are represented was considered necessary to further guide research and development according to the needs in daily practice. Strategies for change could be applied within the present system of drug regulation, or affect its basic principles. Regulatory authorities were primarily identified to initiate changes, but many other parties should be involved. Barriers for change were identified regarding differences in interests between parties, organizational matters, and with respect to broader healthcare policies. Based on the respondents' opinions, there is a need to focus regulatory standards more on the needs in medical practice. Therefore, regulatory authorities should further develop their influence in the pre- and post-marketing drug development process, together with other parties involved, in order to bridge the gap between clinical research and medical practice.

Clinical balance assessment: perceptions of commonly-used standardized measures and current practices among physiotherapists in Ontario, Canada.

PubMed

Sibley, Kathryn M; Straus, Sharon E; Inness, Elizabeth L; Salbach, Nancy M; Jaglal, Susan B

2013-03-20

Balance impairment is common in multiple clinical populations, and comprehensive assessment is important for identifying impairments, planning individualized treatment programs, and evaluating change over time. However, little information is available regarding whether clinicians who treat balance are satisfied with existing assessment tools. In 2010 we conducted a cross-sectional survey of balance assessment practices among physiotherapists in Ontario, Canada, and reported on the use of standardized balance measures (Sibley et al. 2011 Physical Therapy; 91: 1583-91). The purpose of this study was to analyse additional survey data and i) evaluate satisfaction with current balance assessment practices and standardized measures among physiotherapists who treat adult or geriatric populations with balance impairment, and ii) identify factors associated with satisfaction. The questionnaire was distributed to 1000 practicing physiotherapists. This analysis focuses on questions in which respondents were asked to rate their general perceptions about balance assessment, the perceived utility of individual standardized balance measures, whether they wanted to improve balance assessment practices, and why. Data were summarized with descriptive statistics and utility of individual measures was compared across clinical practice areas (orthopaedic, neurological, geriatric or general rehabilitation). The questionnaire was completed by 369 respondents, of which 43.4% of respondents agreed that existing standardized measures of balance meet their needs. In ratings of individual measures, the Single Leg Stance test and Berg Balance Scale were perceived as useful for clinical decision-making and evaluating change over time by over 70% of respondents, and the Timed Up-and-Go test was perceived as useful for decision-making by 56.9% of respondents and useful for evaluating change over time by 62.9% of respondents, but there were significant differences across practice groups. Seventy-nine percent of respondents wanted to improve their assessments, identifying individual, environmental and measure-specific barriers. The most common barriers were lack of time and knowledge. This study offers new information on issues affecting the evaluation of balance in clinical settings from a broad sample of physiotherapists. Continued work to address barriers by specific practice area will be critical for the success of any intervention attempting to implement optimal balance assessment practices in the clinical setting.

Evidence based vaccinology.

PubMed

Nalin, David R

2002-02-22

Evidence based vaccinology (EBV) is the identification and use of the best evidence in making and implementing decisions during all of the stages of the life of a vaccine, including pre-licensure vaccine development and post-licensure manufacture and research, and utilization of the vaccine for disease control. Vaccines, unlike most pharmaceuticals, are in a continuous process of development both before and after licensure. Changes in biologics manufacturing technology and changes that vaccines induce in population and disease biology lead to periodic review of regimens (and sometimes dosage) based on changing immunologic data or public perceptions relevant to vaccine safety and effectiveness. EBV includes the use of evidence based medicine (EBM) both in clinical trials and in national disease containment programs. The rationale for EBV is that the highest evidentiary standards are required to maintain a rigorous scientific basis of vaccine quality control in manufacture and to ensure valid determination of vaccine efficacy, field effectiveness and safety profiles (including post-licensure safety monitoring), cost-benefit analyses, and risk:benefit ratios. EBV is increasingly based on statistically validated, clearly defined laboratory, manufacturing, clinical and epidemiological research methods and procedures, codified as good laboratory practices (GLP), good manufacturing practices (GMP), good clinical research practices (GCRP) and in clinical and public health practice (good vaccination practices, GVP). Implementation demands many data-driven decisions made by a spectrum of specialists pre- and post-licensure, and is essential to maintaining public confidence in vaccines.

Research methods to change clinical practice for patients with rare cancers.

PubMed

Billingham, Lucinda; Malottki, Kinga; Steven, Neil

2016-02-01

Rare cancers are a growing group as a result of reclassification of common cancers by molecular markers. There is therefore an increasing need to identify methods to assess interventions that are sufficiently robust to potentially affect clinical practice in this setting. Methods advocated for clinical trials in rare diseases are not necessarily applicable in rare cancers. This Series paper describes research methods that are relevant for rare cancers in relation to the range of incidence levels. Strategies that maximise recruitment, minimise sample size, or maximise the usefulness of the evidence could enable the application of conventional clinical trial design to rare cancer populations. Alternative designs that address specific challenges for rare cancers with the aim of potentially changing clinical practice include Bayesian designs, uncontrolled n-of-1 trials, and umbrella and basket trials. Pragmatic solutions must be sought to enable some level of evidence-based health care for patients with rare cancers. Copyright © 2016 Elsevier Ltd. All rights reserved.

Duration of luteal support after IVF is important, so why is there no consistency in practice? The results of a dynamic survey of practice in the United Kingdom.

PubMed

Russell, Richard; Kingsland, Charles; Alfirevic, Zarko; Gazvani, Rafet

2015-03-01

Luteal support is considered as an essential component of IVF treatment following ovarian stimulation and embryo transfer. Several studies have consistently demonstrated a benefit of luteal support compared with no treatment and whilst a number of preparations are available, no product has been demonstrated as superior. There is an emerging body of evidence which suggests that extension of luteal support beyond biochemical pregnancy does not confer a benefit in terms of successful pregnancy outcome. We performed two surveys separated by 5 years of practice evolution, with the latter reporting on the use of luteal support in all IVF clinics in the UK. All clinics reported utilising luteal support with the majority favouring the use of Cyclogest 400 mg twice daily. In contrast, there was no consensus on the optimal duration of luteal support. Whilst 24% of clinics withdrew luteal support at biochemical confirmation of pregnancy, 40% continued treatment until 12 weeks gestation. Several clinics even extended luteal support beyond 12 weeks gestation. We observed no difference in practice based on the size of the IVF unit or treatment funding source. Although there was some change in practice between surveys in many clinics, there was no uniformity in the direction of change.

Perceptions of Radiation Oncologists and Urologists on Sources and Type of Evidence to Inform Prostate Cancer Treatment Decisions

DOE Office of Scientific and Technical Information (OSTI.GOV)

Han, Leona C.; Delpe, Sophia; Shah, Nilay D.

2014-06-01

Purpose: To perform a national survey of radiation oncologists and urologists about the type of resources used and the level of evidence needed to change clinical practice in localized prostate cancer. Methods and Materials: From a random sample, 1422 physicians were mailed a survey assessing the types of information used and what level of evidence could alter their clinical practice in prostate cancer. Multivariable logistic regression models were used to identify differences in physician characteristics for each outcome. Results: Survey response rates were similar for radiation oncologists and urologists (44% vs 46%; P=.46). Specialty-specific journals represented the most commonly usedmore » resource for informing the clinical practice for radiation oncologists (65%) and urologists (70%). Relative to radiation oncologists, urologists were less likely to report utilizing top-tier medical journals (25% vs 39%; adjusted odds ratio [OR] 0.50; P=.01) or cancer journals (22% vs 51%; adjusted OR 0.50; P<.001) but more likely to rely on clinical guidelines (46% vs 38%; adjusted OR 1.6; P=.006). Both radiation oncologists and urologists most commonly reported large randomized, clinical trials as the level of evidence to change treatment recommendations for localized prostate cancer (85% vs 77%; P=.009). Conclusions: Both specialties rely on their own specialty-specific journals and view randomized, clinical trials as the level of evidence needed to change clinical practice. Our study provides a context on meaningful ways of disseminating evidence for localized prostate cancer.« less

Changing physician behavior: what works?

PubMed

Mostofian, Fargoi; Ruban, Cynthiya; Simunovic, Nicole; Bhandari, Mohit

2015-01-01

There are various interventions for guideline implementation in clinical practice, but the effects of these interventions are generally unclear. We conducted a systematic review to identify effective methods of implementing clinical research findings and clinical guidelines to change physician practice patterns, in surgical and general practice. Systematic review of reviews. We searched electronic databases (MEDLINE, EMBASE, and PubMed) for systematic reviews published in English that evaluated the effectiveness of different implementation methods. Two reviewers independently assessed eligibility for inclusion and methodological quality, and extracted relevant data. Fourteen reviews covering a wide range of interventions were identified. The intervention methods used include: audit and feedback, computerized decision support systems, continuing medical education, financial incentives, local opinion leaders, marketing, passive dissemination of information, patient-mediated interventions, reminders, and multifaceted interventions. Active approaches, such as academic detailing, led to greater effects than traditional passive approaches. According to the findings of 3 reviews, 71% of studies included in these reviews showed positive change in physician behavior when exposed to active educational methods and multifaceted interventions. Active forms of continuing medical education and multifaceted interventions were found to be the most effective methods for implementing guidelines into general practice. Additionally, active approaches to changing physician performance were shown to improve practice to a greater extent than traditional passive methods. Further primary research is necessary to evaluate the effectiveness of these methods in a surgical setting.

Survey of knowledge and perception on the access to evidence-based practice and clinical practice change among maternal and infant health practitioners in South East Asia.

PubMed

Martis, Ruth; Ho, Jacqueline J; Crowther, Caroline A

2008-08-05

Evidence-based practice (EBP) can provide appropriate care for women and their babies; however implementation of EBP requires health professionals to have access to knowledge, the ability to interpret health care information and then strategies to apply care. The aim of this survey was to assess current knowledge of evidence-based practice, information seeking practices, perceptions and potential enablers and barriers to clinical practice change among maternal and infant health practitioners in South East Asia. Questionnaires about IT access for health information and evidence-based practice were administered during August to December 2005 to health care professionals working at the nine hospitals participating in the South East Asia Optimising Reproductive and Child Health in Developing countries (SEA-ORCHID) project in Indonesia, Malaysia, Thailand and The Philippines. The survey was completed by 660 staff from six health professional groups. Overall, easy IT access for health care information was available to 46% of participants. However, over a fifth reported no IT access was available and over half of nurses and midwives never used IT health information. Evidence-based practice had been heard of by 58% but the majority did not understand the concept. The most frequent sites accessed were Google and PubMed. The Cochrane Library had been heard of by 47% of whom 51% had access although the majority did not use it or used it less than monthly. Only 27% had heard of the WHO Reproductive Health Library and 35% had been involved in a clinical practice change and were able to identify enablers and barriers to change. Only a third of participants had been actively involved in practice change with wide variation between the countries. Willingness to participate in professional development workshops on evidence-based practice was high. This survey has identified the need to improve IT access to health care information and health professionals' knowledge of evidence-based health care to assist in employing evidence base practice effectively.

Survey of knowledge and perception on the access to evidence-based practice and clinical practice change among maternal and infant health practitioners in South East Asia

PubMed Central

Martis, Ruth; Ho, Jacqueline J; Crowther, Caroline A

2008-01-01

Background Evidence-based practice (EBP) can provide appropriate care for women and their babies; however implementation of EBP requires health professionals to have access to knowledge, the ability to interpret health care information and then strategies to apply care. The aim of this survey was to assess current knowledge of evidence-based practice, information seeking practices, perceptions and potential enablers and barriers to clinical practice change among maternal and infant health practitioners in South East Asia. Methods Questionnaires about IT access for health information and evidence-based practice were administered during August to December 2005 to health care professionals working at the nine hospitals participating in the South East Asia Optimising Reproductive and Child Health in Developing countries (SEA-ORCHID) project in Indonesia, Malaysia, Thailand and The Philippines. Results The survey was completed by 660 staff from six health professional groups. Overall, easy IT access for health care information was available to 46% of participants. However, over a fifth reported no IT access was available and over half of nurses and midwives never used IT health information. Evidence-based practice had been heard of by 58% but the majority did not understand the concept. The most frequent sites accessed were Google and PubMed. The Cochrane Library had been heard of by 47% of whom 51% had access although the majority did not use it or used it less than monthly. Only 27% had heard of the WHO Reproductive Health Library and 35% had been involved in a clinical practice change and were able to identify enablers and barriers to change. Only a third of participants had been actively involved in practice change with wide variation between the countries. Willingness to participate in professional development workshops on evidence-based practice was high. Conclusion This survey has identified the need to improve IT access to health care information and health professionals' knowledge of evidence-based health care to assist in employing evidence base practice effectively. PMID:18680603

Patient Satisfaction in Adjacent Family Practice and Non-Family Practice Navy Outpatient Clinics

DTIC Science & Technology

1982-11-29

approach to health care promotes the economic concepts of supply and demand and recasts the patient into a more active role as a consumer in the...34""van den Heuvel WJA: The role of the consumer in health policy. Soc Sci Med 14A:423, 1980 Martin JF: The active patient : A necessary development...Outpatient Clinics Interest in patient satisfaction is based largely on the changing roles of the . patient in the health care system. This change from

Influence on general practitioners of teaching undergraduates: qualitative study of London general practitioner teachers

PubMed Central

Hartley, Sarah; Macfarlane, Fraser; Gantley, Madeleine; Murray, Elizabeth

1999-01-01

Objective To examine the perceived effect of teaching clinical skills and associated teacher training programmes on general practitioners' morale and clinical practice. Design Qualitative semistructured interview study. Setting General practices throughout north London. Subjects 30 general practitioners who taught clinical skills were asked about the effect of teaching and teacher training on their morale, confidence in clinical and teaching skills, and clinical practice. Results The main theme was a positive effect on morale. Within teacher training this was attributed to developing peer and professional support; improved teaching skills; and revision of clinical knowledge and skills. Within teaching this was attributed to a broadening of horizons; contact with enthusiastic students; increased time with patients; improved clinical practice; improved teaching skills; and an improved image of the practice. Problems with teaching were due to external factors such as lack of time and space and anxieties about adequacy of clinical cover while teaching. Conclusions Teaching clinical skills can have a positive effect on the morale of general practitioner teachers as a result of contact with students and peers, as long as logistic and funding issues are adequately dealt with. Key messagesThe increase in community based teaching of clinical skills requires an increase in the number of general practitioner teachersLittle evidence is available about the effect of teaching of clinical skills and teacher training on general practitioner teachers and practicesGeneral practitioner teachers reported an increase in morale, improvements in clinical skills, and changes in clinical practice and in practice infrastructure as a result of teaching and trainingGeneral practitioner teachers reported problems because of pressure on time, lack of space, problems recruiting patients, and unsupportive practice partnersPositive effects on morale and clinical practice may be important for sustainable teaching and continuing medical education PMID:10541508

Evaluation of nurse engagement in evidence-based practice.

PubMed

Davidson, Judy E; Brown, Caroline

2014-01-01

The purpose of this project was to explore nurses' willingness to question and change practice. Nurses were invited to report practice improvement opportunities, and participants were supported through the process of a practice change. The project leader engaged to the extent desired by the participant. Meetings proceeded until the participant no longer wished to continue, progress was blocked, or practice was changed. Evaluation of the evidence-based practice change process occurred. Fifteen nurses reported 23 practice improvement opportunities. The majority (12 of 15) preferred to have the project leader review the evidence. Fourteen projects changed practice; 4 were presented at conferences. Multiple barriers were identified throughout the process and included loss of momentum, the proposed change involved other disciplines, and low level or controversial evidence. Practice issues were linked to quality metrics, cost of care, patient satisfaction, regulatory compliance, and patient safety. Active engagement by nurse leaders was needed for a practice change to occur. Participants identified important problems previously unknown to hospital administrators. The majority of nurses preferred involvement in practice change based on clinical problem solving when supported by others to provide literature review and manage the process through committees. Recommendations include supporting a culture that encourages employees to report practice improvement opportunities and provide resources to assist in navigating the identified practice change.

How to Measure and Interpret Quality Improvement Data.

PubMed

McQuillan, Rory Francis; Silver, Samuel Adam; Harel, Ziv; Weizman, Adam; Thomas, Alison; Bell, Chaim; Chertow, Glenn M; Chan, Christopher T; Nesrallah, Gihad

2016-05-06

This article will demonstrate how to conduct a quality improvement project using the change idea generated in "How To Use Quality Improvement Tools in Clinical Practice: How To Diagnose Solutions to a Quality of Care Problem" by Dr. Ziv Harel and colleagues in this Moving Points feature. This change idea involves the introduction of a nurse educator into a CKD clinic with a goal of increasing rates of patients performing dialysis independently at home (home hemodialysis or peritoneal dialysis). Using this example, we will illustrate a Plan-Do-Study-Act (PDSA) cycle in action and highlight the principles of rapid cycle change methodology. We will then discuss the selection of outcome, process, and balancing measures, and the practicalities of collecting these data in the clinic environment. We will also introduce the PDSA worksheet as a practical way to oversee the progress of a quality improvement project. Finally, we will demonstrate how run charts are used to visually illustrate improvement in real time, and how this information can be used to validate achievement, respond appropriately to challenges the project may encounter, and prove the significance of results. This article aims to provide readers with a clear and practical framework upon which to trial their own ideas for quality improvement in the clinical setting. Copyright © 2016 by the American Society of Nephrology.

A cost-effective method to characterize variation in clinical practice.

PubMed

Chang, K; Sauereisen, S; Dlutowski, M; Veloski, J J; Nash, D B

1999-06-01

This study's objective was to measure variation in physicians' practice styles and policies. Family physicians and general internists were surveyed about evidence-based medicine in the areas of asthma, congestive heart failure, and diabetes mellitus. They were asked about clinical recommendations where standards of practice were uncertain, controversial, or changing in response to published guidelines. Also included were items dealing with managed care. Although there was wide variation in responses to 20 of 36 items, some responses were consistent with practice guidelines. Responses to several items indicated a tendency to overuse expensive tests. Overall, the results indicate that a brief, open-ended survey can assess practice variation quickly and economically, as contrasted with more expensive analyses of medical records or claims data. With proper validation such assessments can be used as baselines to guide interventions, as well as measures of the outcomes of these interventions to change practice styles.

Implementation Science Supports Core Clinical Competencies: An Overview and Clinical Example.

PubMed

Kirchner, JoAnn E; Woodward, Eva N; Smith, Jeffrey L; Curran, Geoffrey M; Kilbourne, Amy M; Owen, Richard R; Bauer, Mark S

2016-12-08

Instead of asking clinicians to work faster or longer to improve quality of care, implementation science provides another option. Implementation science is an emerging interdisciplinary field dedicated to studying how evidence-based practice can be adopted into routine clinical care. This article summarizes principles and methods of implementation science, illustrates how they can be applied in a routine clinical setting, and highlights their importance to practicing clinicians as well as clinical trainees. A hypothetical clinical case scenario is presented that explains how implementation science improves clinical practice. The case scenario is also embedded within a real-world implementation study to improve metabolic monitoring for individuals prescribed antipsychotics. Context, recipient, and innovation (ie, the evidence-based practice) factors affected improvement of metabolic monitoring. To address these factors, an external facilitator and a local quality improvement team developed an implementation plan involving a multicomponent implementation strategy that included education, performance reports, and clinician follow-up. The clinic remained compliant with recommended metabolic monitoring at 1-year follow up. Implementation science improves clinical practice by addressing context, recipient, and innovation factors and uses this information to develop and utilize specific strategies that improve clinical practice. It also enriches clinical training, aligning with core competencies by the Accreditation Council for Graduate Medical Education and American Boards of Medical Specialties. By learning how to change clinical practice through implementation strategies, clinicians are more able to adapt in complex systems of practice. © Copyright 2016 Physicians Postgraduate Press, Inc.

Disparate Inclusion of Older Adults in Clinical Trials: Priorities and Opportunities for Policy and Practice Change

PubMed Central

Snipes, Shedra Amy; King, Denae W.; Torres-Vigil, Isabel; Goldberg, Daniel S.; Weinberg, Armin D.

2010-01-01

Older adults are vastly underrepresented in clinical trials in spite of shouldering a disproportionate burden of disease and consumption of prescription drugs and therapies, restricting treatments' generalizability, efficacy, and safety. Eliminating Disparities in Clinical Trials, a national initiative comprising a stakeholder network of researchers, community advocates, policymakers, and federal representatives, undertook a critical analysis of older adults' structural barriers to clinical trial participation. We present practice and policy change recommendations emerging from this process and their rationale, which spanned multiple themes: (1) decision making with cognitively impaired patients; (2) pharmacokinetic differences and physiological age; (3) health literacy, communication, and aging; (4) geriatric training; (5) federal monitoring and accountability; (6) clinical trial costs; and (7) cumulative effects of aging and ethnicity. PMID:20147682

Effects of a change in entry-to-practice criteria for cardiovascular perfusion in Canada: results of a national survey.

PubMed

Belway, Dean; Tran, Diem T T; Rubens, Fraser D

2017-05-01

Years of experience and level of education are two important determinants of a clinician's expertise. While entry-to-practice criteria for admission to perfusion training in Canada changed from clinical experience-based criteria to education-based criteria in 2006, the effects of these changes have not been studied. To determine the academic and clinical backgrounds of perfusionists in Canada, ascertain perceptions about the adequacy of training and evaluate the effects of the changes on the composition of the perfusion community of Canada. An electronic questionnaire was distributed to all practicing perfusionists in Canada, addressing details regarding clinical experience, academic education and perceptions about the adequacy of training. Two hundred and twenty-eight questionnaires were completed, representing a 72% response rate. Perfusionists admitted under academic-based criteria have significantly higher levels of education (100% degree holders vs 69.1%, p<0.001), but less antecedent clinical training and experience (median, IQR: 0, 0 - 4.5 years vs 2, 2 - 8 years, p<0.0001), are younger (median age range 31-35 years vs 51-55 years, p<0.0001), more likely to be female (58.7% vs 41.3%, p=0.006) and are significantly more likely to enter perfusion because of attraction to the type of work (p=0.045). Many perfusionists (70, 32%) in Canada believe themselves inadequately trained for their clinical assignments outside the OR. In addition, 19% of perfusionists plan to retire over the next 10 years. The introduction of education-based entry criteria has changed the academic and clinical experience levels of perfusionists in Canada. Strategies designed to better prepare perfusionists for their clinical assignments outside the OR are merited.

The utah beacon experience: integrating quality improvement, health information technology, and practice facilitation to improve diabetes outcomes in small health care facilities.

PubMed

Tennison, Janet; Rajeev, Deepthi; Woolsey, Sarah; Black, Jeff; Oostema, Steven J; North, Christie

2014-01-01

The Utah Improving Care through Connectivity and Collaboration (IC3) Beacon community (2010-2013) was spearheaded by HealthInsight, a nonprofit, community-based organization. One of the main objectives of IC(3) was to improve health care provided to patients with diabetes in three Utah counties, collaborating with 21 independent smaller clinics and two large health care enterprises. This paper will focus on the use of health information technology (HIT) and practice facilitation to develop and implement new care processes to improve clinic workflow and ultimately improve patients' diabetes outcomes at 21 participating smaller, independent clinics. Early in the project, we learned that most of the 21 clinics did not have the resources needed to successfully implement quality improvement (QI) initiatives. IC(3) helped clinics effectively use data generated from their electronic health records (EHRs) to design and implement interventions to improve patients' diabetes outcomes. This close coupling of HIT, expert practice facilitation, and Learning Collaboratives was found to be especially valuable in clinics with limited resources. Through this process we learned that (1) an extensive readiness assessment improved clinic retention, (2) clinic champions were important for a successful collaboration, and (3) current EHR systems have limited functionality to assist in QI initiatives. In general, smaller, independent clinics lack knowledge and experience with QI and have limited HIT experience to improve patient care using electronic clinical data. Additionally, future projects like IC(3) Beacon will be instrumental in changing clinic culture so that QI is integrated into routine workflow. Our efforts led to significant changes in how practice staff optimized their EHRs to manage and improve diabetes care, while establishing the framework for sustainability. Some of the IC(3) Beacon practices are currently smoothly transitioning to new models of care such as Patient-Centered Medical Homes. Thus, IC(3) Beacon has been instrumental in creating a strong community partnership among various organizations to meet the shared vision of better health and lower costs, and the experience over the last few years has helped the community prepare for the changing health care landscape.

The Utah Beacon Experience: Integrating Quality Improvement, Health Information Technology, and Practice Facilitation to Improve Diabetes Outcomes in Small Health Care Facilities

PubMed Central

Tennison, Janet; Rajeev, Deepthi; Woolsey, Sarah; Black, Jeff; Oostema, Steven J.; North, Christie

2014-01-01

Purpose: The Utah Improving Care through Connectivity and Collaboration (IC3) Beacon community (2010–2013) was spearheaded by HealthInsight, a nonprofit, community-based organization. One of the main objectives of IC3 was to improve health care provided to patients with diabetes in three Utah counties, collaborating with 21 independent smaller clinics and two large health care enterprises. This paper will focus on the use of health information technology (HIT) and practice facilitation to develop and implement new care processes to improve clinic workflow and ultimately improve patients’ diabetes outcomes at 21 participating smaller, independent clinics. Innovation: Early in the project, we learned that most of the 21 clinics did not have the resources needed to successfully implement quality improvement (QI) initiatives. IC3 helped clinics effectively use data generated from their electronic health records (EHRs) to design and implement interventions to improve patients’ diabetes outcomes. This close coupling of HIT, expert practice facilitation, and Learning Collaboratives was found to be especially valuable in clinics with limited resources. Findings: Through this process we learned that (1) an extensive readiness assessment improved clinic retention, (2) clinic champions were important for a successful collaboration, and (3) current EHR systems have limited functionality to assist in QI initiatives. In general, smaller, independent clinics lack knowledge and experience with QI and have limited HIT experience to improve patient care using electronic clinical data. Additionally, future projects like IC3 Beacon will be instrumental in changing clinic culture so that QI is integrated into routine workflow. Conclusion and Discussion: Our efforts led to significant changes in how practice staff optimized their EHRs to manage and improve diabetes care, while establishing the framework for sustainability. Some of the IC3 Beacon practices are currently smoothly transitioning to new models of care such as Patient-Centered Medical Homes. Thus, IC3 Beacon has been instrumental in creating a strong community partnership among various organizations to meet the shared vision of better health and lower costs, and the experience over the last few years has helped the community prepare for the changing health care landscape. PMID:25848624

Appreciative Inquiry for quality improvement in primary care practices.

PubMed

Ruhe, Mary C; Bobiak, Sarah N; Litaker, David; Carter, Caroline A; Wu, Laura; Schroeder, Casey; Zyzanski, Stephen J; Weyer, Sharon M; Werner, James J; Fry, Ronald E; Stange, Kurt C

2011-01-01

To test the effect of an Appreciative Inquiry (AI) quality improvement strategy on clinical quality management and practice development outcomes. Appreciative inquiry enables the discovery of shared motivations, envisioning a transformed future, and learning around the implementation of a change process. Thirty diverse primary care practices were randomly assigned to receive an AI-based intervention focused on a practice-chosen topic and on improving preventive service delivery (PSD) rates. Medical-record review assessed change in PSD rates. Ethnographic field notes and observational checklist analysis used editing and immersion/crystallization methods to identify factors affecting intervention implementation and practice development outcomes. The PSD rates did not change. Field note analysis suggested that the intervention elicited core motivations, facilitated development of a shared vision, defined change objectives, and fostered respectful interactions. Practices most likely to implement the intervention or develop new practice capacities exhibited 1 or more of the following: support from key leader(s), a sense of urgency for change, a mission focused on serving patients, health care system and practice flexibility, and a history of constructive practice change. An AI approach and enabling practice conditions can lead to intervention implementation and practice development by connecting individual and practice strengths and motivations to the change objective.

Appreciative Inquiry for Quality Improvement in Primary Care Practices

PubMed Central

Ruhe, Mary C.; Bobiak, Sarah N.; Litaker, David; Carter, Caroline A.; Wu, Laura; Schroeder, Casey; Zyzanski, Stephen; Weyer, Sharon M.; Werner, James J.; Fry, Ronald E.; Stange, Kurt C.

2014-01-01

Purpose To test the effect of an Appreciative Inquiry (AI) quality improvement strategy, on clinical quality management and practice development outcomes. AI enables discovery of shared motivations, envisioning a transformed future, and learning around implementation of a change process. Methods Thirty diverse primary care practices were randomly assigned to receive an AI-based intervention focused on a practice-chosen topic and on improving preventive service delivery (PSD) rates. Medical record review assessed change in PSD rates. Ethnographic fieldnotes and observational checklist analysis used editing and immersion/crystallization methods to identify factors affecting intervention implementation and practice development outcomes. Results PSD rates did not change. Field note analysis suggested that the intervention elicited core motivations, facilitated development of a shared vision, defined change objectives and fostered respectful interactions. Practices most likely to implement the intervention or develop new practice capacities exhibited one or more of the following: support from key leader(s), a sense of urgency for change, a mission focused on serving patients, health care system and practice flexibility, and a history of constructive practice change. Conclusions An AI approach and enabling practice conditions can lead to intervention implementation and practice development by connecting individual and practice strengths and motivations to the change objective. PMID:21192206

Does social marketing provide a framework for changing healthcare practice?

PubMed

Morris, Zoë Slote; Clarkson, Peter John

2009-07-01

We argue that social marketing can be used as a generic framework for analysing barriers to the take-up of clinical guidelines, and planning interventions which seek to enable this change. We reviewed the literature on take-up of clinical guidelines, in particular barriers and enablers to change; social marketing principles and social marketing applied to healthcare. We then applied the social marketing framework to analyse the literature and to consider implications for future guideline policy to assess its feasibility and accessibility. There is sizeable extant literature on healthcare practitioners' non-compliance with clinical guidelines. This is an international problem common to a number of settings. The reasons for poor levels of take up appear to be well understood, but not addressed adequately in practice. Applying a social marketing framework brings new insights to the problem." We show that a social marketing framework provides a useful solution-focused framework for systematically understanding barriers to individual behaviour change and designing interventions accordingly. Whether the social marketing framework provides an effective means of bringing about behaviour change remains an empirical question which has still to be tested in practice. The analysis presented here provides strong motivation to begin such testing.

Using Concept Maps with Simulation: Learning Experiences of Associate Degree in Nursing Students

ERIC Educational Resources Information Center

O'Halloran, Bernadette D.

2017-01-01

Graduate nurses have experienced a difficult transition to clinical practice. With the continuing gap in educational preparation and clinical nursing practice leading to errors in health care delivery, the nurse faculty remains challenged in performing innovative changes to the curriculum to improve and maintain quality and safe patient care. The…

Speech-language pathologists and the Common Core Standards initiative: an opportunity for leadership and organizational change.

PubMed

Dunkle, Jennifer; Flynn, Perry

2012-05-01

The Common Core State Standards initiative within public school education is designed to provide uniform guidelines for academic standards, including more explicit language targets. Speech-language pathologists (SLPs) are highly qualified language experts who may find new leadership roles within their clinical practice using the Common Core Standards. However, determining its usage by SLPs in clinical practice needs to be examined. This article seeks to discover the social context of organizations and organizational change in relation to clinical practice. Specifically, this article presents the diffusion of innovations theory to explain how initiatives move from ideas to institutionalization and the importance of social context in which these initiatives are introduced. Next, the values of both SLPs and organizations will be discussed. Finally, this article provides information on how to affect organizational change through the value of an affirmative, socially based theoretical perspective and methodology, appreciative inquiry. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Learning From a Lifetime of Leading Effective Change

PubMed Central

Johnson, Claire; Clum, Gerard; Lassiter, Wright L.; Phillips, Reed; Sportelli, Louis; Hunter, James C.

2014-01-01

Objective The purpose of this article is to report on the opening plenary session of the Association of Chiropractic Colleges Educational Conference—Research Agenda Conference (ACC-RAC) 2014, “Aiming for Effective Change: Leadership in Chiropractic Education, Research and Clinical Practice.” Discussion Speakers with extensive backgrounds with implementing substantial change on a broad level shared personal examples from their experiences in education, research, political organizations, and clinical practice. They described efforts, challenges, and opportunities that are encountered in order to implement effective change and shared their personal thoughts on leadership. Conclusion Each of the speakers shared their diverse, unique insights and personal experiences to convey the process and meaning of leadership. PMID:25431543

[Evidence based medicine. A new paradigm for medical practice].

PubMed

Carneiro, A V

1998-01-01

Modern medical practice is an ever-changing process, and the doctor's need for information has been partially met by continuous medical education (CME) activities. It has been shown that CME activities have not prevented clinical knowledge, as well as medical practice, from deteriorating with time. When faced with the need to get the most recent and relevant information possible, the busy clinician has two major problems: most of the published medical literature is either irrelevant or not useful; and there is little time to read it. Evidence-based medicine constitutes a new paradigm for medical practice in the sense that it tries to transform clinical problems into well formulated clinical questions, selecting and critically appraising scientific evidence with predefined and rigorous rules. It combines the expertise of the individual clinician with the best external evidence from clinical research for rational, ethical and efficacious practice. Evidence-based medicine can be taught and practiced by physicians with different degrees of autonomy, with several subspecialties, working in the hospital or in outpatient clinics, alone or in groups.

Dimensions of the transition service coordinator role.

PubMed

Betz, Cecily L; Redcay, Gay

2005-01-01

This article describes the development and implementation of an innovative advanced practice role, as a transition service coordinator for nurses who work with adolescents with special healthcare needs. Transition services for adolescents with special healthcare needs is an area of growing clinical need requiring that all healthcare professionals, including advanced practice nurses develop new clinical knowledge and skills to practice effectively. This emerging specialty area will require advanced practice nurses to provide direct services blending both pediatric and adult healthcare needs and to function in advanced practice roles such as case managers who can ensure the coordination of services between these two very different systems of care while promoting the youth's acquisition of goals for adulthood. This nursing role was first created to provide and coordinate transition services to youth seen in a piloted clinic titled Creating Healthy Futures. This article describes the various components of this nursing role that incorporated the advanced practice dimensions of clinical expert, consultant, change agent, leader, researcher, and educator that can be replicated in other clinical settings.

Clarity and strength of implications for practice in medical journal articles: an exploratory analysis

PubMed Central

Owens, Allessia P; Bartunek, Jean M

2011-01-01

Objective To examine how leading clinical journals report research findings, aiming to assess how they frame their implications for medical practice and to compare that literature's patterns with those of the management literature. Data Source Clinically relevant research articles from three leading clinical journals (N Engl J Med, JAMA, and Ann Intern Med). Methods Review of wording of a sequential sample from 2010, with categorisation, comparison among journals, and comparison with management literature. Results Clinical journals usually state that one approach did or did not differ from another approach (35 of 51 articles, 68.6%), but they recommended a specific course of action (‘therefore, x should be done’) in just 25.5%. One article gave instruction on how to implement the changes. Two-thirds of the reports called for further research. Half used tentative language. Management research articles nearly always specified who should use the information and drew from over 60 types of potential users, whereas the clinical literature named the audience in only 23.5% of clinicians. Conclusions Authors and editors of the clinical literature could test being more clear and direct in presenting implications of research findings for practice, including stating when the findings do not justify changes in practice. PMID:21450773

Implementation science: a role for parallel dual processing models of reasoning?

PubMed Central

Sladek, Ruth M; Phillips, Paddy A; Bond, Malcolm J

2006-01-01

Background A better theoretical base for understanding professional behaviour change is needed to support evidence-based changes in medical practice. Traditionally strategies to encourage changes in clinical practices have been guided empirically, without explicit consideration of underlying theoretical rationales for such strategies. This paper considers a theoretical framework for reasoning from within psychology for identifying individual differences in cognitive processing between doctors that could moderate the decision to incorporate new evidence into their clinical decision-making. Discussion Parallel dual processing models of reasoning posit two cognitive modes of information processing that are in constant operation as humans reason. One mode has been described as experiential, fast and heuristic; the other as rational, conscious and rule based. Within such models, the uptake of new research evidence can be represented by the latter mode; it is reflective, explicit and intentional. On the other hand, well practiced clinical judgments can be positioned in the experiential mode, being automatic, reflexive and swift. Research suggests that individual differences between people in both cognitive capacity (e.g., intelligence) and cognitive processing (e.g., thinking styles) influence how both reasoning modes interact. This being so, it is proposed that these same differences between doctors may moderate the uptake of new research evidence. Such dispositional characteristics have largely been ignored in research investigating effective strategies in implementing research evidence. Whilst medical decision-making occurs in a complex social environment with multiple influences and decision makers, it remains true that an individual doctor's judgment still retains a key position in terms of diagnostic and treatment decisions for individual patients. This paper argues therefore, that individual differences between doctors in terms of reasoning are important considerations in any discussion relating to changing clinical practice. Summary It is imperative that change strategies in healthcare consider relevant theoretical frameworks from other disciplines such as psychology. Generic dual processing models of reasoning are proposed as potentially useful in identifying factors within doctors that may moderate their individual uptake of evidence into clinical decision-making. Such factors can then inform strategies to change practice. PMID:16725023

Implementation science: a role for parallel dual processing models of reasoning?

PubMed

Sladek, Ruth M; Phillips, Paddy A; Bond, Malcolm J

2006-05-25

A better theoretical base for understanding professional behaviour change is needed to support evidence-based changes in medical practice. Traditionally strategies to encourage changes in clinical practices have been guided empirically, without explicit consideration of underlying theoretical rationales for such strategies. This paper considers a theoretical framework for reasoning from within psychology for identifying individual differences in cognitive processing between doctors that could moderate the decision to incorporate new evidence into their clinical decision-making. Parallel dual processing models of reasoning posit two cognitive modes of information processing that are in constant operation as humans reason. One mode has been described as experiential, fast and heuristic; the other as rational, conscious and rule based. Within such models, the uptake of new research evidence can be represented by the latter mode; it is reflective, explicit and intentional. On the other hand, well practiced clinical judgments can be positioned in the experiential mode, being automatic, reflexive and swift. Research suggests that individual differences between people in both cognitive capacity (e.g., intelligence) and cognitive processing (e.g., thinking styles) influence how both reasoning modes interact. This being so, it is proposed that these same differences between doctors may moderate the uptake of new research evidence. Such dispositional characteristics have largely been ignored in research investigating effective strategies in implementing research evidence. Whilst medical decision-making occurs in a complex social environment with multiple influences and decision makers, it remains true that an individual doctor's judgment still retains a key position in terms of diagnostic and treatment decisions for individual patients. This paper argues therefore, that individual differences between doctors in terms of reasoning are important considerations in any discussion relating to changing clinical practice. It is imperative that change strategies in healthcare consider relevant theoretical frameworks from other disciplines such as psychology. Generic dual processing models of reasoning are proposed as potentially useful in identifying factors within doctors that may moderate their individual uptake of evidence into clinical decision-making. Such factors can then inform strategies to change practice.

Clinical trial design in the neurocritical care unit.

PubMed

Hall, C E; Mirski, M; Palesch, Y Y; Diringer, M N; Qureshi, A I; Robertson, C S; Geocadin, R; Wijman, C A C; Le Roux, P D; Suarez, Jose I

2012-02-01

Clinical trials provide a robust mechanism to advance science and change clinical practice across the widest possible spectrum. Fundamental in the Neurocritical Care Society's mission is to promote Quality Patient Care by identifying and implementing best medical practices for acute neurological disorders that are consistent with the current scientific knowledge. The next logical step will be to foster rapid growth of our scientific body of evidence, to establish and disseminate these best practices. In this manuscript, five invited experts were impaneled to address questions, identified by the conference organizing committee as fundamental issues for the design of clinical trials in the neurological intensive care unit setting.

Spectators & spectacles: nurses, midwives and visuality.

PubMed

Barnard, Alan G; Sinclair, Marlene

2006-09-01

In this paper we reflect on how linear perspective vision influences the practice of nurses and midwives and to advance understanding of clinical practice in technologically intensive environments through examination of drawings by nurses and midwives and through critical analysis. There is increasing emphasis on vision in Western culture, and both nurses and midwives spend a great deal of time observing their clinical environment(s). Healthcare practitioners work increasingly in image-based realities and nurses rely on visual skills. Vision and visual representation are central to our practice and are important to examine because we look often at technology to assess people and care. The world in which we practise is one of meaning(s). Technological development is transformative in nature and produces changes that alter the way(s) we give care. Amongst all this change, it is unclear how we practise in environments characterized by increasing technology and it is unknown how nursing and midwifery practice alter as a result. Simple drawings included in this paper highlight an important and shared experience of clinical practice(s). They emphasize the importance and scope of the visual sense and expose practitioner behaviour that has enormous implications for current and future professional development and person-focussed care provision. Experiences described in this paper require further examination and highlight substantial changes to nurse-patient relationships, health care and the way we practise.

[Impact of digital technology on clinical practices: perspectives from surgery].

PubMed

Zhang, Y; Liu, X J

2016-04-09

Digital medical technologies or computer aided medical procedures, refer to imaging, 3D reconstruction, virtual design, 3D printing, navigation guided surgery and robotic assisted surgery techniques. These techniques are integrated into conventional surgical procedures to create new clinical protocols that are known as "digital surgical techniques". Conventional health care is characterized by subjective experiences, while digital medical technologies bring quantifiable information, transferable data, repeatable methods and predictable outcomes into clinical practices. Being integrated into clinical practice, digital techniques facilitate surgical care by improving outcomes and reducing risks. Digital techniques are becoming increasingly popular in trauma surgery, orthopedics, neurosurgery, plastic and reconstructive surgery, imaging and anatomic sciences. Robotic assisted surgery is also evolving and being applied in general surgery, cardiovascular surgery and orthopedic surgery. Rapid development of digital medical technologies is changing healthcare and clinical practices. It is therefore important for all clinicians to purposefully adapt to these technologies and improve their clinical outcomes.

Cross-sectional study to examine evidence-based practice skills and behaviors of physical therapy graduates: is there a knowledge-to-practice gap?

PubMed

Manns, Patricia J; Norton, Amy V; Darrah, Johanna

2015-04-01

Curricula changes in physical therapist education programs in Canada emphasize evidence-based practice skills, including literature retrieval and evaluation. Do graduates use these skills in practice? The aim of this study was to evaluate the use of research information in the clinical decision making of therapists with different years of experience and evidence-based practice preparation. Perceptions about evidence-based practice were explored qualitatively. A cross-sectional study with 4 graduating cohorts was conducted. Eighty physical therapists representing 4 different graduating cohorts participated in interviews focused on 2 clinical scenarios. Participants had varying years of clinical experience (range=1-15 years) and academic knowledge of evidence-based practice skills. Therapists discussed the effectiveness of interventions related to the scenarios and identified the sources of information used to reach decisions. Participants also answered general questions related to evidence-based practice knowledge. Recent graduates demonstrated better knowledge of evidence-based practice skills compared with therapists with 6 to 15 years of clinical experience. However, all groups used clinical experience most frequently as their source of information for clinical decisions. Research evidence was infrequently included in decision making. This study used a convenience sample of therapists who agreed to volunteer for the study. The results suggest a knowledge-to-practice gap; graduates are not using the new skills to inform their practice. Tailoring academic evidence-based activities more to the time constraints of clinical practice may help students to be more successful in applying evidence in practice. Academic programs need to do more to create and nurture environments in both academic and clinical settings to ensure students practice using evidence-based practice skills across settings. © 2015 American Physical Therapy Association.

Prevention of DNA contamination during forensic medical examinations in a clinical forensic medical service: A best practice implementation project.

PubMed

Lutz, Tasha

2015-01-01

Contamination of forensic specimens can have significant and detrimental effects on cases presented in court. In 2010 a wrongful conviction in Australia resulted in an inquiry with 25 recommendations to minimize the risk of DNA contamination of forensic specimens. DNA decontamination practices in a clinical forensic medical service currently attempt to comply with these recommendations. Evaluation of these practices has not been undertaken. The aim of this project was to audit the current DNA decontamination practices of forensic medical and nursing examiners in the forensic medical examination process and implement changes based on the audit findings. A re-audit following implementation would be undertaken to identify change and inform further research. The Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice were used as the audit tool in this project. A baseline audit was conducted; analysis of this audit process was then undertaken. Following education and awareness training targeted at clinicians, a re-audit was completed. There were a total of 24 audit criteria; the baseline audit reflected 20 of these criteria had 100% compliance. The remaining 4 audit criteria demonstrated compliance between 65% and 90%. Education and awareness training resulted in improved compliance in 2 of the 4 audit criteria, with the remaining 2 having unchanged compliance. The findings demonstrated that education and raising awareness can improve clinical practice; however there are also external factors outside the control of the clinicians that influence compliance with best practice.

Implementation of an Electronic Health Records System in a Small Clinic: The Viewpoint of Clinic Staff

ERIC Educational Resources Information Center

Carayon, Pascale; Smith, Paul; Hundt, Ann Schoofs; Kuruchittham, Vipat; Li, Qian

2009-01-01

In this study, we examined the implementation of an electronic health records (EHR) system in a small family practice clinic. We used three data collection instruments to evaluate user experience, work pattern changes, and organisational changes related to the implementation and use of the EHR system: (1) an EHR user survey, (2) interviews with…

[Clinical research evolution. In parallel with the current changes in welfare expectations and information technology incorporation, study designs and data collection and analysis are quickly changing as well].

PubMed

Tavazzi, Luigi

2015-10-01

The development of both technology, biological, and clinical knowledge leads to remarkable changes of scientific research methodology, including the clinical research. Major changes deal with the pragmatic approach of trial designs, an explosive diffusion of observational research which is becoming a usual component of clinical practice, and an active modelling of new research design. Moreover, a new healthcare landscape could be generated from the information technology routinely used to collect clinical data in huge databases, the management and the analytic methodology of big data, and the development of biological sensors compatible with the daily life delivering signals remotely forwardable to central databases. Precision medicine and individualized medicine seem to be the big novelties of the coming years, guiding to a shared pattern of patient/physician relationship. In healthcare, a huge business related mainly, but not exclusively, to the implementation of information technology is growing. This development will favor radical changes in the health systems, also reshaping the clinical activity. A new governance of the research strategies is needed and the application of the results should be based on shared ethical foundations. This new evolving profile of medical research and practice is discussed in this paper.

Implementing practice change in chronic cancer pain management: clinician response to a phase III study of ketamine.

PubMed

Hardy, J R; Spruyt, O; Quinn, S J; Devilee, L R; Currow, D C

2014-06-01

An adequately powered, double-blind, multisite, randomised controlled trial has shown no net clinical benefit for subcutaneous ketamine over placebo in the management of cancer pain refractory to combination opioid and co-analgesic therapy. The results of the trial were disseminated widely both nationally and internationally. To determine whether the trial had impacted on clinical practice in Australasia. Members of the Australia and New Zealand Society of Palliative Medicine were sent an online ketamine utilisation survey. A total of 123/392 clinicians responded (31% response rate). The majority of respondents had practised for more than 10 years in a metropolitan hospital setting. Ketamine had been prescribed by 91% of respondents, and 92% were aware of the trial. As a result, 65% of respondents had changed practice (17% no longer prescribed ketamine, 46% used less and 2% more). Thirty-five per cent had not changed practice. Reasons for change included belief in the results of the study, concerns over the toxicity reported or because there were alternatives for pain control. Of those who prescribed less, over 80% were more selective and would now only use the drug in certain clinical situations or pain types, or when all other medications had failed. Although two-thirds of respondents reported practice change as a result of the randomised controlled trial, a minority remained convinced of the benefit of the drug from their own observations and would require additional evidence. © 2014 The Authors; Internal Medicine Journal © 2014 Royal Australasian College of Physicians.

Evaluation of economic efficiencies in clinical retina practice: activity-based cost analysis and modeling to determine impacts of changes in patient management

PubMed Central

Murray, Timothy G; Tornambe, Paul; Dugel, Pravin; Tong, Kuo Bianchini

2011-01-01

Background The purpose of this study is to report the use of activity-based cost analysis to identify areas of practice efficiencies and inefficiencies within a large academic retinal center and a small single-specialty group. This analysis establishes a framework for evaluating rapidly shifting clinical practices (anti-vascular endothelial growth factor therapy, microincisional vitrectomy surgery) and incorporating changing reimbursements for care delivery (intravitreal injections, optical coherence tomography [OCT]) to determine the impact on practice profitability. Pro forma modeling targeted the impact of declining reimbursement for OCT imaging and intravitreal injection using a strategy that incorporates activity-based cost analysis into a direct evaluation schema for clinical operations management. Methods Activity-based costing analyses were performed at two different types of retinal practices in the US, ie, a small single-specialty group practice and an academic hospital-based practice (Bascom Palmer Eye Institute). Retrospective claims data were utilized to identify all procedures performed and billed, submitted charges, allowed charges, and net collections from each of these two practices for the calendar years 2005–2006 and 2007–2008. A pro forma analysis utilizing current reimbursement profiles was performed to determine the impact of altered reimbursement on practice profitability. All analyses were performed by a third party consulting firm. Results The small single-specialty group practice outperformed the academic hospital-based practice on almost all markers of efficiency. In the academic hospital-based practice, only four service lines were profitable, ie, nonlaser surgery, laser surgery, non-OCT diagnostics, and injections. Profit margin varied from 62% for nonlaser surgery to 1% for intravitreal injections. Largest negative profit contributions were associated with office visits and OCT imaging. Conclusion Activity-based cost analysis is a powerful tool to evaluate retinal practice efficiencies. These two distinct practices were able to provide significant increases in clinical care (office visits, ophthalmic imaging, and patient procedures) through maintaining efficiencies of care. Pro forma analysis of 2011 data noted that OCT payments to facilities and physicians continue to decrease dramatically and that this payment decrease further reduced the profitability for the two largest aspects of these retinal practices, ie, intravitreal injections and OCT retinal imaging. Ultimately, all retinal practices are at risk for significant shifts in financial health related to rapidly evolving changes in patterns of care and reimbursement associated with providing outstanding clinical care. PMID:21792278

A survey of audit activity in general practice.

PubMed Central

Hearnshaw, H; Baker, R; Cooper, A

1998-01-01

BACKGROUND: Since 1991, all general practices have been encouraged to undertake clinical audit. Audit groups report that participation is high, and some local surveys have been undertaken, but no detailed national survey has been reported. AIM: To determine audit activities in general practices and the perceptions of general practitioners (GPs) regarding the future of clinical audit in primary care. METHOD: A questionnaire on audit activities was sent to 707 practices from 18 medical audit advisory group areas. The audit groups had been ranked by annual funding from 1992 to 1995. Six groups were selected at random from the top, middle, and lowest thirds of this rank order. RESULTS: A total of 428 (60.5%) usable responses were received. Overall, 346 (85%) responders reported 125.7 audits from the previous year with a median of three audits per practice. There was no correlation between the number of audits reported and the funding per GP for the medical audit advisory group. Of 997 audits described in detail, changes were reported as 'not needed' in 220 (22%), 'not made' in 142 (14%), 'made' in 439 (44%), and 'made and remeasured' in 196 (20%). Thus, 635 (64%) audits were reported to have led to changes. Some 853 (81%) of the topics identified were on clinical care. Responders made 242 (42%) positive comments on the future of clinical audit in primary care, and 152 (26%) negative views were recorded. CONCLUSION: The level of audit activity in general practice is reasonably high, and most of the audits result in change. The number of audits per practice seems to be independent of the level of funding that the medical audit advisory group has received. Although there is room for improvement in the levels of effective audit activity in general practice, continued support by the professionally led audit groups could enable all practices to undertake effective audit that leads to improvement in patient care. PMID:9624769

A prospective survey of chiropractic student experiences with pediatric care and variability of case mix while on clinical placement in Rarotonga.

PubMed

Todd, Angela J; Carroll, Matthew T; Russell, David G; Mitchell, Eleanor K L

2017-03-01

To compare chiropractic students' perceptions of preparedness for practice before and after a clinical placement in Rarotonga and to report demographics from these experiences. The students completed deidentified pre- and postplacement surveys assessing pediatric practice preparedness. Students tallied the patient numbers, age, and chiropractic techniques used per visit for each day of clinic placement. On completion of the program, participating students (27/34, or 79% of the student cohort) did a postplacement survey on their perception of practice preparedness. Data were analyzed with the Spearman rho correlation, the Mann-Whitney U test, and regression analysis. There was an increase in perceived preparedness for pediatric practice, ranging from 24.1% of the student cohort at the start of the study to 82.1% following clinical placement in Rarotonga. The change in student preparedness to practice with children was positively correlated with the total number of children managed (r s = .05, p = .01) and the number of children managed who were under 10 years of age (r s = .60, p = .001). Multiple regression analysis demonstrated a medium positive effect for postprogram preparedness (F [4, 20] = 3.567, p = .024). Clinical outreach to Rarotonga provided a broad case mix of patients and a change in student perceptions of preparedness to practice with children, which was positively affected by the total number of children managed and the number of children managed who were under 10 years of age.

Educating change agents: a qualitative descriptive study of graduates of a Master's program in evidence-based practice.

PubMed

Hole, Grete Oline; Brenna, Sissel Johansson; Graverholt, Birgitte; Ciliska, Donna; Nortvedt, Monica Wammen

2016-02-25

Health care professionals are expected to build decisions upon evidence. This implies decisions based on the best available, current, valid and relevant evidence, informed by clinical expertise and patient values. A multi-professional master's program in evidence-based practice was developed and offered. The aims of this study were to explore how students in this program viewed their ability to apply evidence-based practice and their perceptions of what constitute necessary conditions to implement evidence-based practice in health care organizations, one year after graduation. A qualitative descriptive design was chosen to examine the graduates' experiences. All students in the first two cohorts of the program were invited to participate. Six focus-group interviews, with a total of 21 participants, and a telephone interview of one participant were conducted. The data was analyzed thematically, using the themes from the interview guide as the starting point. The graduates reported that an overall necessary condition for evidence-based practice to occur is the existence of a "readiness for change" both at an individual level and at the organizational level. They described that they gained personal knowledge and skills to be "change-agents" with "self-efficacy, "analytic competence" and "tools" to implement evidence based practice in clinical care. An organizational culture of a "learning organization" was also required, where leaders have an "awareness of evidence- based practice", and see the need for creating "evidence-based networks". One year after graduation the participants saw themselves as "change agents" prepared to improve clinical care within a learning organization. The results of this study provides useful information for facilitating the implementation of EBP both from educational and health care organizational perspectives.

Partnering with patients to promote holistic diabetes management: changing paradigms.

PubMed

Lorenzo, Lenora

2013-07-01

To provide a review of best practice for clinical management of diabetes mellitus (DM) for nurse practitioners (NPs) and accelerate incorporation of key findings into current practice. A search was conducted in Pub Med, Ovid, CINAHL, and Cochrane's Database of Systematic Reviews. There are many challenges for DM care identified in the current health system. There is a great need to change care paradigms to engage patients in partnership for enhanced management and self-management in DM. A review of the best practice evidence revealed numerous models of care, strategies, and tools available to enhance diabetes care and promote health and well-being. The primary focus of this article is to engage NP clinicians to incorporate new strategies to augment management and improve clinical outcomes. Incorporation of best practice for DM management may accelerate the paradigm shift to more patient-focused care. Engaged, informed, and activated patients along with clinicians working in partnerships may enhance clinical outcomes. ©2013 The Author ©2013 American Association of Nurse Practitioners.

Role of champions in the implementation of patient safety practice change.

PubMed

Soo, Stephanie; Berta, Whitney; Baker, G Ross

2009-01-01

Practitioners of patient safety practice change agree that champions are central to the success of implementation. The clinical champion role is a concept that has been widely promoted yet empirically underdeveloped in health services literature. Questions remain as to who these champions are, what roles they play in patient safety practice change and what contexts serve to facilitate their efforts. This investigation used a multiple-case study design to critically examine the role of champions in the implementation of rapid response teams (RRTs), an innovative complex patient safety intervention, in two large urban acute care facilities. An analysis of interviews with key individuals involved in the RRT implementation process revealed a typology of the patient safety practice champion that extended beyond clinical personnel to include managerial and executive staff. Champions engaged to a varying extent in a number of core activities, including education, advocacy, relationship building and boundary spanning. Individuals became champions both through informal emergence and a combination of formal appointment and informal emergence. By identifying and elaborating upon specific features of the champion role, this study aims to expand the dialogue about champions for patient safety practice change.

Fostering clinical engagement and medical leadership and aligning cultural values: an evaluation of a general practice specialty trainee integrated training placement in a primary care trust.

PubMed

Ruston, Annmarie; Tavabie, Abdol

2010-01-01

To report on the extent to which a general practice specialty trainee integrated training placement (ITP) developed the leadership skills and knowledge of general practice specialty trainees (GPSTRs) and on the potential of the ITP to improve clinical engagement. A case study method was used in a Kent primary care trust (PCT). Sources of data included face-to-face and telephone interviews (three GPSTRs, three PCT clinical supervisors, three general practitioner (GP) clinical supervisors and three Deanery/PCT managers), reflective diaries, documentary sources and observation. Interview data were transcribed and analysed using the constant comparative method. All respondents were positive about the value and success of the ITP in developing the leadership skills of the GPSTRs covering three dimensions: leadership of self, leadership of teams and leadership of organisations within systems. The ITP had enabled GP trainees to understand the context for change, to develop skills to set the direction for change and to collect and apply evidence to decision making. The ITP was described as an effective means of breaking down cultural barriers between general practice and the PCT and as having the potential for improving clinical engagement. The ITP provided a model to enable the effective exchange of knowledge and understanding of differing cultures between GPSTRs, general practice and the PCT. It provided a sound basis for effective, dispersed clinical engagement and leadership.

Promoting evidence-based practice: managing change in the assessment of pressure damage risk.

PubMed

Gerrish, K; Clayton, J; Nolan, M; Parker, K; Morgan, L

1999-11-01

This study set out to facilitate the development of evidence-based practice in the assessment of pressure damage risk to patients within a large acute hospital. The importance of nursing practice being based on the best available evidence is emphasized in recent health policy. Meeting this objective is not easy as both individual and organizational factors create barriers to the implementation of research findings and the achievement of change. The study was based on an action research model. It comprised three stages: a review of the research evidence; a survey of qualified nurses' knowledge of risk assessment of pressure damage and an audit of record keeping, and a multifaceted approach to achieving change in which researchers, managers, practitioners and clinical nurse specialists worked together collaboratively. The findings from the survey and audit indicated a shortfall in nurses' knowledge of risk assessment of pressure damage and in their record keeping. The researchers, with the help of the clinical nurse specialist, built upon these findings by assisting practitioners and managers to take ownership of the need to base practice on the appropriate evidence. Achieving evidence-based practice is a complex undertaking that requires the development of an evaluative culture and a commitment by practitioners and managers to change practice. Researchers can play a valuable role in facilitating this process.

Interprofessional communication supporting clinical handover in emergency departments: An observation study.

PubMed

Redley, Bernice; Botti, Mari; Wood, Beverley; Bucknall, Tracey

2017-08-01

Poor interprofessional communication poses a risk to patient safety at change-of-shift in emergency departments (EDs). The purpose of this study was to identify and describe patterns and processes of interprofessional communication impacting quality of ED change-of-shift handovers. Observation of 66 change-of-shift handovers at two acute hospital EDs in Victoria, Australia. Focus groups with 34 nurse participants complemented the observations. Qualitative data analysis involved content and thematic methods. Four structural components of ED handover processes emerged represented by (ABCD): (1) Antecedents; (2) Behaviours and interactions; (3) Content; and (4) Delegation of ongoing care. Infrequent and ad hoc interprofessional communication and discipline-specific handover content and processes emerged as specific risks to patient safety at change-of-shift handovers. Three themes related to risky and effective practices to support interprofessional communications across the four stages of ED handovers emerged: 1) standard processes and practices, 2) teamwork and interactions and 3) communication activities and practices. Unreliable interprofessional communication can impact the quality of change-of-shift handovers in EDs and poses risk to patient safety. Structured reflective analysis of existing practices can identify opportunities for standardisation, enhanced team practices and effective communication across four stages of the handover process to support clinicians to enhance local handover practices. Future research should test and refine models to support analysis of practice, and identify and test strategies to enhance ED interprofessional communication to support clinical handovers. Copyright © 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

Clinical balance assessment: perceptions of commonly-used standardized measures and current practices among physiotherapists in Ontario, Canada

PubMed Central

2013-01-01

Background Balance impairment is common in multiple clinical populations, and comprehensive assessment is important for identifying impairments, planning individualized treatment programs, and evaluating change over time. However, little information is available regarding whether clinicians who treat balance are satisfied with existing assessment tools. In 2010 we conducted a cross-sectional survey of balance assessment practices among physiotherapists in Ontario, Canada, and reported on the use of standardized balance measures (Sibley et al. 2011 Physical Therapy; 91: 1583-91). The purpose of this study was to analyse additional survey data and i) evaluate satisfaction with current balance assessment practices and standardized measures among physiotherapists who treat adult or geriatric populations with balance impairment, and ii) identify factors associated with satisfaction. Methods The questionnaire was distributed to 1000 practicing physiotherapists. This analysis focuses on questions in which respondents were asked to rate their general perceptions about balance assessment, the perceived utility of individual standardized balance measures, whether they wanted to improve balance assessment practices, and why. Data were summarized with descriptive statistics and utility of individual measures was compared across clinical practice areas (orthopaedic, neurological, geriatric or general rehabilitation). Results The questionnaire was completed by 369 respondents, of which 43.4% of respondents agreed that existing standardized measures of balance meet their needs. In ratings of individual measures, the Single Leg Stance test and Berg Balance Scale were perceived as useful for clinical decision-making and evaluating change over time by over 70% of respondents, and the Timed Up-and-Go test was perceived as useful for decision-making by 56.9% of respondents and useful for evaluating change over time by 62.9% of respondents, but there were significant differences across practice groups. Seventy-nine percent of respondents wanted to improve their assessments, identifying individual, environmental and measure-specific barriers. The most common barriers were lack of time and knowledge. Conclusions This study offers new information on issues affecting the evaluation of balance in clinical settings from a broad sample of physiotherapists. Continued work to address barriers by specific practice area will be critical for the success of any intervention attempting to implement optimal balance assessment practices in the clinical setting. PMID:23510277

Clinical and regulatory considerations in pharmacogenetic testing.

PubMed

Schuck, Robert N; Marek, Elizabeth; Rogers, Hobart; Pacanowski, Michael

2016-12-01

Both regulatory science and clinical practice rely on best available scientific data to guide decision-making. However, changes in clinical practice may be driven by numerous other factors such as cost. In this review, we reexamine noteworthy examples where pharmacogenetic testing information was added to drug labeling to explore how the available evidence, potential public health impact, and predictive utility of each pharmacogenetic biomarker impacts clinical uptake. Advances in the field of pharmacogenetics have led to new discoveries about the genetic basis for variability in drug response. The Food and Drug Administration recognizes the value of pharmacogenetic testing strategies and has been proactive about incorporating pharmacogenetic information into the labeling of both new drugs and drugs already on the market. Although some examples have readily translated to routine clinical practice, clinical uptake of genetic testing for many drugs has been limited. Both regulatory science and clinical practice rely on data-driven approaches to guide decision making; however, additional factors are also important in clinical practice that do not impact regulatory decision making, and these considerations may result in heterogeneity in clinical uptake of pharmacogenetic testing. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Elizabeth Usher Memorial Lecture: How do we change our profession? Using the lens of behavioural economics to improve evidence-based practice in speech-language pathology.

PubMed

McCabe, Patricia J

2018-06-01

Evidence-based practice (EBP) is a well-accepted theoretical framework around which speech-language pathologists strive to build their clinical decisions. The profession's conceptualisation of EBP has been evolving over the last 20 years with the practice of EBP now needing to balance research evidence, clinical data and informed patient choices. However, although EBP is not a new concept, as a profession, we seem to be no closer to closing the gap between research evidence and practice than we were at the start of the movement toward EBP in the late 1990s. This paper examines why speech-language pathologists find it difficult to change our own practice when we are experts in changing the behaviour of others. Using the lens of behavioural economics to examine the heuristics and cognitive processes which facilitate and inhibit change, the paper explores research showing how inconsistency of belief and action, or cognitive dissonance, is inevitable unless we act reflectively instead of automatically. The paper argues that heuristics that prevent us changing our practice toward EBP include the sunk cost fallacy, loss aversion, social desirability bias, choice overload and inertia. These automatic cognitive processes work to inhibit change and may partially account for the slow translation of research into practice. Fortunately, understanding and using other heuristics such as the framing effect, reciprocity, social proof, consistency and commitment may help us to understand our own behaviour as speech-language pathologists and help the profession, and those we work with, move towards EBP.

Evaluation of counseling outcomes at a university counseling center: the impact of clinically significant change on problem resolution and academic functioning.

PubMed

Choi, Keum-Hyeong; Buskey, Wendy; Johnson, Bonita

2010-07-01

The main purpose of this study was to investigate how receiving personal counseling at a university counseling center helps students deal with their personal problems and facilitates academic functioning. To that end, this study used both clinical and academic outcome measures that are relevant to the practice of counseling provided at a counseling center and its unique function in an institution of higher education. In addition, this study used the clinical significance methodology (N. S. Jacobson & P. Truax, 1991) that takes into account clients' differences in making clinically reliable and significant change. Pre-intake and post-termination surveys, including the Outcome Questionnaire (M. J. Lambert, K. Lunnen, V. Umphress, N. Hansen, & G. Burlingame, 1994), were completed by 78 clients, and the responses were analyzed using clinical significance methodology. The results revealed that those who made clinically reliable and significant change (i.e., the recovered group) reported the highest level of improvement in academic commitment to their educational goals and problem resolution, compared with those who did not make clinically significant change. The implications of the findings on practice for counseling at university counseling centers and for administrators in higher education institutions are discussed. (c) 2010 APA, all rights reserved.

National Institutes of Health eliminates funding for national architecture linking primary care research.

PubMed

Peterson, Kevin A

2007-01-01

With the ending of the National Electronic Clinical Trial and Research Network (NECTAR) pilot programs and the abridgement of Clinical Research Associate initiative, the National Institutes of Health Roadmap presents a strategic shift for practice-based research networks from direct funding of a harmonized national infrastructure of cooperating research networks to a model of local engagement of primary care clinics performing practice-based research under the aegis of regional academic health centers through Clinical and Translational Science Awards. Although this may present important opportunities for partnering between community practices and large health centers, for primary care researchers, the promise of a transformational change that brings a unified national primary care community into the clinical research enterprise seems likely to remain unfulfilled.

Discharge planning for heart failure patients in a tertiary hospital in Shanghai: a best practice implementation project.

PubMed

Chen, Yu; Zhu, Li; Xu, Fei; Chen, Jun

2016-02-01

Heart failure is a major public health concern which contributes significantly to rising healthcare costs. Comprehensive discharge planning can improve health outcomes and reduce readmission rates which, in turn, can lead to cost savings. The aim of this project was to promote best practice in the discharge planning of heart failure patients admitted in the coronary care unit of Zhongshan Hospital. A clinical audit was undertaken using the Joanna Briggs Institute Practical Application of Clinical Evidence System tool. Five audit criteria that represent best practice recommendations for heart failure discharge planning were used. A baseline audit was conducted followed by the implementation of multiple strategies, and the project was finalized with a follow-up audit to determine change in practice. Improvements in practice were observed for all five criteria. The most significant improvements were in the following: completion of a discharge checklist (from 0% to 100% compliance), comprehensive (i.e. inclusion of six topics for self-care) discharge education for patients (from 7% to 100% compliance), and conducting a telephone follow-up (from 0% to 76% compliance). The compliance rates for the two remaining criteria, completion of a structured education for patients and scheduling an outpatient clinic visit, both increased from 93% to 100%.Strategies that were implemented to achieve change in practice included development of a local discharge planning checklist, provision of training for nurses, and development of resources. The project demonstrated positive changes in the discharge planning practices of nurses in the coronary care unit of Zhongshan Hospital. A formalized discharge planning is currently in place and plans for sustaining practice change are underway. A continuous cycle of audit and re-audit will need to be carried out in the future to determine the impact of this evidence implementation activity on heart failure patient outcomes.

Developmental procedures for the clinical practice guidelines for conscious sedation in dentistry for the Korean Academy of Dental Sciences.

PubMed

An, So-Youn; Seo, Kwang-Suk; Kim, Seungoh; Kim, Jongbin; Lee, Deok-Won; Hwang, Kyung-Gyun; Kim, Hyun Jeong

2016-12-01

Evidence-based clinical practice guidelines (CPGs) are defined as "statements that are scientifically reviewed about evidence and systematically developed to assist in the doctors' and patients' decision making in certain clinical situations." This recommendation aims to promote good clinical practice for the provision of safe and effective practices of conscious sedation in dentistry. The development of this clinical practice guideline was conducted by performing a systematic search of the literature for evidence-based CPGs. Existing guidelines, relevant systematic reviews, policy documents, legislation, or other recommendations were reviewed and appraised. To supplement this information, key questions were formulated by the Guideline Development Group and used as the basis for designing systematic literature search strategies to identify literature that may address these questions. Guideline documents were evaluated through a review of domestic and international databases for the development of a renewing of existing conscious sedation guidelines for dentistry. Clinical practice guidelines were critically appraised for their methodologies using Appraisal of guidelines for research and evaluation (AGREE) II. A total of 12 existing CPGs were included and 13 recommendations were made in a range of general, adult, and pediatric areas. The clinical practice guidelines for conscious sedation will be reviewed in 5 years' time for further updates to reflect significant changes in the field.

Leadership for learning: a literature study of leadership for learning in clinical practice.

PubMed

Allan, Helen T; Smith, Pamela A; Lorentzon, Maria

2008-07-01

To report a literature study of leadership for learning in clinical practice in the United Kingdom. Background Previous research in the United Kingdom showed that the ward sister was central to creating a positive learning environment for student nurses. Since the 1990s, the ward mentor has emerged as the key to student nurses' learning in the United Kingdom. A literature study of new leadership roles and their influence on student nurse learning (restricted to the United Kingdom) which includes an analysis of ten qualitative interviews with stakeholders in higher education in the United Kingdom undertaken as part of the literature study. Learning in clinical placements is led by practice teaching roles such as mentors, clinical practice facilitators and practice educators rather than new leadership roles. However, workforce changes in clinical placements has restricted the opportunities for trained nurses to role model caring activities for student nurses and university based lecturers are increasingly distant from clinical practice. Leadership for learning in clinical practice poses three unresolved questions for nurse managers, practitioners and educators - what is nursing, what should student nurses learn and from whom? Leadership for student nurse learning has passed to new learning and teaching roles with Trusts and away from nursing managers. This has implications for workforce planning and role modelling within the profession.

Knowledge Translation Tools are Emerging to Move Neck Pain Research into Practice.

PubMed

Macdermid, Joy C; Miller, Jordan; Gross, Anita R

2013-01-01

Development or synthesis of the best clinical research is in itself insufficient to change practice. Knowledge translation (KT) is an emerging field focused on moving knowledge into practice, which is a non-linear, dynamic process that involves knowledge synthesis, transfer, adoption, implementation, and sustained use. Successful implementation requires using KT strategies based on theory, evidence, and best practice, including tools and processes that engage knowledge developers and knowledge users. Tools can provide instrumental help in implementing evidence. A variety of theoretical frameworks underlie KT and provide guidance on how tools should be developed or implemented. A taxonomy that outlines different purposes for engaging in KT and target audiences can also be useful in developing or implementing tools. Theoretical frameworks that underlie KT typically take different perspectives on KT with differential focus on the characteristics of the knowledge, knowledge users, context/environment, or the cognitive and social processes that are involved in change. Knowledge users include consumers, clinicians, and policymakers. A variety of KT tools have supporting evidence, including: clinical practice guidelines, patient decision aids, and evidence summaries or toolkits. Exemplars are provided of two KT tools to implement best practice in management of neck pain-a clinician implementation guide (toolkit) and a patient decision aid. KT frameworks, taxonomies, clinical expertise, and evidence must be integrated to develop clinical tools that implement best evidence in the management of neck pain.

Using clinical governance levers to support change in a cancer care reform.

PubMed

Brault, Isabelle; Denis, Jean-Louis; Sullivan, Terrence James

2015-01-01

Introducing change is a difficult issue facing all health care systems. The use of various clinical governance levers can facilitate change in health care systems. The purpose of this paper is to define clinical governance levers, and to illustrate their use in a large-scale transformation. The empirical analysis deals with the in-depth study of a specific case, which is the organizational model for Ontario's cancer sector. The authors used a qualitative research strategy and drew the data from three sources: semi-structured interviews, analysis of documents, and non-participative observations. From the results, the authors identified three phases and several steps in the reform of cancer services in this province. The authors conclude that a combination of clinical governance levers was used to transform the system. These levers operated at different levels of the system to meet the targeted objectives. To exercise clinical governance, managers need to acquire new competencies. Mobilizing clinical governance levers requires in-depth understanding of the role and scope of clinical governance levers. This study provides a better understanding of clinical governance levers. Clinical governance levers are used to implement an organizational environment that is conducive to developing clinical practice, as well as to act directly on practices to improve quality of care.

Strategic planning in medical education: enhancing the learning environment for students in clinical settings.

PubMed

Gordon, J; Hazlett, C; Ten Cate, O; Mann, K; Kilminster, S; Prince, K; O'Driscoll, E; Snell, L; Newble, D

2000-10-01

The 1999 Cambridge Conference was held in Northern Queensland, Australia, on the theme of clinical teaching and learning. It provided an opportunity for groups of academic medical educators to consider some of the challenges posed by recent changes to health care delivery and medical education across a number of countries. This paper describes the issues raised by the practical challenges posed by the current environment and how they might be addressed in ways that could promote more effective learning in clinical settings. A SWOT analysis is a tool that can help in forward planning by identifying the strengths, weaknesses, opportunities and threats presented by any situation. Our SWOT analysis was used to generate a list of items, from which we chose those most feasible and most likely to promote positive change. Twenty different issues were identified, with four of them chosen by consensus for further elaboration. The discussion gave rise to four main recommended strategies: ensuring that clinical teachers thoroughly understand the purpose and process of learning in clinical settings; equipping learners with 'survival skills'; making the best use of learning resources within different clinical environments and making judicious use of information technology to enhance learning efficiency. The four strategies were selected not only because of their inherent importance, but also because of their feasibility. Modest changes can motivate students to feel part of a clinical team and a 'community of practice' and enhance their capacity for self-regulated practice.

“At 150 kg, you can't run” men's weight loss stories in a popular health magazine provide appropriate examples of good health practice

PubMed Central

Couch, Danielle; Han, Gil-Soo; Robinson, Priscilla; Komesaroff, Paul

2014-01-01

We explore weight loss stories from 47 men collected from the Australian edition of Men's Health magazine between January 2009 and December 2012. Our analysis uses a mixed methods approach that combines thematic analysis and descriptive statistics to examine weight loss strategies against clinical practice guidelines for the management of overweight and obesity. All the stories reported the use of physical activity for weight loss and most stories detailed dietary changes for weight loss. Our findings indicate that most of the men reportedly used some form of behavioural strategies to assist them in their behaviour change efforts. The weight loss methods used were consistent with clinical practice guidelines, with the exception of some dietary practices. As narratives may assist with behaviour change, stories like those examined in this study could prove to be very useful in promoting weight loss to men. PMID:25750780

What drives quality improvement in chronic kidney disease (CKD) in primary care: process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) trial.

PubMed

Nihat, Akin; de Lusignan, Simon; Thomas, Nicola; Tahir, Mohammad Aumran; Gallagher, Hugh

2016-04-06

This study is a process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) study, comparing audit-based education (ABE) and sending clinical guidelines and prompts (G&P) with usual practice, in improving systolic blood pressure control in primary care. This evaluation aimed to explore how far clinical staff in participating practices were aware of the intervention, and why change in practice might have taken place. 4 primary care practices in England: 2 received ABE, and 2 G&P. We purposively selected 1 northern/southern/city and rural practice from each study arm (from a larger pool of 132 practices as part of the QICKD trial). The 4 study practices were purposively sampled, and focus groups conducted with staff from each. All staff members were invited to attend. Focus groups in each of 4 practices, at the mid-study point and at the end. 4 additional trial practices not originally selected for in-depth process evaluation took part in end of trial focus groups, to a total of 12 focus groups. These were recorded, transcribed and analysed using the framework approach. 5 themes emerged: (1) involvement in the study made participants more positive about the CKD register; (2) clinicians did not always explain to patients that they had CKD; (3) while practitioners improved their monitoring of CKD, many were sceptical that it improved care and were more motivated by pay-for-performance measures; (4) the impact of study interventions on practice was generally positive, particularly the interaction with specialists, included in ABE; (5) the study stimulated ideas for future clinical practice. Improving quality in CKD is complex. Lack of awareness of clinical guidelines and scepticism about their validity are barriers to change. While pay-for-performance incentives are the main driver for change, quality improvement interventions can have a complementary influence. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Road Map For Diffusion Of Innovation In Health Care.

PubMed

Balas, E Andrew; Chapman, Wendy W

2018-02-01

New scientific knowledge and innovation are often slow to disseminate. In other cases, providers rush into adopting what appears to be a clinically relevant innovation, based on a single clinical trial. In reality, adopting innovations without appropriate translation and repeated testing of practical application is problematic. In this article we provide examples of clinical innovations (for example, tight glucose control in critically ill patients) that were adopted inappropriately and that caused what we term a malfunction. To address the issue of malfunctions, we review various examples and suggest frameworks for the diffusion of knowledge leading to the adoption of useful innovations. The resulting model is termed an integrated road map for coordinating knowledge transformation and innovation adoption. We make recommendations for the targeted development of practice change procedures, practice change assessment, structured descriptions of tested interventions, intelligent knowledge management technologies, and policy support for knowledge transformation, including further standardization to facilitate sharing among institutions.

Creating innovative clinical nurse leader practicum experiences through academic and practice partnerships.

PubMed

Jukkala, Angela; Greenwood, Rebecca; Motes, Terry; Block, Velinda

2013-01-01

The new Clinical Nurse Leader (CNL) nursing role was developed to meet the complex health care needs of patients, families, and health care systems. This article describes the process used by nurse leaders at the University of Alabama at Birmingham School of Nursing and Hospital to develop Model C CNL practicum courses, recruit and prepare clinical preceptors, prepare clinical microsystems for CNL students, and develop additional practice partnerships throughout the region. MANAGEMENT AND OUTCOME: Critical to the success of the CNL role is a dynamic partnership between academic and practice leaders.The partnership allows faculty to develop curricula that are relevant and responsive to the rapidly changing health care system. Clinical leaders become more aware of trends and issues in nursing education. Continued growth and success of the CNL role is largely dependent on the ability of faculty and practice partners to collaborate on innovative educational programs and models of care delivery.

Impact of the Provider and Healthcare team Adherence to Treatment Guidelines (PHAT-G) intervention on adherence to national obesity clinical practice guidelines in a primary care centre.

PubMed

Barnes, Emily R; Theeke, Laurie A; Mallow, Jennifer

2015-04-01

Obesity is significantly underdiagnosed and undertreated in primary care settings. The purpose of this clinical practice change project was to increase provider adherence to national clinical practice guidelines for the diagnosis and treatment of obesity in adults. Based upon the National Institutes of Health guidelines for the diagnosis and treatment of obesity, a clinical change project was implemented. Guided by the theory of planned behaviour, the Provider and Healthcare team Adherence to Treatment Guidelines (PHAT-G) intervention includes education sessions, additional provider resources for patient education, a provider reminder system and provider feedback. Primary care providers did not significantly increase on documentation of diagnosis and planned management of obesity for patients with body mass index (BMI) greater than or equal to 30. Medical assistants increased recording of height, weight and BMI in the patient record by 13%, which was significant. Documentation of accurate BMI should lead to diagnosis of appropriate weight category and subsequent care planning. Future studies will examine barriers to adherence to clinical practice guidelines for obesity. Interventions are needed that include inter-professional team members and may be more successful if delivered separately from routine primary care visits. © 2015 John Wiley & Sons, Ltd.

Is linking research, teaching and practice in communication in health care the way forward?

PubMed

van Weel-Baumgarten, Evelyn

2016-09-01

This paper is based on the keynote lecture given at the ICCH conference in New Orleans in October 2015. With as background the observation that even though research and teaching of communication have been receiving attention for some time now, patients still encounter many problems when they visit clinicians because of health problems, it subsequently touches upon research on integration of communication with correct medical content, person centered communication and the role of placebo on outcomes. For teaching it emphasizes methods working best to teach clinical communication skills and lead to behavior changes in professionals: experiential teaching methods but taking care of a balance with cognitive methods. It then discusses the challenge of transfer to clinical practice and what is needed to overcome these challenges: learning from reflecting on undesired outcomes in clinical practice, feedback from clinicians who are open to communication and support learners with effective feedback in that specific context. It adds suggestions about where linking more between research, teaching and clinical practice could help moving communication in health care forward and builds the case for involving policymakers and members of hospital boards to help manage the necessary climate change in clinical settings. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Cervical cancer screening in adolescents: an evidence-based internet education program for practice improvement among advanced practice nurses.

PubMed

Choma, Kim; McKeever, Amy E

2015-02-01

The literature reports great variation in the knowledge levels and application of the recent changes of cervical cancer screening guidelines into clinical practice. Evidence-based screening guidelines for the prevention and early detection of cervical cancer offers healthcare providers the opportunity to improve practice patterns among female adolescents by decreasing psychological distress as well as reducing healthcare costs and morbidities associated with over-screening. The purpose of this pilot intervention study was to determine the effects of a Web-based continuing education unit (CEU) program on advanced practice nurses' (APNs) knowledge of current cervical cancer screening evidence-based recommendations and their application in practice. This paper presents a process improvement project as an example of a way to disseminate updated evidence-based practice guidelines among busy healthcare providers. This Web-based CEU program was developed, piloted, and evaluated specifically for APNs. The program addressed their knowledge level of cervical cancer and its relationship with high-risk human papillomavirus. It also addressed the new cervical cancer screening guidelines and the application of those guidelines into clinical practice. Results of the study indicated that knowledge gaps exist among APNs about cervical cancer screening in adolescents. However, when provided with a CEU educational intervention, APNs' knowledge levels increased and their self-reported clinical practice behaviors changed in accordance with the new cervical cancer screening guidelines. Providing convenient and readily accessible up-to-date electronic content that provides CEU enhances the adoption of clinical practice guidelines, thereby decreasing the potential of the morbidities associated with over-screening for cervical cancer in adolescents and young women. © 2014 Sigma Theta Tau International.

Faculty Practice: Facilitation of Clinical Integrations into the Academic Triad Model.

ERIC Educational Resources Information Center

Newland, Jamesetta A.; Truglio-Londrigan, Marie

2003-01-01

Uses the Pace University School of Nursing as an example of the evolution of models of nursing faculty practice. Discusses outcomes of evaluation of faculty practice through surveys and interviews: formation of a support group for faculty involved in practice and recommendations for university-wide culture change regarding the academic triad.…

Relate better and judge less: poverty simulation promoting culturally competent care in community health nursing.

PubMed

Yang, Kyeongra; Woomer, Gail Ratliff; Agbemenu, Kafuli; Williams, Lynne

2014-11-01

The study aim was to evaluate the effectiveness of a poverty simulation in increasing understanding of and attitudes toward poverty and resulting in changes in clinical practice among nursing seniors. A poverty simulation was conducted using a diverse group of nursing professors and staff from local community agencies assuming the role of community resource providers. Students were assigned roles as members of low-income families and were required to complete tasks during a simulated month. A debriefing was held after the simulation to explore students' experiences in a simulated poverty environment. Students' understanding of and attitude toward poverty pre- and post-simulation were examined. Changes in the students' clinical experiences following the simulation were summarized into identified categories and themes. The poverty simulation led to a greater empathy for the possible experiences of low income individuals and families, understanding of barriers to health care, change in attitudes towards poverty and to those living in poverty, and changes in the students' nursing practice. Use of poverty simulation is an effective means to teach nursing students about the experience of living in poverty. The simulation experience changed nursing students' clinical practice, with students providing community referrals and initiating inter-professional collaborations. Copyright © 2014 Elsevier Ltd. All rights reserved.

Readiness for organisational change among general practice staff.

PubMed

Christl, B; Harris, M F; Jayasinghe, U W; Proudfoot, J; Taggart, J; Tan, J

2010-10-01

Increasing demands on general practice to manage chronic disease may warrant organisational change at the practice level. Staff's readiness for organisational change can act as a facilitator or barrier to implementing interventions aimed at organisational change. To explore general practice staff readiness for organisational change and its association with staff and practices characteristics. This is a cross-sectional study of practices in three Australian states involved in a randomised control trial on the effectiveness of an intervention to enhance the role of non-general practitioner staff in chronic disease management. Readiness for organisational change, job satisfaction and practice characteristics were assessed using questionnaires. 502 staff from 58 practices completed questionnaires. Practice characteristics were not associated with staff readiness for change. A multilevel regression analysis showed statistically significant associations between staff readiness for organisational change (range 1 to 5) and having a non-clinical staff role (vs general practitioner; B=-0.315; 95% CI -0.47 to -0.16; p<0.001), full-time employment (vs part-time; B=0.175, 95% CI 0.06 to 0.29; p<0.01) and lower job satisfaction (B=-0.277, 95% CI -0.40 to -0.15; p<0.001). The results suggest that different approaches are needed to facilitate change which addresses the mix of practice staff. Moderately low job satisfaction may be an opportunity for organisational change.

Survey of Irish general practitioners' preferences for continuing professional development.

PubMed

Maher, B; O'Neill, R; Faruqui, A; Bergin, C; Horgan, M; Bennett, D; O'Tuathaigh, C M P

2018-01-01

Doctors' continuing professional development (CPD) training needs are known to be strongly influenced by national and local contextual characteristics. Given the changing national demographic profile and government-mandated changes to primary care health care provision, this study aimed to investigate Irish General Practitioners' (GPs) perceptions of, and preferences for, current and future CPD programmes. A cross-sectional questionnaire, using closed- and open-ended questions, was administered to Irish GPs, focusing on training needs analysis; CPD course content; preferred format and the learning environment. The response rate was 719/1000 (71.9%). GPs identified doctor-patient communication as the most important and best-performed GP skill. Discrepancies between perceived importance (high) and current performance (low) emerged for time/workload management, practice finance and business skills. GPs identified clinically-relevant primary care topics and non-clinical topics (stress management, business skills, practice management) as preferences for future CPD. Flexible methods for CPD delivery were important. Gender and practice location (urban or rural) significantly influenced CPD participation and future course preference. The increasing diversity of services offered in the Irish primary care setting, in both clinical and non-clinical areas, should be tailored based to include GP practice location and structure.

Translation of clinical practice guidelines for childhood obesity prevention in primary care mobilizes a rural Midwest community.

PubMed

Gibson, S Jo

2016-03-01

The purpose of this project was to implement clinic system changes that support evidence-based guidelines for childhood obesity prevention. Adherence rates for prevention and screening of children in a rural Midwest primary care setting were used to measure the success of the program. Retrospective chart reviews reflected gaps in current practice and documentation. An evidence-based toolkit for childhood obesity prevention was used to implement clinic system changes for the identified gaps. The quality improvement approach proved to be effective in translating knowledge of obesity prevention guidelines into rural clinic practices with significant improvements in documentation of prevention measures that may positively impact the childhood obesity epidemic. Primary care providers, including nurse practitioners (NPs), are at the forefront of diagnosing, educating, and counseling children and families on obesity prevention and need appropriate resources and tools to deliver premier care. The program successfully demonstrated how barriers to practice, even with the unique challenges in a rural setting, can be overcome. NPs fulfill a pivotal primary care role and can provide leadership that may positively impact obesity prevention in their communities. ©2015 American Association of Nurse Practitioners.

The Partners for Change Outcome Management System: A Both/And System for Collaborative Practice.

PubMed

Sparks, Jacqueline A; Duncan, Barry L

2018-03-09

Systematic client feedback (SCF) is increasingly employed in mental health services worldwide. While research supports its efficacy over treatment as usual, clinicians, especially those who highly value relational practices, may be concerned that routine data collection detracts from clinical process. This article describes one SCF system, the Partners for Change Outcome Management System (PCOMS), along a normative (standardized measurement) to communicative (conversational) continuum, highlighting PCOMS' origins in everyday clinical practice. The authors contend that PCOMS represents "both/and," providing a valid signal of client progress while facilitating communicative process particularly prized by family therapists steeped in relational traditions. The article discusses application of PCOMS in systemic practice and describes how it actualizes time-honored family therapy approaches. The importance of giving voice to individualized client experience is emphasized. © 2018 Family Process Institute.

The Minimally Important Difference for the Fatigue Visual Analog Scale in Patients with Rheumatoid Arthritis followed in an Academic Clinical Practice

PubMed Central

Khanna, Dinesh; Pope, Janet; Khanna, Puja P.; Maloney, Michelle; Samedi, Nooshin; Norrie, Debbie; Ouimet, Gillian; Hays, Ron D

2011-01-01

Introduction Fatigue is a common symptom in RA and used as an outcome measure in RA clinical trials. We studied a large academic clinical practice to estimate the minimally important difference (MID) for a fatigue visual analog scale using patient-reported anchors (fatigue, pain and overall health). Methods RA patients (N=307) had clinic visits at 2 time points at a median of 5.9 months apart. They completed fatigue visual analog scale (VAS; 0–10) and retrospective anchor items, “How would you describe your overall fatigue/pain/overall health since the last visit?” Much worsened, Somewhat worsened, Same, Somewhat better, or Much better. The fatigue anchor was used for primary analysis and the pain/ overall health anchors for sensitivity analyses. The minimally changed group was defined by those reporting they were somewhat better or somewhat worsened. Results The mean (SD) age was 59.4 (13.2) years, disease duration was 14.1 (11.5) years, and 83% of patients were women. The baseline mean (SD) HAQ-DI score was 0.84 (0.75). The baseline fatigue VAS score was 4.2 (2.9) and at follow up was 4.3 (2.8) (mean change of −0.07 [2.5], p=NS). The fatigue change score (0–10 scale) for somewhat better and somewhat worsened for fatigue anchor averaged −1.12 and 1.26, respectively. Using pain anchor, the fatigue changed score for somewhat better and somewhat worsened averaged −0.87 and 1.13 and using global anchor, the fatigue changed score for somewhat better and somewhat worsened averaged −0.82 and 1.17, respectively. Effect size (ES) estimates using 3 anchors were small for somewhat better (range: 0.27 to 0.39) and somewhat worsened (range: 0.40 to 0.44) groups but larger than the no-change group (range: 0.03 to 0.08). Conclusions The MID for fatigue VAS is between −0.82 to −1.12 for improvement and 1.13 to 1.26 for worsening on 0–10 scale in a large RA clinical practice and similar to that seen in RA clinical trials. This information can aid in interpreting fatigue VAS in day-to-day care in clinical practice. PMID:19004044

Keys to success of a community of clinical practice in primary care: a qualitative evaluation of the ECOPIH project.

PubMed

Lacasta Tintorer, David; Manresa Domínguez, Josep Maria; Pujol-Rivera, Enriqueta; Flayeh Beneyto, Souhel; Mundet Tuduri, Xavier; Saigí-Rubió, Francesc

2018-05-09

The current reality of primary care (PC) makes it essential to have telemedicine systems available to facilitate communication between care levels. Communities of practice have great potential in terms of care and education, and that is why the Online Communication Tool between Primary and Hospital Care was created. This tool enables PC and non-GP specialist care (SC) professionals to raise clinical cases for consultation and to share information. The objective of this article is to explore healthcare professionals' views on communities of clinical practice (CoCPs) and the changes that need to be made in an uncontrolled real-life setting after more than two years of use. A descriptive-interpretative qualitative study was conducted on a total of 29 healthcare professionals who were users and non-users of a CoCP using 2 focus groups, 3 triangular groups and 5 individual interviews. There were 18 women, 21 physicians and 8 nurses. Of the interviewees, 21 were PC professionals, 24 were users of a CoCP and 7 held managerial positions. For a system of communication between PC and SC to become a tool that is habitually used and very useful, the interviewees considered that it would have to be able to find quick, effective solutions to the queries raised, based on up-to-date information that is directly applicable to daily clinical practice. Contact should be virtual - and probably collaborative - via a platform integrated into their habitual workstations and led by PC professionals. Organisational changes should be implemented to enable users to have more time in their working day to spend on the tool, and professionals should have a proactive attitude in order to make the most if its potential. It is also important to make certain technological changes, basically aimed at improving the tool's accessibility, by integrating it into habitual clinical workstations. The collaborative tool that provides reliable, up-to-date information that is highly transferrable to clinical practice is valued for its effectiveness, efficiency and educational capacity. In order to make the most of its potential in terms of care and education, organisational changes and techniques are required to foster greater use.

Practice development: implementing a change of practice as a team.

PubMed

Covill, Carl; Hope, Angela

2012-08-01

Practice development (PD), as a framework for multiprofessional working, has immense potential, specifically within change management and the clinical governance agenda. It has been acknowledged as a vehicle for 'continuous improvement'. This article discusses PD through collaborative working using the example of a case study on change of practice in falls reduction within a localised community setting. The process is underpinned by a PD framework and facilitated by leaders of PD within a university setting. The article identifies that PD frameworks are conducive to developing leadership and management roles within a democratic process. The article discusses the potential for multiprofessional PD within the locality and further afield.

Advanced practice nursing role delineation in acute and critical care: application of the strong model of advanced practice.

PubMed

Mick, D J; Ackerman, M H

2000-01-01

This purpose of this study was to differentiate between the roles of clinical nurse specialists and acute care nurse practitioners. Hypothesized blending of the clinical nurse specialist and acute care nurse practitioner roles is thought to result in an acute care clinician who integrates the clinical skills of the nurse practitioner with the systems knowledge, educational commitment, and leadership ability of the clinical nurse specialist. Ideally, this role blending would facilitate excellence in both direct and indirect patient care. The Strong Model of Advanced Practice, which incorporates practice domains of direct comprehensive care, support of systems, education, research, and publication and professional leadership, was tested to search for practical evidence of role blending. This descriptive, exploratory, pilot study included subjects (N = 18) solicited from an academic medical center and from an Internet advanced practice listserv. Questionnaires included self-ranking of expertise in practice domains, as well as valuing of role-related tasks. Content validity was judged by an expert panel of advanced practice nurses. Analyses of descriptive statistics revealed that clinical nurse specialists, who had more experience both as registered nurses and in the advanced practice nurse role, self-ranked their expertise higher in all practice domains. Acute care nurse practitioners placed higher importance on tasks related to direct comprehensive care, including conducting histories and physicals, diagnosing, and performing diagnostic procedures, whereas clinical nurse specialists assigned greater importance to tasks related to education, research, and leadership. Levels of self-assessed clinical expertise as well as valuing of role-related tasks differed among this sample of clinical nurse specialists and acute care nurse practitioners. Groundwork has been laid for continuing exploration into differentiation in advanced practice nursing roles. As the clinical nurse specialist role changes and the acute care nurse practitioner role emerges, it is imperative that advanced practice nurses describe their contribution to health care. Associating advanced practice nursing activities with outcomes will help further characterize these 2 advanced practice roles.

Impact of disease management programs on hospital and community nursing practice.

PubMed

Goldstein, Perry C

2006-01-01

The impact of disease management progrmms on the role of the nursing profession in the evolving U.S. health care system is reviewed. Needed changes in educational and training programs are discussed in relation to demands for changing clinical and administrative skills in nursing with an emphasis on increasing demand for advanced practice nurses.

Adaptation of clinical prediction models for application in local settings.

PubMed

Kappen, Teus H; Vergouwe, Yvonne; van Klei, Wilton A; van Wolfswinkel, Leo; Kalkman, Cor J; Moons, Karel G M

2012-01-01

When planning to use a validated prediction model in new patients, adequate performance is not guaranteed. For example, changes in clinical practice over time or a different case mix than the original validation population may result in inaccurate risk predictions. To demonstrate how clinical information can direct updating a prediction model and development of a strategy for handling missing predictor values in clinical practice. A previously derived and validated prediction model for postoperative nausea and vomiting was updated using a data set of 1847 patients. The update consisted of 1) changing the definition of an existing predictor, 2) reestimating the regression coefficient of a predictor, and 3) adding a new predictor to the model. The updated model was then validated in a new series of 3822 patients. Furthermore, several imputation models were considered to handle real-time missing values, so that possible missing predictor values could be anticipated during actual model use. Differences in clinical practice between our local population and the original derivation population guided the update strategy of the prediction model. The predictive accuracy of the updated model was better (c statistic, 0.68; calibration slope, 1.0) than the original model (c statistic, 0.62; calibration slope, 0.57). Inclusion of logistical variables in the imputation models, besides observed patient characteristics, contributed to a strategy to deal with missing predictor values at the time of risk calculation. Extensive knowledge of local, clinical processes provides crucial information to guide the process of adapting a prediction model to new clinical practices.

Detection of Practice Pattern Trends through Natural Language Processing of Clinical Narratives and Biomedical Literature

PubMed Central

Chen, Elizabeth S.; Stetson, Peter D.; Lussier, Yves A.; Markatou, Marianthi; Hripcsak, George; Friedman, Carol

2007-01-01

Clinical knowledge, best evidence, and practice patterns evolve over time. The ability to track these changes and study practice trends may be valuable for performance measurement and quality improvement efforts. The goal of this study was to assess the feasibility and validity of methods to generate and compare trends in biomedical literature and clinical narrative. We focused on the challenge of detecting trends in medication usage over time for two diseases: HIV/AIDS and asthma. Information about disease-specific medications in published randomized control trials and discharge summaries at New York-Presbyterian Hospital over a ten-year period were extracted using Natural Language Processing. This paper reports on the ability of our semi-automated process to discover disease-drug practice pattern trends and interpretation of findings across the biomedical and clinical text sources. PMID:18693810

Lost in translation: neuropsychiatric drug development.

PubMed

Becker, Robert E; Greig, Nigel H

2010-12-08

Recent studies have identified troubling method and practice lapses in neuropsychiatric drug developments. These problems have resulted in errors that are of sufficient magnitude to invalidate clinical trial data and interpretations. We identify two potential sources for these difficulties: investigators selectively choosing scientific practices for demonstrations of efficacy in human-testing phases of drug development and investigators failing to anticipate the needs of practitioners who must optimize treatment for the individual patient. When clinical investigators neglect to use clinical trials as opportunities to test hypotheses of disease mechanisms in humans, the neuropsychiatric knowledge base loses both credibility and scope. When clinical investigators do not anticipate the need to translate discoveries into applications, the practitioner cannot provide optimal care for the patient. We conclude from this evidence that clinical trials, and other aspects of neuropsychiatric drug development, must adopt more practices from basic science and show greater responsiveness to conditions of clinical practice. We feel that these changes are necessary to overcome current threats to the validity and utility of studies of neurological and psychiatric drugs.

Hurdles and delays in access to anti-cancer drugs in Europe

PubMed Central

Ades, F; Zardavas, D; Senterre, C; de Azambuja, E; Eniu, A; Popescu, R; Piccart, M; Parent, F

2014-01-01

Demographic changes in the world population will cause a significant increase in the number of new cases of cancer. To handle this challenge, societies will need to adapt how they approach cancer prevention and treatment, with changes to the development and uptake of innovative anticancer drugs playing an important role. However, there are obstacles to implementing innovative drugs in clinical practice. Prior to being incorporated into daily practice, the drug must obtain regulatory and reimbursement approval, succeed in changing the prescription habits of physicians, and ultimately gain the compliance of individual patients. Developing an anticancer drug and bringing it into clinical practice is, therefore, a lengthy and complex process involving multiple partners in several areas. To optimize patient treatment and increase the likelihood of implementing health innovation, it is essential to have an overview of the full process. This review aims to describe the process and discuss the hurdles arising at each step. PMID:25525460

Hurdles and delays in access to anti-cancer drugs in Europe.

PubMed

Ades, F; Zardavas, D; Senterre, C; de Azambuja, E; Eniu, A; Popescu, R; Piccart, M; Parent, F

2014-01-01

Demographic changes in the world population will cause a significant increase in the number of new cases of cancer. To handle this challenge, societies will need to adapt how they approach cancer prevention and treatment, with changes to the development and uptake of innovative anticancer drugs playing an important role. However, there are obstacles to implementing innovative drugs in clinical practice. Prior to being incorporated into daily practice, the drug must obtain regulatory and reimbursement approval, succeed in changing the prescription habits of physicians, and ultimately gain the compliance of individual patients. Developing an anticancer drug and bringing it into clinical practice is, therefore, a lengthy and complex process involving multiple partners in several areas. To optimize patient treatment and increase the likelihood of implementing health innovation, it is essential to have an overview of the full process. This review aims to describe the process and discuss the hurdles arising at each step.

Changing Nephrology Nurses' Beliefs about the Value of Evidence-Based Practice and Their Ability to Implement in Clinical Practice.

PubMed

Hain, Debra; Haras, Mary S

2015-01-01

A rapidly evolving healthcare environment demands sound research evidence to inform clinical practice and improve patient outcomes. Over the past several decades, nurses have generated new knowledge by conducting research studies, but it takes time for this evidence to be implemented in practice. As nurses strive to be leaders and active participants in healthcare redesign, it is essential that they possess the requisite knowledge and skills to engage in evidence-based practice (EBP). Professional nursing organizations can make substantial contributions to the move healthcare quality forward by providing EBP workshops similar to those conducted by the American Nephrology Nurses'Association.

What features of educational interventions lead to competence in aseptic insertion and maintenance of CV catheters in acute care? BEME Guide No. 15.

PubMed

Cherry, M Gemma; Brown, Jeremy M; Neal, Timothy; Ben Shaw, Nigel

2010-01-01

Up to 6000 patients per year in England acquire a central venous catheter (CVC)-related bloodstream infection (Shapey et al. 2008 ). Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained reductions in CVC-related blood stream infections (Pronovost et al. 2002), and cost (Hu et al. 2004 ). This review aimed to determine the features of structured educational interventions that impact on competence in aseptic insertion technique and maintenance of CV catheters by healthcare workers. We looked at changes in infection control behaviour of healthcare workers, and considered changes in service delivery and the clinical welfare of patients involved, provided they were related directly to the delivery method of the educational intervention. A total of 9968 articles were reviewed, of which 47 articles met the inclusion criteria. Findings suggest implications for practice: First, educational interventions appear to have the most prolonged and profound effect when used in conjunction with audit, feedback, and availability of new clinical supplies consistent with the content of the education provided. Second, educational interventions will have a greater impact if baseline compliance to best practice is low. Third, repeated sessions, fed into daily practice, using practical participation appear to have a small, additional effect on practice change when compared to education alone. Active involvement from healthcare staff, in conjunction with the provision of formal responsibilities and motivation for change, may change healthcare worker practice.

Development and Validation of a Primary Care-Based Family Health History and Decision Support Program (MeTree)

PubMed Central

Orlando, Lori A.; Buchanan, Adam H.; Hahn, Susan E.; Christianson, Carol A.; Powell, Karen P.; Skinner, Celette Sugg; Chesnut, Blair; Blach, Colette; Due, Barbara; Ginsburg, Geoffrey S.; Henrich, Vincent C.

2016-01-01

INTRODUCTION Family health history is a strong predictor of disease risk. To reduce the morbidity and mortality of many chronic diseases, risk-stratified evidence-based guidelines strongly encourage the collection and synthesis of family health history to guide selection of primary prevention strategies. However, the collection and synthesis of such information is not well integrated into clinical practice. To address barriers to collection and use of family health histories, the Genomedical Connection developed and validated MeTree, a Web-based, patient-facing family health history collection and clinical decision support tool. MeTree is designed for integration into primary care practices as part of the genomic medicine model for primary care. METHODS We describe the guiding principles, operational characteristics, algorithm development, and coding used to develop MeTree. Validation was performed through stakeholder cognitive interviewing, a genetic counseling pilot program, and clinical practice pilot programs in 2 community-based primary care clinics. RESULTS Stakeholder feedback resulted in changes to MeTree’s interface and changes to the phrasing of clinical decision support documents. The pilot studies resulted in the identification and correction of coding errors and the reformatting of clinical decision support documents. MeTree’s strengths in comparison with other tools are its seamless integration into clinical practice and its provision of action-oriented recommendations guided by providers’ needs. LIMITATIONS The tool was validated in a small cohort. CONCLUSION MeTree can be integrated into primary care practices to help providers collect and synthesize family health history information from patients with the goal of improving adherence to risk-stratified evidence-based guidelines. PMID:24044145

Robot-aided assessment of lower extremity functions: a review.

PubMed

Maggioni, Serena; Melendez-Calderon, Alejandro; van Asseldonk, Edwin; Klamroth-Marganska, Verena; Lünenburger, Lars; Riener, Robert; van der Kooij, Herman

2016-08-02

The assessment of sensorimotor functions is extremely important to understand the health status of a patient and its change over time. Assessments are necessary to plan and adjust the therapy in order to maximize the chances of individual recovery. Nowadays, however, assessments are seldom used in clinical practice due to administrative constraints or to inadequate validity, reliability and responsiveness. In clinical trials, more sensitive and reliable measurement scales could unmask changes in physiological variables that would not be visible with existing clinical scores.In the last decades robotic devices have become available for neurorehabilitation training in clinical centers. Besides training, robotic devices can overcome some of the limitations in traditional clinical assessments by providing more objective, sensitive, reliable and time-efficient measurements. However, it is necessary to understand the clinical needs to be able to develop novel robot-aided assessment methods that can be integrated in clinical practice.This paper aims at providing researchers and developers in the field of robotic neurorehabilitation with a comprehensive review of assessment methods for the lower extremities. Among the ICF domains, we included those related to lower extremities sensorimotor functions and walking; for each chapter we present and discuss existing assessments used in routine clinical practice and contrast those to state-of-the-art instrumented and robot-aided technologies. Based on the shortcomings of current assessments, on the identified clinical needs and on the opportunities offered by robotic devices, we propose future directions for research in rehabilitation robotics. The review and recommendations provided in this paper aim to guide the design of the next generation of robot-aided functional assessments, their validation and their translation to clinical practice.

Simulation as a Tool to Facilitate Practice Changes in Teams Taking Care of Patients Under Investigation for Ebola Virus Disease in Spain.

PubMed

Rojo, Elena; Oruña, Clara; Sierra, Dolores; García, Gema; Del Moral, Ignacio; Maestre, Jose M

2016-04-01

We analyzed the impact of simulation-based training on clinical practice and work processes on teams caring for patients with possible Ebola virus disease (EVD) in Cantabria, Spain. The Government of Spain set up a special committee for the management of EVD, and the Spanish Ministry of Health and foreign health services created an action protocol. Each region is responsible for selecting a reference hospital and an in-house care team to care for patients under investigation. Laboratory-confirmed cases of EVD have to be transferred to the Carlos III Health Institute in Madrid. Predeployment training and follow-up support are required to help personnel work safely and effectively. Simulation-based scenarios were designed to give staff the opportunity to practice before encountering a real-life situation. Lessons learned by each team during debriefings were listed, and a survey administered 3 months later assessed the implementation of practice and system changes. Implemented changes were related to clinical practice (eg, teamwork principles application), protocol implementation (eg, addition of new processes and rewriting of confusing parts), and system and workflow (eg, change of shift schedule and rearrangement of room equipment). Simulation can be used to detect needed changes in protocol or guidelines or can be adapted to meet the needs of a specific team.

SI units and the clinical practice of infectious diseases: application to the usage of antimicrobial agents.

PubMed

Quentzel, H L; Nadelman, R B; Ng, J; Wormser, G P

1989-01-01

Over the next few years, le Système international d'Unités or SI units may replace the presently used metric system in reporting laboratory data. The change to SI units will likely result in some confusion among clinicians who are not well versed in the new system. Application of SI units to the clinical practice of infectious diseases is discussed, including changes in drug dosages, serum drug levels, and minimum inhibitory concentrations. A table is presented to facilitate conversion of metric units to SI units and vice versa.

Personality traits and career choices among physicians in Finland: employment sector, clinical patient contact, specialty and change of specialty.

PubMed

Mullola, Sari; Hakulinen, Christian; Presseau, Justin; Gimeno Ruiz de Porras, David; Jokela, Markus; Hintsa, Taina; Elovainio, Marko

2018-03-27

Personality influences an individual's adaptation to a specific job or organization. Little is known about personality trait differences between medical career and specialty choices after graduating from medical school when actually practicing different medical specialties. Moreover, whether personality traits contribute to important career choices such as choosing to work in the private or public sector or with clinical patient contact, as well as change of specialty, have remained largely unexplored. In a nationally representative sample of Finnish physicians (N = 2837) we examined how personality traits are associated with medical career choices after graduating from medical school, in terms of employment sector, patient contact, medical specialty and change of specialty. Personality was assessed using the shortened version of the Big Five Inventory (S-BFI). An analysis of covariance with posthoc tests for pairwise comparisons was conducted, adjusted for gender and age with confounders (employment sector, clinical patient contact and medical specialty). Higher openness was associated with working in the private sector, specializing in psychiatry, changing specialty and not practicing with patients. Lower openness was associated with a high amount of patient contact and specializing in general practice as well as ophthalmology and otorhinolaryngology. Higher conscientiousness was associated with a high amount of patient contact and specializing in surgery and other internal medicine specialties. Lower conscientiousness was associated with specializing in psychiatry and hospital service specialties. Higher agreeableness was associated with working in the private sector and specializing in general practice and occupational health. Lower agreeableness and neuroticism were associated with specializing in surgery. Higher extraversion was associated with specializing in pediatrics and change of specialty. Lower extraversion was associated with not practicing with patients. The results showed distinctive personality traits to be associated with physicians' career and specialty choices after medical school independent of known confounding factors. Openness was the most consistent personality trait associated with physicians' career choices in terms of employment sector, amount of clinical patient contact, specialty choice and change of specialty. Personality-conscious medical career counseling and career guidance during and after medical education might enhance the person-job fit among physicians.

Evaluating a standardised clinical assessment tool for pre-registration midwifery students: A cross-sectional survey of midwifery students and midwives in Australia.

PubMed

Morrow, Jane; Biggs, Laura; Stelfox, Sara; Phillips, Diane; McKellar, Lois; McLachlan, Helen

2016-02-01

Assessment of clinical competence is a core component of midwifery education. Clinical assessment tools have been developed to help increase consistency and overcome subjectivity of assessment. The study had two main aims. The first was to explore midwifery students and educators/clinical midwives' views and experiences of a common clinical assessment tool used for all preregistration midwifery programmes in Victoria and the University of South Australia. The second was to assess the need for changes to the tool to align with developments in clinical practice and evidence-based care. A cross-sectional, web-based survey including Likert-type scales and open-ended questions was utilised. Students enrolled in all four entry pathways to midwifery at seven Victorian and one South Australian university and educators/clinical midwives across both states. One hundred and ninety-one midwifery students' and 86 educators/clinical midwives responded. Overall, students and educators/clinical midwives were positive about the Clinical Assessment Tool with over 90% reporting that it covered the necessary midwifery skills. Students and educators/clinical midwives reported high levels of satisfaction with the content of the learning tools. Only 4% of educators/clinical midwives and 6% of students rated the Clinical Assessment Tool as poor overall. Changes to some learning tools were necessary in order to reflect recent practice and evidence. A common clinical assessment tool for evaluating midwifery students' clinical practice may facilitate the provision of consistent, reliable and objective assessment of student skills and competency. Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Reasoning, evidence, and clinical decision-making: The great debate moves forward.

PubMed

Loughlin, Michael; Bluhm, Robyn; Buetow, Stephen; Borgerson, Kirstin; Fuller, Jonathan

2017-10-01

When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical import, is currently the preoccupation of some of the most influential and insightful contributors to the on-going evidence-based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human life. © 2017 John Wiley & Sons, Ltd.

Predicting response to EGFR inhibitors in metastatic colorectal cancer: current practice and future directions.

PubMed

Shankaran, Veena; Obel, Jennifer; Benson, Al B

2010-01-01

The identification of KRAS mutational status as a predictive marker of response to antibodies against the epidermal growth factor receptor (EGFR) has been one of the most significant and practice-changing recent advances in colorectal cancer research. Recently, data suggesting a potential role for other markers (including BRAF mutations, loss of phosphatase and tension homologue deleted on chromosome ten expression, and phosphatidylinositol-3-kinase-AKT pathway mutations) in predicting response to anti-EGFR therapy have emerged. Ongoing clinical trials and correlative analyses are essential to definitively identify predictive markers and develop therapeutic strategies for patients who may not derive benefit from anti-EGFR therapy. This article reviews recent clinical trials supporting the predictive role of KRAS, recent changes to clinical guidelines and pharmaceutical labeling, investigational predictive molecular markers, and newer clinical trials targeting patients with mutated KRAS.

The American Academy of Clinical Neuropsychology, National Academy of Neuropsychology, and Society for Clinical Neuropsychology (APA Division 40) 2015 TCN Professional Practice and 'Salary Survey': Professional Practices, Beliefs, and Incomes of U.S. Neuropsychologists.

PubMed

Sweet, Jerry J; Benson, Laura M; Nelson, Nathaniel W; Moberg, Paul J

2015-01-01

The current survey updated professional practice and income information pertaining to clinical neuropsychology. Doctoral-level members of the American Academy of Clinical Neuropsychology, Division 40 (Clinical Neuropsychology) of the American Psychological Association, and the National Academy of Neuropsychology and other neuropsychologists, as well as postdoctoral trainees in the Association of Postdoctoral Programs in Clinical Neuropsychology and at other training sites were invited to participate in a web-based survey in early 2015. The sample of 1777 respondents, of whom 1579 were doctoral-level practitioners and 198 were postdoctoral trainees, was larger than the prior 2010 income and practice survey. The substantial proportional change in gender has continued, with women now a clear majority in the postdoctoral trainee sample as well as in the practitioner sample. Dissimilar from the median age trajectory of American Psychological Association members, the median age of clinical neuropsychologists remains essentially unchanged since 1989, indicating a substantial annual influx of young neuropsychologists. The question of whether the Houston Conference training model has become an important influence in the specialty can now be considered settled in the affirmative among postdoctoral trainees and practitioners. Testing assistant usage remains commonplace, and continues to be more common in institutions. The vast majority of clinical neuropsychologists work full-time and very few are unemployed and seeking employment. The numbers of neuropsychologists planning to retire in the coming 5-10 years do not suggest a "baby boomer" effect or an unexpected bolus of planned retirements in the next 10 years that would be large enough to be worrisome. Average length of time reported for evaluations appears to be increasing across time. The most common factors affecting evaluation length were identified, with the top three being: (1) goal of evaluation, (2) stamina/health of examinee, and (3) age of examinee. Pediatric specialists remain more likely than others to work part-time, more likely to work in institutions, report lower incomes than respondents with a lifespan professional identity, and are far more likely to be women. Incomes continue to vary considerably by years of clinical practice, work setting, amount of forensic practice, state, and region of country. Neurologists are the number one referral source in institutions and in private practice, as well as for pediatric, adult, and lifespan practitioners. Learning disability is no longer among the top five conditions seen by pediatric neuropsychologists; traumatic brain injury and seizure disorder are common reasons for clinical evaluations at all age ranges. There is a continued increase in forensic practice and a clear consensus on the use of validity testing. There is a substantial interest in subspecialization board certification, with the greatest interest evident among postdoctoral trainees. Income satisfaction, job satisfaction, and work-life balance satisfaction are higher for men. Job satisfaction varies across general work setting and across age range of practice. Work-life balance satisfaction is moderately correlated with income satisfaction and job satisfaction. Again in this five-year interval survey, a substantial majority of respondents reported increased incomes, despite experiencing substantial negative practice effects related to changes in the US health care system. Numerous breakdowns related to income and professional activities are provided. Professional practice survey information continues to provide valuable perspectives regarding consistency and change in the activities, beliefs, and incomes of US clinical neuropsychologists.

National Service Frameworks and UK general practitioners: street-level bureaucrats at work?

PubMed

Checkland, Kath

2004-11-01

This paper argues that the past decade has seen significant changes in the nature of medical work in general practice in the UK. Increasing pressure to use normative clinical guidelines and the move towards explicit quantitative measures of performance together have the potential to alter the way in which health care is delivered to patients. Whilst it is possible to view these developments from the well-established sociological perspectives of deprofessionalisation and proletarianisation, this paper takes a view of general practice as work, and uses the ideas of Lipsky to analyse practice-level responses to some of these changes. In addition to evidence-based clinical guidelines, National Service Frameworks, introduced by the UK government in 1997, also specify detailed models of service provision that health care providers are expected to follow. As part of a larger study examining the impact of National Service Frameworks in general practice, the response of three practices to the first four NSFs were explored. The failure of NSFs to make a significant impact is compared to the practices' positive responses to purely clinical guidelines such as those developed by the British Hypertension Society. Lipsky's concept of public service workers as 'street-level bureaucrats' is discussed and used as a framework within which to view these findings.

The Experience of Implementing an Interprofessional Research Methods Course for Student Health Professionals of Population Healt and Clinical Practice. Getting the Right Fit

ERIC Educational Resources Information Center

Wilson, Anne

2008-01-01

Purpose: This paper reports on the adaptation of an existing interpretive and critical research methods course in nursing for postgraduate student health professionals in a School of Population Health and Clinical Practice. Methods: A cyclical approach of inquiry, reflection and planning was undertaken by the teaching team to make changes to the…

Types of Programs and Evaluation Processes Needed to Maximize the Pharmacist's Contribution to Society: 2--The Role of the Clinical Sciences.

ERIC Educational Resources Information Center

Gans, John A.; Downs, George E.

1978-01-01

The role of clinical sciences in the continuing education of pharmacists is seen to be primarily in the area of changing the practice of pharmacy. Programs are described that would alter pharmacists' practice setting, namely the services they provide, and thus establish a rationale for pharmacists' need for continuing education. (JMD)

Reliability and Validity of the Evidence-Based Practice Confidence (EPIC) Scale

ERIC Educational Resources Information Center

Salbach, Nancy M.; Jaglal, Susan B.; Williams, Jack I.

2013-01-01

Introduction: The reliability, minimal detectable change (MDC), and construct validity of the evidence-based practice confidence (EPIC) scale were evaluated among physical therapists (PTs) in clinical practice. Methods: A longitudinal mail survey was conducted. Internal consistency and test-retest reliability were estimated using Cronbach's alpha…

Exploring Organizational Characteristics Associated with Practice Changes Following a Mentored Online Educational Module

ERIC Educational Resources Information Center

Rappolt, Susan; Pearce, Kristine; McEwen, Sara; Polatajko, Helene J.

2005-01-01

Introduction: Studies of health professionals' perceptions of barriers to and facilitators of research utilization in clinical practices suggest that structural and resource characteristics of service provider organizations are key determinants of the capacity of individual practitioners to provide evidence-based practices. In this pilot study, we…

Undertaking clinical audit, with reference to a Prescribing Observatory for Mental Health audit of lithium monitoring.

PubMed

Paton, Carol; Barnes, Thomas R E

2014-06-01

Audit is an important tool for quality improvement. The collection of data on clinical performance against evidence-based and clinically relevant standards, which are considered by clinicians to be realistic in routine practice, can usefully prompt reflective practice and the implementation of change. Evidence of participation in clinical audit is required to achieve intended learning outcomes for trainees in psychiatry and revalidation for those who are members of the Royal College of Psychiatrists. This article addresses some of the practical steps involved in conducting an audit project, and, to illustrate key points, draws on lessons learnt from a national, audit-based, quality improvement programme of lithium prescribing and monitoring conducted through the Prescribing Observatory for Mental Health.

Textbooks on tap: using electronic books housed in handheld devices in nursing clinical courses.

PubMed

Williams, Margaret G; Dittmer, Arlis

2009-01-01

Changing technology is creating new ways to approach nursing education and practice. Beginning in 2003, using a quasi-experimental design, this project introduced personal digital assistants (PDAs) as a clinical tool to five experimental and control groups of students and faculty. The handheld device, or PDA, was loaded with e-books for clinical practice. Differences in learning styles and preferences emerged during the different phases of the study. Students were quickly able to master the technology and use the device effectively, reporting that they liked the concise nature of the information obtained. No students expressed dissatisfaction or regret at being in the experimental group. Results and implications for clinical practice, education, and library resources are discussed.

[Introduction of translational research in omics science to clinical anesthesia].

PubMed

Sugino, Shigekazu; Hayase, Tomo; Yamakage, Michiaki

2013-03-01

Much progress has been made in omics research following completion of the Human Genome Project. This comprehensive analysis produced a new discipline (i.e., bioinformatics), and its findings contributed to the clinical practice of anesthesiology. Genomes of patients show genetic variations and may predict the sensitivity to anesthetics and analgesics, incidence of adverse effects, and intensity of postsurgical pain. Changes in the transcriptomes of patients may also reflect anesthesia-related expression profiles of various types of neurons in the brain, and information on such changes may contribute to molecular targeted therapy in anesthetized patients. In addition, novel epigenome research may explain why environments change the phenotypes of clinical anesthesia. We currently hypothesize that female gender is associated with DNA methylation in pain-related and vomiting-related gene promoter regions at the genome-wide level and that epigenetic mechanisms are involved in gender differences in anesthesia practice.

Metabolic and Homeostatic Changes in Seizures and Acquired Epilepsy—Mitochondria, Calcium Dynamics and Reactive Oxygen Species

PubMed Central

Kovac, Stjepana; Dinkova Kostova, Albena T.; Melzer, Nico; Meuth, Sven G.; Gorji, Ali

2017-01-01

Acquired epilepsies can arise as a consequence of brain injury and result in unprovoked seizures that emerge after a latent period of epileptogenesis. These epilepsies pose a major challenge to clinicians as they are present in the majority of patients seen in a common outpatient epilepsy clinic and are prone to pharmacoresistance, highlighting an unmet need for new treatment strategies. Metabolic and homeostatic changes are closely linked to seizures and epilepsy, although, surprisingly, no potential treatment targets to date have been translated into clinical practice. We summarize here the current knowledge about metabolic and homeostatic changes in seizures and acquired epilepsy, maintaining a particular focus on mitochondria, calcium dynamics, reactive oxygen species and key regulators of cellular metabolism such as the Nrf2 pathway. Finally, we highlight research gaps that will need to be addressed in the future which may help to translate these findings into clinical practice. PMID:28885567

Adherence with bisphosphonate therapy and change in bone mineral density among women with osteoporosis or osteopenia in clinical practice.

PubMed

Weycker, D; Lamerato, L; Schooley, S; Macarios, D; Siu Woodworth, T; Yurgin, N; Oster, G

2013-04-01

In clinical practice, adherence with bisphosphonate therapy varies greatly among women with osteoporosis or osteopenia. Our study suggests that better adherence with bisphosphonates confers tangible benefits in terms of graded increases in bone mineral density. Interventions to improve drug adherence should be an important component of disease management. In clinical trials, bisphosphonates have been found to increase bone mineral density (BMD) in women with osteoporosis or osteopenia. In clinical practice, where drug adherence is more variable, change in BMD with bisphosphonate therapy-overall and by level of adherence-is largely unknown. A retrospective cohort study was conducted at Henry Ford Health System (Detroit, MI, USA). Study subjects were women who had low BMD at the left total hip (T-score<-1.0), began oral bisphosphonate therapy, and had ≥1 BMD measurements at the left total hip≥6 months following treatment initiation. Change in BMD was calculated between the most recent pretreatment scan and the first follow-up scan. Adherence (i.e., medication possession ratio (MPR)) was measured from therapy initiation to the first follow-up scan. Among 644 subjects, mean age was 66 years, pretreatment BMD was 0.73 g/cm2, and pretreatment T-score was -1.8. Over a mean follow-up of 27.1 months, mean MPR was 0.57 (95% CI, 0.54 and 0.59), and mean percentage change in BMD was 1.5% (1.1 and 1.9%). Within the MPR strata (five consecutive equi-intervals, from low (0-0.19) to high (0.80-1.0)), mean change in BMD was -0.8% (-1.6 and 0.1%), 0.7% (-0.3 and 1.7%), 2.1% (1.1 and 3.0%), 2.1% (1.4 and 2.9%), and 2.9% (2.3 and 3.5%), respectively. In adjusted analyses, percentage change in BMD was higher (by 1.4-3.4%, p<0.05 for all) in the highest four MPR intervals, respectively, versus MPR 0-0.19. Among women with osteoporosis or osteopenia in clinical practice, better adherence with bisphosphonates appears to confer tangible benefits in terms of increases in BMD.

What do we think we are doing? How might a clinical information network be promoting implementation of recommended paediatric care practices in Kenyan hospitals?

PubMed

English, Mike; Ayieko, Philip; Nyamai, Rachel; Were, Fred; Githanga, David; Irimu, Grace

2017-02-02

The creation of a clinical network was proposed as a means to promote implementation of a set of recommended clinical practices targeting inpatient paediatric care in Kenya. The rationale for selecting a network as a strategy has been previously described. Here, we aim to describe network activities actually conducted over its first 2.5 years, deconstruct its implementation into specific components and provide our 'insider' interpretation of how the network is functioning as an intervention. We articulate key activities that together have constituted network processes over 2.5 years and then utilise a recently published typology of implementation components to give greater granularity to this description from the perspective of those delivering the intervention. Using the Behaviour Change Wheel we then suggest how the network may operate to achieve change and offer examples of change before making an effort to synthesise our understanding in the form of a realist context-mechanism-outcome configuration. We suggest our network is likely to comprise 22 from a total of 73 identifiable intervention components, of which 12 and 10 we consider major and minor components, respectively. At the policy level, we employed clinical guidelines, marketing and communication strategies with intervention characteristics operating through incentivisation, persuasion, education, enablement, modelling and environmental restructuring. These might influence behaviours by enhancing psychological capability, creating social opportunity and increasing motivation largely through a reflective pathway. We previously proposed a clinical network as a solution to challenges implementing recommended practices in Kenyan hospitals based on our understanding of theory and context. Here, we report how we have enacted what was proposed and use a recent typology to deconstruct the intervention into its elements and articulate how we think the network may produce change. We offer a more generalised statement of our theory of change in a context-mechanism-outcome configuration. We hope this will complement a planned independent evaluation of 'how things work', will help others interpret results of change reported more formally in the future and encourage others to consider further examination of networks as means to scale up improvement practices in health in lower income countries.

Lessons learned from a pharmacy practice model change at an academic medical center.

PubMed

Knoer, Scott J; Pastor, John D; Phelps, Pamela K

2010-11-01

The development and implementation of a new pharmacy practice model at an academic medical center are described. Before the model change, decentralized pharmacists responsible for order entry and verification and clinical specialists were both present on the care units. Staff pharmacists were responsible for medication distribution and sterile product preparation. The decentralized pharmacists handling orders were not able to use their clinical training, the practice model was inefficient, and few clinical services were available during evenings and weekends. A task force representing all pharmacy department roles developed a process and guiding principles for the model change, collected data, and decided on a model. Teams consisting of decentralized pharmacists, decentralized pharmacy technicians, and team leaders now work together to meet patients' pharmacy needs and further departmental safety, quality, and cost-saving goals. Decentralized service hours have been expanded through operational efficiencies, including use of automation (e.g., computerized provider order entry, wireless computers on wheels used during rounds with physician teams). Nine clinical specialist positions were replaced by five team leader positions and four pharmacists functioning in decentralized roles. Additional staff pharmacist positions were shifted into decentralized roles, and the hospital was divided into areas served by teams including five to eight pharmacists. Technicians are directly responsible for medication distribution. No individual's job was eliminated. The new practice model allowed better alignment of staff with departmental goals, expanded pharmacy hours and services, more efficient medication distribution, improved employee engagement, and a staff succession plan.

Facilitating and obstructing factors for development of learning in clinical practice: a student perspective.

PubMed

Löfmark, A; Wikblad, K

2001-04-01

The aim of this study was to provide information on what the student nurses found facilitating and obstructing for their learning during clinical practice. Earlier studies of experiences of learning in clinical practice have shown that factors as the possibilities of variations of experiences, the culture of the workplace, and communication between the educational institution and health care facilities are of importance. Less is known about the opportunities which students are given in order to practise the skills that they will be expected to perform as new graduate nurses. The experiences of 47 degree student nurses from two colleges in Sweden were gathered in weekly diaries during their final period of clinical practice. A content analysis technique was used to analyse their diaries. The students emphasized responsibility and independence, opportunities to practise different tasks, and receiving feedback as facilitating factors. Other perceived promoting factors included perceptions of control of the situation and understanding of the 'total picture'. Examples of obstructing factors were the nurses as supervisors not relying on the students, supervision that lacked continuity and lack of opportunities to practise. Perception of their own insufficiency and low self-reliance were drawbacks for some students. Recommended proposals are presented to lecturers and supervising staff concerning organizational and educational changes, and changes of attitudes for elucidating the students' experiences of different facilitating and obstructing factors. Changes may contribute to making easier the students' transition into the nursing profession.

Bringing central line-associated bloodstream infection prevention home: catheter maintenance practices and beliefs of pediatric oncology patients and families.

PubMed

Rinke, Michael L; Chen, Allen R; Milstone, Aaron M; Hebert, Lindsay C; Bundy, David G; Colantuoni, Elizabeth; Fratino, Lisa; Herpst, Cynthia; Kokoszka, Michelle; Miller, Marlene R

2015-04-01

A study was conducted to investigate (1) the extent to which best-practice central line maintenance practices were employed in the homes of pediatric oncology patients and by whom, (2) caregiver beliefs about central line care and central line-associated blood stream infection (CLABSI) risk, (3) barriers to optimal central line care by families, and (4) educational experiences and preferences regarding central line care. Researchers administered a survey to patients and families in a tertiary care pediatric oncology clinic that engaged in rigorous ambulatory and inpatient CLABSI prevention efforts. Of 110 invited patients and caregivers, 105 participated (95% response rate) in the survey (March-May 2012). Of the 50 respondents reporting that they or another caregiver change central line dressings, 48% changed a dressing whenever it was soiled as per protocol (many who did not change dressings per protocol also never personally changed dressings); 67% reported the oncology clinic primarily cares for their child's central line, while 29% reported that an adult caregiver or the patient primarily cares for the central line. Eight patients performed their own line care "always" or "most of the time." Some 13% of respondents believed that it was "slightly likely" or "not at all likely" that their child will get an infection if caregivers do not perform line care practices perfectly every time. Dressing change practices were the most difficult to comply with at home. Some 18% of respondents wished they learned more about line care, and 12% received contradictory training. Respondents cited a variety of preferences regarding line care teaching, although the majority looked to clinic nurses for modeling line care. Interventions aimed at reducing ambulatory CLABSIs should target appropriate educational experiences for adult caregivers and patients and identify ways to improve compliance with best-practice care.

What is the impact of a national postgraduate medical specialist education reform on the daily clinical training 3.5 years after implementation? A questionnaire survey.

PubMed

Mortensen, Lene; Malling, Bente; Ringsted, Charlotte; Rubak, Sune

2010-06-18

Many countries have recently reformed their postgraduate medical education (PGME). New pedagogic initiatives and blueprints have been introduced to improve quality and effectiveness of the education. Yet it is unknown whether these changes improved the daily clinical training. The purpose was to examine the impact of a national PGME reform on the daily clinical training practice. The Danish reform included change of content and format of specialist education in line with outcome-based education using the CanMEDS framework. We performed a questionnaire survey among all hospital doctors in the North Denmark Region. The questionnaire included items on educational appraisal meetings, individual learning plans, incorporating training issues into work routines, supervision and feedback, and interpersonal acquaintance. Data were collected before start and 31/2 years later. Mean score values were compared, and response variables were analysed by multiple regression to explore the relation between the ratings and seniority, type of hospital, type of specialty, and effect of attendance to courses in learning and teaching among respondents. Response rates were 2105/2817 (75%) and 1888/3284 (58%), respectively. We found limited impact on clinical training practice and learning environment. Variances in ratings were hardly affected by type of hospital, whereas belonging to the laboratory specialities compared to other specialties was related to higher ratings concerning all aspects. The impact on daily clinical training practice of a national PGME reform was limited after 31/2 years. Future initiatives must focus on changing the pedagogical competences of the doctors participating in daily clinical training and on implementation strategies for changing educational culture.

Outcomes From Pediatric Gastroenterology Maintenance of Certification Using Web-based Modules.

PubMed

Sheu, Josephine; Chun, Stanford; O'Day, Emily; Cheung, Sara; Cruz, Rusvelda; Lightdale, Jenifer R; Fishman, Douglas S; Bousvaros, Athos; Huang, Jeannie S

2017-05-01

Beginning in 2013, the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) sponsored and developed subspecialty field-specific quality improvement (QI) activities to provide Part 4 Maintenance of Certification (MOC) credit for ongoing certification of pediatric gastroenterologists by the American Board of Pediatrics. Each activity was a Web-based module that measured clinical practice data repeatedly over at least 3 months as participants implemented rapid cycle change. Here, we examine existing variations in clinical practice among participating pediatric gastroenterologists and determine whether completion of Web-based MOC activities improves patient care processes and outcomes. We performed a cross-sectional and prospective analysis of physician and parent-reported clinical practice data abstracted from Web-based MOC modules on the topics of upper endoscopy, colonoscopy, and informed consent collected from pediatric gastroenterologists from North America from 2013 to 2016. Among 134 participating pediatric gastroenterologists, 56% practitioners practiced at an academic institution and most (94%) were NASPGHAN members. Participating physicians reported data from 6300 procedures. At baseline, notable practice variation across measured activities was demonstrated. Much of the rapid cycle changes implemented by participants involved individual behaviors, rather than system/team-based improvement activities. Participants demonstrated significant improvements on most targeted process and quality care outcomes. Pediatric gastroenterologists and parents reported baseline practice variation, and improvement in care processes and outcomes measured during NASPGHAN-sponsored Web-based MOC QI activities. Subspecialty-oriented Web-based MOC QI activities can reveal targets for reducing unwarranted variation in clinical pediatric practice, and can effectively improve care and patient outcomes.

Exploring Organizational Barriers to Strengthening Clinical Supervision of Psychiatric Nursing Staff: A Longitudinal Controlled Intervention Study.

PubMed

Gonge, Henrik; Buus, Niels

2016-05-01

This article reports findings from a longitudinal controlled intervention study of 115 psychiatric nursing staff. The twofold objective of the study was: (a) To test whether the intervention could increase clinical supervision participation and effectiveness of existing supervision practices, and (b) To explore organizational constraints to implementation of these strengthened practices. Questionnaire responses and registration of participation in clinical supervision were registered prior and subsequent to the intervention consisting of an action learning oriented reflection on staff's existing clinical supervision practices. Major organizational changes in the intervention group during the study period obstructed the implementation of strengthened clinical supervision practices, but offered an opportunity for studying the influences of organizational constraints. The main findings were that a) diminishing experience of social support from colleagues was associated with reduced participation in clinical supervision, while b) additional quantitative demands were associated with staff reporting difficulties finding time for supervision. This probably explained a negative development in the experienced effectiveness of supervision. It is concluded that organizational support is an imperative for implementation of clinical supervision.

mHealth: Mobile Technologies to Virtually Bring the Patient Into an Oncology Practice.

PubMed

Pennell, Nathan A; Dicker, Adam P; Tran, Christine; Jim, Heather S L; Schwartz, David L; Stepanski, Edward J

2017-01-01

Accompanied by the change in the traditional medical landscape, advances in wireless technology have led to the development of telehealth or mobile health (mHealth), which offers an unparalleled opportunity for health care providers to continually deliver high-quality care. This revolutionary shift makes the patient the consumer of health care and empowers patients to be the driving force of management of their own health through mobile devices and wearable technology. This article presents an overview of technology as it pertains to clinical practice considerations. Telemedicine is changing the way clinical care is delivered without regard for proximity to the patient, whereas nonclinical telehealth applications affect distance education for consumers or clinicians, meetings, research, continuing medical education, and health care management. Technology has the potential to reduce administrative burdens and improve both efficiency and quality of care delivery in the clinic. Finally, the potential for telehealth approaches as cost-effective ways to improve adherence to treatment is explored. As telehealth advances, health care providers must understand the fundamental framework for applying telehealth strategies to incorporate into successful clinical practice.

Knowledge translation of the American College of Emergency Physicians' clinical policy on syncope using computerized clinical decision support.

PubMed

Melnick, Edward R; Genes, Nicholas G; Chawla, Neal K; Akerman, Meredith; Baumlin, Kevin M; Jagoda, Andy

2010-06-01

To influence physician practice behavior after implementation of a computerized clinical decision support system (CDSS) based upon the recommendations from the 2007 ACEP Clinical Policy on Syncope. This was a pre-post intervention with a prospective cohort and retrospective controls. We conducted a medical chart review of consecutive adult patients with syncope. A computerized CDSS prompting physicians to explain their decision-making regarding imaging and admission in syncope patients based upon ACEP Clinical Policy recommendations was embedded into the emergency department information system (EDIS). The medical records of 410 consecutive adult patients presenting with syncope were reviewed prior to implementation, and 301 records were reviewed after implementation. Primary outcomes were physician practice behavior demonstrated by admission rate and rate of head computed tomography (CT) imaging before and after implementation. There was a significant difference in admission rate pre- and post-intervention (68.1% vs. 60.5% respectively, p = 0.036). There was no significant difference in the head CT imaging rate pre- and post-intervention (39.8% vs. 43.2%, p = 0.358). There were seven physicians who saw ten or more patients during the pre- and post-intervention. Subset analysis of these seven physicians' practice behavior revealed a slight significant difference in the admission rate pre- and post-intervention (74.3% vs. 63.9%, p = 0.0495) and no significant difference in the head CT scan rate pre- and post-intervention (42.9% vs. 45.4%, p = 0.660). The introduction of an evidence-based CDSS based upon ACEP Clinical Policy recommendations on syncope correlated with a change in physician practice behavior in an urban academic emergency department. This change suggests emergency medicine clinical practice guideline recommendations can be incorporated into the physician workflow of an EDIS to enhance the quality of practice.

Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries.

PubMed

Wagaarachchi, P T; Graham, W J; Penney, G C; McCaw-Binns, A; Yeboah Antwi, K; Hall, M H

2001-08-01

The objective of the study described is to assess the feasibility and effectiveness of using a criterion-based clinical audit to measure and improve the quality of obstetric care at the district hospital level in developing countries. The focus is on the management of five life-threatening obstetric complications--hemorrhage, eclampsia, genital tract infection, obstructed labor and uterine rupture was audited using a "before and after" design. The five steps of the audit cycle were followed: establish criteria of good quality care; measure current practice (Review I); feedback findings and set targets; take action to change practice; and re-evaluate practice (Review II). Systematic literature review, panel discussions and pilot work led to the development of 31 audit criteria. Review I included 555 life-threatening complications occurring over 66 hospital-months; Review II included 342 complications over 42 hospital-months. Many common areas for improvement were identified across the four hospitals. Agreed mechanisms for achieving these improvements included clinical protocols, reviews of staffing, and training workshops. Some aspects of clinical monitoring, drug use and record keeping improved significantly between Reviews I and II. Criterion-based clinical audit in four typical district hospitals in Ghana and Jamaica is a feasible and acceptable method for quality assurance and appears to have improved the management of life-threatening obstetric complications.

Dissemination and Adoption of Comparative Effectiveness Research Findings When Findings Challenge Current Practices

PubMed Central

Schneider, Eric C.; Timbie, Justin W.; Fox, D. Steven; Van Busum, Kristin R.; Caloyeras, John P.

2013-01-01

Abstract Insufficient evidence regarding the effectiveness of medical treatments has been identified as a key source of inefficiency in the U.S. healthcare system. Variation in the use of diagnostic tests and treatments for patients with similar symptoms or conditions has been attributed to clinical uncertainty, since the published scientific evidence base does not provide adequate information to determine which treatments are most effective for patients with specific clinical needs. The federal government has made a dramatic investment in comparative effectiveness research (CER), with the expectation that CER will influence clinical practice and improve the efficiency of healthcare delivery. To do this, CER must provide information that supports fundamental changes in healthcare delivery and informs the choice of diagnostic and treatment strategies. This article summarizes findings from a qualitative analysis of the factors that impede the translation of CER into clinical practice and those that facilitate it. A case-study methodology is used to explore the extent to which these factors led to changes in clinical practice following five recent key CER studies. The enabling factors and barriers to translation for each study are discussed, the root causes for the failure of translation common to the studies are synthesized, and policy options that may optimize the impact of future CER—particularly CER funded through the American Recovery and Reinvestment Act of 2009—are proposed. PMID:28083277

The impact of the Quality and Outcomes Framework on practice organisation and service delivery: summary of evidence from two qualitative studies.

PubMed

Checkland, Kath; Harrison, Stephen

2010-01-01

In 2003, the new General Medical Services Contract introduced a pay-for-performance programme know as the Quality and Outcomes Framework (QOF) into UK general practice, with payment for meeting a number of both clinical and organisational quality standards. To investigate in detail the impact of the QOF on practice organisation and service delivery. Two linked qualitative case studies in England and Scotland, using interviews and observation to investigate in depth the impact of the QOF in four general medical practices. A number of significant changes to practice organisation and service delivery were observed, including: changes to practice organisational structures; an increased role for information technology; a move towards a more biomedical form of medical care; and changes to roles and relationships, including the introduction of internal peer-review and surveillance. In spite of this, the practices maintained a narrative of 'no change', arguing that they had 'fitted QOF in' to their routines with little trouble.

Artificial Intelligence: Threat or Boon to Radiologists?

PubMed

Recht, Michael; Bryan, R Nick

2017-11-01

The development and integration of machine learning/artificial intelligence into routine clinical practice will significantly alter the current practice of radiology. Changes in reimbursement and practice patterns will also continue to affect radiology. But rather than being a significant threat to radiologists, we believe these changes, particularly machine learning/artificial intelligence, will be a boon to radiologists by increasing their value, efficiency, accuracy, and personal satisfaction. Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Feasibility and impact of a computer-guided consultation on guideline-based management of COPD in general practice.

PubMed

Angus, Robert M; Thompson, Elizabeth B; Davies, Lisa; Trusdale, Ann; Hodgson, Chris; McKnight, Eddie; Davies, Andrew; Pearson, Mike G

2012-12-01

Applying guidelines is a universal challenge that is often not met. Intelligent software systems that facilitate real-time management during a clinical interaction may offer a solution. To determine if the use of a computer-guided consultation that facilitates the National Institute for Health and Clinical Excellence-based chronic obstructive pulmonary disease (COPD) guidance and prompts clinical decision-making is feasible in primary care and to assess its impact on diagnosis and management in reviews of COPD patients. Practice nurses, one-third of whom had no specific respiratory training, undertook a computer-guided review in the usual consulting room setting using a laptop computer with the screen visible to them and to the patient. A total of 293 patients (mean (SD) age 69.7 (10.1) years, 163 (55.6%) male) with a diagnosis of COPD were randomly selected from GP databases in 16 practices and assessed. Of 236 patients who had spirometry, 45 (19%) did not have airflow obstruction and the guided clinical history changed the primary diagnosis from COPD in a further 24 patients. In the 191 patients with confirmed COPD, the consultations prompted management changes including 169 recommendations for altered prescribing of inhalers (addition or discontinuation, inhaler dose or device). In addition, 47% of the 55 current smokers were referred for smoking cessation support, 12 (6%) for oxygen assessment, and 47 (24%) for pulmonary rehabilitation. Computer-guided consultations are practicable in general practice. Primary care COPD databases were confirmed to contain a significant proportion of incorrectly assigned patients. They resulted in interventions and the rationalisation of prescribing in line with recommendations. Only in 22 (12%) of those fully assessed was no management change suggested. The introduction of a computer-guided consultation offers the prospect of comprehensive guideline quality management.

Paradigm shifts: using a participatory leadership process to redesign health systems.

PubMed

Saleeby, Erin; Holschneider, Christine H; Singhal, Rita

2014-12-01

Physicians have increasingly given up private practices to become members of, and key stakeholders in, large healthcare systems. These systems are currently transforming to meet the Triple Aim: guaranteeing the equitable provision of high-quality, evidence-based care at a reasonable cost. Participatory leadership is an organizational change theory that engages key stakeholders as architects in the transformation process. This review highlights the utility of this leadership strategy in designing care for women's health. Our blueprint describing participatory leadership theory in women's health systems change is discussed in three case studies, highlighting what we call the six Ps of participatory leadership: participants, principles, purpose, process, and power. The 'sixth P', product, can then be substantially influential in changing the paradigm of care. Obstetrics and gynecology is increasingly practiced in large health systems responsible for the health of populations. Innovations in clinical practice impact care at the level of the individual. In order for advances in clinical practice to reach broad populations of women, they must be integrated into a delivery system. Physician engagement in leadership during this time of system transformation is of critical importance.

Changes in pathology test ordering by early career general practitioners: a longitudinal study.

PubMed

Magin, Parker J; Tapley, Amanda; Morgan, Simon; Henderson, Kim; Holliday, Elizabeth G; Davey, Andrew R; Ball, Jean; Catzikiris, Nigel F; Mulquiney, Katie J; van Driel, Mieke L

2017-07-17

To assess the number of pathology tests ordered by general practice registrars during their first 18-24 months of clinical general practice. Longitudinal analysis of ten rounds of data collection (2010-2014) for the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing, multicentre, cohort study of general practice registrars in Australia. The principal analysis employed negative binomial regression in a generalised estimating equations framework (to account for repeated measures on registrars).Setting, participants: General practice registrars in training posts with five of 17 general practice regional training providers in five Australian states. The registrar participation rate was 96.4%. Number of pathology tests requested per consultation. The time unit for analysis was the registrar training term (the 6-month full-time equivalent component of clinical training); registrars contributed data for up to four training terms. 876 registrars contributed data for 114 584 consultations. The number of pathology tests requested increased by 11% (95% CI, 8-15%; P < 0.001) per training term. Contrary to expectations, pathology test ordering by general practice registrars increased significantly during their first 2 years of clinical practice. This causes concerns about overtesting. As established general practitioners order fewer tests than registrars, test ordering may peak during late vocational training and early career practice. Registrars need support during this difficult period in the development of their clinical practice patterns.

Promoting Good Clinical Laboratory Practices and Laboratory Accreditation to Support Clinical Trials in Sub-Saharan Africa

PubMed Central

Shott, Joseph P.; Saye, Renion; Diakité, Moussa L.; Sanogo, Sintry; Dembele, Moussa B.; Keita, Sekouba; Nagel, Mary C.; Ellis, Ruth D.; Aebig, Joan A.; Diallo, Dapa A.; Doumbo, Ogobara K.

2012-01-01

Laboratory capacity in the developing world frequently lacks quality management systems (QMS) such as good clinical laboratory practices, proper safety precautions, and adequate facilities; impacting the ability to conduct biomedical research where it is needed most. As the regulatory climate changes globally, higher quality laboratory support is needed to protect study volunteers and to accurately assess biological parameters. The University of Bamako and its partners have undertaken a comprehensive QMS plan to improve quality and productivity using the Clinical and Laboratory Standards Institute standards and guidelines. The clinical laboratory passed the College of American Pathologists inspection in April 2010, and received full accreditation in June 2010. Our efforts to implement high-quality standards have been valuable for evaluating safety and immunogenicity of malaria vaccine candidates in Mali. Other disease-specific research groups in resource-limited settings may benefit by incorporating similar training initiatives, QMS methods, and continual improvement practices to ensure best practices. PMID:22492138

Creating a future for nursing through interactive planning at the bedside.

PubMed

Foust, J B

1994-01-01

Interactive planning is introduced as an approach to planning amidst change that may be useful in clinical practice. The underlying principles and unique characteristics of interactive planning are presented. In addition, clinical studies suggesting its inherent presence in nursing practice are identified. Effective care planning as a developmental process provides nurses with a favorable opportunity to both contribute to individualized patient care and create our own professional future.

An Australian general practice based strategy to improve chronic disease prevention, and its impact on patient reported outcomes: evaluation of the preventive evidence into practice cluster randomised controlled trial.

PubMed

Harris, Mark Fort; Parker, Sharon M; Litt, John; van Driel, Mieke; Russell, Grant; Mazza, Danielle; Jayasinghe, Upali W; Smith, Jane; Del Mar, Chris; Lane, Riki; Denney-Wilson, Elizabeth

2017-09-08

Implementing evidence-based chronic disease prevention with a practice-wide population is challenging in primary care. PEP Intervention practices received education, clinical audit and feedback and practice facilitation. Patients (40‑69 years) without chronic disease from trial and control practices were invited to participate in baseline and 12 month follow up questionnaires. Patient-recalled receipt of GP services and referral, and the proportion of patients at risk were compared over time and between intervention and control groups. Mean difference in BMI, diet and physical activity between baseline and follow up were calculated and compared using a paired t-test. Change in the proportion of patients meeting the definition for physical activity diet and weight risk was calculated using McNemar's test and multilevel analysis was used to determine the effect of the intervention on follow-up scores. Five hundred eighty nine patients completed both questionnaires. No significant changes were found in the proportion of patients reporting a BP, cholesterol, glucose or weight check in either group. Less than one in six at-risk patients reported receiving lifestyle advice or referral at baseline with little change at follow up. More intervention patients reported attempts to improve their diet and reduce weight. Mean score improved for diet in the intervention group (p = 0.04) but self-reported BMI and PA risk did not significantly change in either group. There was no significant change in the proportion of patients who reported being at-risk for diet, PA or weight, and no changes in PA, diet and BMI in multilevel linear regression adjusted for patient age, sex, practice size and state. There was good fidelity to the intervention but practices varied in their capacity to address changes. The lack of measurable effect within this trial may be attributable to the complexities around behaviour change and/or system change. This trial highlights some of the challenges in providing suitable chronic disease preventive interventions which are both scalable to whole practice populations and meet the needs of diverse practice structures. Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000578808 (29/5/2012). This trial registration is retrospective as our first patient returned their consent on the 21/5/2012. Patient recruitment was ongoing until 31/10/2012.

How well do final year undergraduate medical students master practical clinical skills?

PubMed Central

Störmann, Sylvère; Stankiewicz, Melanie; Raes, Patricia; Berchtold, Christina; Kosanke, Yvonne; Illes, Gabrielle; Loose, Peter; Angstwurm, Matthias W.

2016-01-01

Introduction: The clinical examination and other practical clinical skills are fundamental to guide diagnosis and therapy. The teaching of such practical skills has gained significance through legislative changes and adjustments of the curricula of medical schools in Germany. We sought to find out how well final year undergraduate medical students master practical clinical skills. Methods: We conducted a formative 4-station objective structured clinical examination (OSCE) focused on practical clinical skills during the final year of undergraduate medical education. Participation was voluntary. Besides the examination of heart, lungs, abdomen, vascular system, lymphatic system as well as the neurological, endocrinological or orthopaedic examination we assessed other basic clinical skills (e.g. interpretation of an ECG, reading a chest X-ray). Participants filled-out a questionnaire prior to the exam, inter alia to give an estimate of their performance. Results: 214 final year students participated in our study and achieved a mean score of 72.8% of the total score obtainable. 9.3% of participants (n=20) scored insufficiently (<60%). We found no influence of sex, prior training in healthcare or place of study on performance. Only one third of the students correctly estimated their performance (35.3%), whereas 30.0% and 18.8% over-estimated their performance by 10% and 20% respectively. Discussion: Final year undergraduate medical students demonstrate considerable deficits performing practical clinical skills in the context of a formative assessment. Half of the students over-estimate their own performance. We recommend an institutionalised and frequent assessment of practical clinical skills during undergraduate medical education, especially in the final year. PMID:27579358

The motivation of health professionals to explore research evidence in their practice: An intervention study.

PubMed

Henderson, Amanda; Winch, Sarah; Holzhauser, Kerri; De Vries, Sue

2006-12-01

To assess the impact of multifaceted clinically focused educational strategies that concentrated on introducing dementia care research evidence on health professionals' awareness and inclination to use research findings in their future practice. The promise of evidence-based practice is slow to materialize with the limitations of adopting research findings in practice readily identifiable. A pre- and post-test quasi experimental design. The study involved the administration of: a pretest (baseline), an intervention phase, and a post-test survey, the same research utilization survey. TOOL: The Edmonton Research Orientation Survey (EROS), a self-report tool that asks participants about their attitudes toward research and about their potential to use research findings, was used to determine health professionals' orientation to research. The introduction of dementia care research evidence through multifaceted clinically focused educational strategies to improve practice. This was achieved through a resource team comprising a Clinical Nurse Consultant, as a leader and resource of localized evidence-based knowledge in aged care; an experienced Registered Nurse to support the introduction of strategies and a further experienced educator and clinician to reinforce the importance of evidence in change. Across all the four subscales that are measured in the Edmonton Research Orientation Survey, statistical analysis by independent samples t-test identified that there was no significant change between the before and after measurements. Successful integration of changes based on evidence does not necessarily mean that staff become more aware or are more inclined to use research findings in future to address problems.

Significance of Medicare and Medicaid Programs for the Practice of Medicine

PubMed Central

DeWalt, Darren A.; Oberlander, Jonathan; Carey, Timothy S.; Roper, William L.

2005-01-01

The 1965 legislation that established Medicare and Medicaid declared that the Federal Government would not interfere in clinical medicine. Despite the original intent, Medicare and Medicaid have had tremendous influence on medical practice. In this article, we focus on four policy areas that illustrate the influence of CMS (and its predecessor agencies) on medical practice. We discuss the implications of the relationship between CMS and clinical medicine and how this relationship has changed over time. We conclude with thoughts about potential future efforts at CMS. PMID:17290639

The Diabetes Care Project: an Australian multicentre, cluster randomised controlled trial [study protocol].

PubMed

Leach, Matthew J; Segal, Leonie; Esterman, Adrian; Armour, Caroline; McDermott, Robyn; Fountaine, Tim

2013-12-20

Diabetes mellitus is an increasingly prevalent metabolic disorder that is associated with substantial disease burden. Australia has an opportunity to improve ways of caring for the growing number of people with diabetes, but this may require changes to the way care is funded, organised and delivered. To inform how best to care for people with diabetes, and to identify the extent of change that is required to achieve this, the Diabetes Care Project (DCP) will evaluate the impact of two different, evidence-based models of care (compared to usual care) on clinical quality, patient and provider experience, and cost. The DCP uses a pragmatic, cluster randomised controlled trial design. Accredited general practices that are situated within any of the seven Australian Medicare Locals/Divisions of General Practice that have agreed to take part in the study were invited to participate. Consenting practices will be randomly assigned to one of three treatment groups for approximately 18 to 22 months: (a) control group (usual care); (b) Intervention 1 (which tests improvements that could be made within the current funding model, facilitated through the use of an online chronic disease management network); or (c) Intervention 2 (which includes the same components as Intervention 1, as well as altered funding to support voluntary patient registration with their practice, incentive payments and a care facilitator). Adult patients who attend the enrolled practices and have established (≥12 month's duration) type 1 diabetes mellitus or newly diagnosed or established type 2 diabetes mellitus are invited to participate. Multiple outcomes will be studied, including changes in glycosylated haemoglobin (primary outcome), changes in other biochemical and clinical metrics, incidence of diabetes-related complications, quality of life, clinical depression, success of tailored care, patient and practitioner satisfaction, and budget sustainability. This project responds to a need for robust evidence of the clinical and economic effectiveness of coordinated care for the management of diabetes in the Australian primary care setting. The outcomes of the study will have implications not only for diabetes management, but also for the management of other chronic diseases, both in Australia and overseas. Australian New Zealand Clinical Trials Registry (ACTRN12612000363886); World Health Organisation (U1111-1128-0481).

The future of research in female pelvic medicine.

PubMed

Chao, Jamie; Chai, Toby C

2015-02-01

Female pelvic medicine and reconstructive surgery (FPMRS) was recently recognized as a subspecialty by the American Board of Medical Specialties (ABMS). FPMRS treats female pelvic disorders (FPD) including pelvic organ prolapse (POP), urinary incontinence (UI), fecal incontinence (FI), lower urinary tract symptoms (LUTS), lower urinary tract infections (UTI), pelvic pain, and female sexual dysfunction (FSD). These conditions affect large numbers of individuals, resulting in significant patient, societal, medical, and financial burdens. Given that treatments utilize both medical and surgical approaches, areas of research in FPD necessarily cover a gamut of topics, ranging from mechanistically driven basic science research to randomized controlled trials. While basic science research is slow to impact clinical care, transformational changes in a field occur through basic investigations. On the other hand, clinical research yields incremental changes to clinical care. Basic research intends to change understanding whereas clinical research intends to change practice. However, the best approach is to incorporate both basic and clinical research into a translational program which makes new discoveries and effects positive changes to clinical practice. This review examines current research in FPD, with focus on translational potential, and ponders the future of FPD research. With a goal of improving the care and outcomes in patients with FPD, a strategic collaboration of stakeholders (patients, advocacy groups, physicians, researchers, professional medical associations, legislators, governmental biomedical research agencies, pharmaceutical companies, and medical device companies) is an absolute requirement in order to generate funding needed for FPD translational research.

Understanding general practice: a conceptual framework developed from case studies in the UK NHS.

PubMed

Checkland, Kath

2007-01-01

General practice in the UK is undergoing a period of rapid and profound change. Traditionally, research into the effects of change on general practice has tended to regard GPs as individuals or as members of a professional group. To understand the impact of change, general practices should also be considered as organisations. To use the organisational studies literature to build a conceptual framework of general practice organisations, and to test and develop this empirically using case studies of change in practice. This study used the implementation of National Service Frameworks (NSFs) and the new General Medical Services (GMS) contract as incidents of change. In-depth, qualitative case studies. The design was iterative: each case study was followed by a review of the theoretical ideas. The final conceptual framework was the result of the dynamic interplay between theory and empirical evidence. Five general practices in England, selected using purposeful sampling. Semi-structured interviews with all clinical and managerial personnel in each practice, participant and nonparticipant observation, and examination of documents. A conceptual framework was developed that can be used to understand how and why practices respond to change. This framework enabled understanding of observed reactions to the introduction of NSFs and the new GMS contract. Important factors for generating responses to change included the story that the practice members told about their practice, beliefs about what counted as legitimate work, the role played by the manager, and previous experiences of change. Viewing general practices as small organisations has generated insights into factors that influence responses to change. Change tends to occur from the bottom up and is determined by beliefs about organisational reality. The conceptual framework suggests some questions that can be asked of practices to explain this internal reality.

Dementia due to metabolic causes

MedlinePlus

... may cause confusion and changes in thinking or reasoning. These changes may be short-term or lasting. ... Mazzotta JC, Pomeroy SL, eds. Bradley's Neurology in Clinical Practice . 7th ed. Philadelphia, PA: Elsevier; 2016:chap ...

Introducing practice-based learning and improvement ACGME core competencies into a family medicine residency curriculum.

PubMed

Coleman, Mary Thoesen; Nasraty, Soraya; Ostapchuk, Michael; Wheeler, Stephen; Looney, Stephen; Rhodes, Sandra

2003-05-01

The Accreditation Council for Graduate Medical Education (ACGME) recommends integrating improvement activities into residency training. A curricular change was designed at the Department of Family and Community Medicine, University of Louisville, to address selected ACGME competencies by incorporating practice-based improvement activities into the routine clinical work of family medicine residents. Teams of residents, faculty, and office staff completed clinical improvement projects at three ambulatory care training sites. Residents were given academic credit for participation in team meetings. After 6 months, residents presented results to faculty, medical students, other residents, and staff from all three training sites. Residents, staff, and faculty were recognized for their participation. Resident teams demonstrated ACGME competencies in practice-based improvement: Chart audits indicated improvement in clinical projects; quality improvement tools demonstrated analysis of root causes and understanding of the process; plan-do-study-act cycle worksheets demonstrated the change process. Improvement activities that affect patient care and demonstrate selected ACGME competencies can be successfully incorporated into the daily work of family medicine residents.

Using simulation to prepare for clinical practice.

PubMed

Morgan, James; Green, Victoria; Blair, John

2018-02-01

A significant proportion of medical students feel underprepared for clinical practice, especially in skills such as decision making, prioritisation and prescribing. Changes to medical curricula, including assistantships and shadowing, provide supervised practise, but students remain unable to fully take responsibility for patient care. Simulation may assist in addressing this deficit. A simulation course entitled 'Simulated ward round and professional skills' (SWAPS) was developed to improve student preparation for clinical practice. Preliminary work surveyed 22 foundation doctors to identify perceived areas of weakness and to guide the learning outcomes of the course. Following the design and development of the course, 133 final-year medical students were observed completing a 60-minute simulation scenario aimed at providing experiential learning in a ward environment, reflecting professional practice. Students received structured feedback and completed pre- and post-course questionnaires to evaluate changes in confidence over the learning domains. Qualitative feedback was also collected. A significant proportion of medical students feel underprepared for clinical practice RESULTS: The p values were significant in all assessed domains, indicating a perceived improvement in confidence following the SWAPS course. Qualitative feedback highlighted the perceived utility of the course in exposing students to clinical ward-based scenarios infrequently encountered in their medical curriculum. Students praised the personal feedback received and realism of the simulation. This paper contributes to the growing body of literature supporting the use of simulation to replicate a ward round and the daily roles of a junior doctor. The SWAPS course seems to empower students to take responsibility for clinical decision making and experience some of the realities of foundation training in a simulated setting. © 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

Didactic CME and practice change: don't throw that baby out quite yet.

PubMed

Olson, Curtis A; Tooman, Tricia R

2012-08-01

Skepticism exists regarding the role of continuing medical education (CME) in improving physician performance. The harshest criticism has been reserved for didactic CME. Reviews of the scientific literature on the effectiveness of CME conclude that formal or didactic modes of education have little or no impact on clinical practice. This has led some to argue that didactic CME is a highly questionable use of organizational and financial resources, and a cause of lost opportunities for physicians to engage in meaningful learning. The authors' current program of research has forced them to reconsider the received wisdom regarding the relationship between didactic modes of education and learning, and the role frank dissemination can play in bringing about practice change. The authors argued that the practice of assessing and valuing educational methods based only on their capacity to directly influence practice reflects an impoverished understanding of how change in clinical practice actually occurs. Drawing on case studies research, examples were given of the functions didactic CME served in the interest of improved practice. Reasons were then explored as to why the contribution of didactic CME is often missed or dismissed. The goal was not to advocate for a return to the status quo ante where lecture-based education is the dominant modality, but rather to acknowledge both the limits and potential of this longstanding approach to delivering continuing education.

The scope of private practice nursing in an Australian sample.

PubMed

Wilson, Anne; Averis, Andrea; Walsh, Ken

2004-01-01

The changing Australian health care system is creating new opportunities for nurses who work directly with clients in private practice settings. This study examines the scope of practice of a cohort of nurses in private practice. In a questionnaire sent to 106 self-employed nurse entrepreneurs, questions were asked pertaining to the participants' scope of practice, their clients, the types of services offered, and their fee structures. Questions about scope of practice were divided into domains of clinical practice, business consultancy, education, and research. Quantitative and qualitative data were collected for a final sample 54 eligible responses. Participants had been in private practice for an average of 7.6 years (range: 1-20) and reported a mean of 21 years of nursing experience (range: 4-42) before entering private practice. Over half held diplomas in specialty areas. Most participants reported clinical practice, consultancy, or education as the primary work domain; research was much less important as a work activity. Nurses reported difficulties with building client base and receiving adequate fees for service, particularly in clinical practice. Increasing awareness within the nursing profession and health sector about various aspects of private practice nursing could improve service quality for their clients.

An Ongoing Randomized Clinical Trial in Dysphagia

ERIC Educational Resources Information Center

Robbins, JoAnne; Hind, Jackie; Logemann, Jerilyn

2004-01-01

Most of us who have clinical practices firmly contend that the treatments we provide cause beneficial changes in the lives of our patients. Indeed, our clinical experience engenders strong convictions to the point of believing that withholding treatment creates ethical violations. Intellectually, however, we must recognize that the value of…

Toward an Ecological Perspective of Resident Teaching Clinic

ERIC Educational Resources Information Center

Smith, C. Scott; Francovich, Chris; Morris, Magdalena; Hill, William; Langlois-Winkle, Francine; Rupper, Randall; Roth, Craig; Wheeler, Stephanie; Vo, Anthony

2010-01-01

Teaching clinic managers struggle to convert performance data into meaningful behavioral change in their trainees, and quality improvement measures in medicine have had modest results. This may be due to several factors including clinical performance being based more on team function than individual action, models of best practice that are…

Mentor Teacher Training: A Hybrid Model to Promote Partnering in Candidate Development

ERIC Educational Resources Information Center

Childre, Amy L.; Van Rie, Ginny L.

2015-01-01

In order to promote high quality clinical experiences for teacher candidates, one of the recent changes to educator preparation accreditation standards specifically targeted clinical faculty qualifications. Qualified mentor teachers are critical clinical faculty because they serve as the model for training practices for teacher candidates, the…

Quality assurance and the need to evaluate interventions and audit programme outcomes.

PubMed

Zhao, Min; Vaartjes, Ilonca; Klipstein-Grobusch, Kerstin; Kotseva, Kornelia; Jennings, Catriona; Grobbee, Diederick E; Graham, Ian

2017-06-01

Evidence-based clinical guidelines provide standards for the provision of healthcare. However, these guidelines have been poorly implemented in daily practice. Clinical audit is a quality improvement tool to promote quality of care in daily practice and to improve outcomes through the systematic review of care delivery and implementation of changes. A major priority in the management of subjects with cardiovascular disease (CVD) management is secondary prevention by controlling cardiovascular risk factors and providing appropriate medical treatment. Clinical audits can be applied to monitor modifiable risk factors and evaluate quality improvements of CVD management in daily practice. Existing clinical audits have provided an overview of the burden of risk factors in subjects with CVD and reflect real-world risk factor recording and management. However, consistent and representative data from clinic audits are still insufficient to fully monitor quality improvement of CVD management. Data are lacking in particular from low- and middle-income countries, limiting the evaluation of CVD management quality by clinical audit projects in many settings. To support the development of clinical standards, monitor daily practice performance, and improve quality of care in CVD management at national and international levels, more widespread clinical audits are warranted.

Benchmarking Curriculum Content in Entry-Level Health Professional Education with Special Reference to Health Promotion Practice in Physical Therapy: A Multi-Institutional International Study

ERIC Educational Resources Information Center

Bodner, Michael E.; Rhodes, Ryan E.; Miller, William C.; Dean, Elizabeth

2013-01-01

Health promotion (HP) warrants being a clinical competency for health professionals given the global burden of lifestyle-related conditions; these are largely preventable with lifestyle behavior change. Physical therapists have a practice pattern conducive to HP, including lifestyle behavior change. The extent to which HP content is included in…

Positive Clinical Psychology: a new vision and strategy for integrated research and practice.

PubMed

Wood, Alex M; Tarrier, Nicholas

2010-11-01

This review argues for the development of a Positive Clinical Psychology, which has an integrated and equally weighted focus on both positive and negative functioning in all areas of research and practice. Positive characteristics (such as gratitude, flexibility, and positive emotions) can uniquely predict disorder beyond the predictive power of the presence of negative characteristics, and buffer the impact of negative life events, potentially preventing the development of disorder. Increased study of these characteristics can rapidly expand the knowledge base of clinical psychology and utilize the promising new interventions to treat disorder through promoting the positive. Further, positive and negative characteristics cannot logically be studied or changed in isolation as (a) they interact to predict clinical outcomes, (b) characteristics are neither "positive" or "negative", with outcomes depending on specific situation and concomitant goals and motivations, and (c) positive and negative well-being often exist on the same continuum. Responding to criticisms of the Positive Psychology movement, we do not suggest the study of positive functioning as a separate field of clinical psychology, but rather that clinical psychology itself changes to become a more integrative discipline. An agenda for research and practice is proposed including reconceptualizing well-being, forming stronger collaborations with allied disciplines, rigorously evaluating the new positive interventions, and considering a role for clinical psychologists in promoting well-being as well as treating distress. Copyright © 2010 Elsevier Ltd. All rights reserved.

Clinical PhD graduate student views of their scientist-practitioner training.

PubMed

VanderVeen, Joseph W; Reddy, L Felice; Veilleux, Jennifer C; January, Alicia M; DiLillo, David

2012-09-01

The goal of the scientist-practitioner (S-P) training model is to produce clinical psychologists equipped to integrate and utilize both science and practice in the clinical and research domains. However, much has been written regarding the possible shortcomings of S-P training and whether clinical psychology graduate students are actually gaining the knowledge and skills to integrate science and practice during graduate training and beyond (Chang, Lee, & Hargreaves, 2008; Gelso, 2006; Merlo, Collins, & Bernstein, 2008; Phillips, 1993). As such, the present study assessed ratings of satisfaction, perception of ability, and use of the S-P training model within 653 clinical psychology graduate students enrolled in programs that are members of the Council of University Directors of Clinical Psychology. Findings suggest that students are consistently trained in the integration of science and practice and have confidence in their abilities to apply the S-P integration to research and clinical work. However, despite understanding the ways in which science can influence practice, over one third of students reported that they rarely use science-based decisions when informing clients of the clinical services they will be providing. The implications of these results support the need for a more detailed evaluation of clinical psychology graduate students as well as the use of research-informed practice and the process of providing clients with information they need to make informed choices about treatment. © 2012 Wiley Periodicals, Inc.

The development and evaluation of a 'blended' enquiry based learning model for mental health nursing students: "making your experience count".

PubMed

Rigby, Lindsay; Wilson, Ian; Baker, John; Walton, Tim; Price, Owen; Dunne, Kate; Keeley, Philip

2012-04-01

To meet the demands required for safe and effective care, nurses must be able to integrate theoretical knowledge with clinical practice (Kohen and Lehman, 2008; Polit and Beck, 2008; Shirey, 2006). This should include the ability to adapt research in response to changing clinical environments and the changing needs of service users. It is through reflective practice that students develop their clinical reasoning and evaluation skills to engage in this process. This paper aims to describe the development, implementation and evaluation of a project designed to provide a structural approach to the recognition and resolution of clinical, theoretical and ethical dilemmas identified by 3rd year undergraduate mental health nursing students. This is the first paper to describe the iterative process of developing a 'blended' learning model which provides students with an opportunity to experience the process of supervision and to become more proficient in using information technology to develop and maintain their clinical skills. Three cohorts of student nurses were exposed to various combinations of face to face group supervision and a virtual learning environment (VLE) in order to apply their knowledge of good practice guidelines and evidenced-based practice to identified clinical issues. A formal qualitative evaluation using independently facilitated focus groups was conducted with each student cohort and thematically analysed (Miles & Huberman, 1994). The themes that emerged were: relevance to practice; facilitation of independent learning; and the discussion of clinical issues. The results of this study show that 'blending' face-to-face groups with an e-learning component was the most acceptable and effective form of delivery which met the needs of students' varied learning styles. Additionally, students reported that they were more aware of the importance of clinical supervision and of their role as supervisees. Copyright © 2011 Elsevier Ltd. All rights reserved.

A brief report on the development of a theoretically-grounded intervention to promote patient autonomy and self-management of physiotherapy patients: face validity and feasibility of implementation.

PubMed

Matthews, James; Hall, Amanda M; Hernon, Marian; Murray, Aileen; Jackson, Ben; Taylor, Ian; Toner, John; Guerin, Suzanne; Lonsdale, Chris; Hurley, Deirdre A

2015-07-05

Clinical practice guidelines for the treatment of low back pain suggest the inclusion of a biopsychosocial approach in which patient self-management is prioritized. While many physiotherapists recognise the importance of evidence-based practice, there is an evidence practice gap that may in part be due to the fact that promoting self-management necessitates change in clinical behaviours. Evidence suggests that a patient's motivation and maintenance of self-management behaviours can be positively influenced by the clinician's use of an autonomy supportive communication style. Therefore, the aim of this study was to develop and pilot-test the feasibility of a theoretically derived implementation intervention to support physiotherapists in using an evidence-based autonomy supportive communication style in practice for promoting patient self-management in clinical practice. A systematic process was used to develop the intervention and pilot-test its feasibility in primary care physiotherapy. The development steps included focus groups to identify barriers and enablers for implementation, the theoretical domains framework to classify determinants of change, a behaviour change technique taxonomy to select appropriate intervention components, and forming a testable theoretical model. Face validity and acceptability of the intervention was pilot-tested with two physiotherapists and monitoring their communication with patients over a three-month timeframe. Using the process described above, eight barriers and enablers for implementation were identified. To address these barriers and enablers, a number of intervention components were selected ranging from behaviour change techniques such as, goal-setting, self-monitoring and feedback to appropriate modes of intervention delivery (i.e. continued education meetings and audit and feedback focused coaching). Initial pilot-testing revealed the acceptability of the intervention to recipients and highlighted key areas for refinement prior to scaling up for a definitive trial. The development process utilised in this study ensured the intervention was theory-informed and evidence-based, with recipients signalling its relevance and benefit to their clinical practice. Future research should consider additional intervention strategies to address barriers of social support and those beyond the clinician level.

Embedding evidence-based practice among nursing undergraduates: Results from a pilot study.

PubMed

André, Beate; Aune, Anne G; Brænd, Jorunn A

2016-05-01

Evidence-based practice is currently one of the most important developments in health care. Research in nursing science is rapidly growing; however, translating the knowledge based on this research into clinical practice is often hampered, and may be dependent on reflective skills. The aim of this study was to see how undergraduate nursing students in nursing should increase their skills and knowledge related to evidence-based practice through participation in clinical research projects. A qualitative approach was used in collecting and analyzing the data. Students participated in a pilot clinical research project and a received guidance related to their bachelor thesis. After the project was completed, all students filled in a questionnaire. The students' motivation to participate in this study was reported to be high, but they reported low knowledge related to evidence-based practice. All students reported that their attitude towards evidence-based practice changed in a positive direction during their participation in the project. Evidence-based practice influenced nursing practices by putting more focus on critical thinking, increasing pride and giving a sense of ownership in the clinical field. The curricula and the pedagogical perspectives in nursing education can influence the attitude towards evidence-based practice and skills among nursing bachelor students. Copyright © 2016 Elsevier Ltd. All rights reserved.

Developing education tailored to clinical roles: genetics education for haemophilia nurses.

PubMed

Burke, Sarah; Barker, Colin; Marshall, Dianne

2012-01-01

Genetics is an important component of the clinical work of haemophilia nurses, but little was known about the genetic education needs of haemophilia nurses. To develop, deliver and evaluate genetic education for haemophilia nurses, based on clinical roles. Perceived relevance of genetics to haemophilia nursing practice was explored using electronic voting (response rate 75%, 58/77). A follow-on questionnaire to a volunteer sample of participants explored educational preferences (response rate 41%, 17/41). Results informed development of a two-hour genetics workshop session, evaluated by questionnaire (response rate 67%, 47/70). Genetic competences were considered relevant to the clinical practice of haemophilia nurses, and learning needs were identified. Preference was expressed for education focused on practical skills. During the subsequent workshop, participant confidence ratings significantly increased in the four areas addressed. Planned changes to clinical care and training were reported. Within new areas of advanced nursing practice, learning needs can be addressed by: identifying relevant clinical activities and associated learning needs; creating a strategy and resources using preferred forms of delivery; implementing the strategy; and evaluating its effect. This will enable development of education that addresses the real needs of practising nurses, grounded in their daily clinical practice. Copyright © 2011 Elsevier Ltd. All rights reserved.

The experience of Australian project leaders in encouraging practitioners to adopt research evidence in their clinical practice.

PubMed

Henderson, Amanda J; Davies, Jan; Willet, Michaela R

2006-11-01

This paper describes a qualitative program evaluation which sought to identify factors that either assist or impede the adoption of clinical evidence in everyday practice. Thirteen Australian projects were funded in a competitive grant program to adopt innovative strategies to improve the uptake of research evidence in everyday clinical practice. Project leaders' reports were analysed to collate common themes related to 1) critical elements in successful application of research knowledge, 2) barriers to implementing evidence, and 3) lessons for other organisations that might implement a similar project. Despite the diversity of the methods used to establish projects and the range of topics and clinical settings, many similarities were identified in the perceived critical success elements, barriers, and lessons for adopting clinical evidence. Eighteen themes emerged across the data including: leadership support; key stakeholder involvement; practice changes; communication; resources; education of staff; evaluation of outcomes; consumers; knowledge gaps; adoption/implementing staff; access to knowledge; risk assessment; collaboration; effectiveness of clinical research evidence; structure/organisation; cultural barriers; previous experiences; and information technology. Leaders of projects to adopt evidence in clinical practice identified barriers, critical success elements and lessons that impacted on their projects. A range of influences on the adoption of evidence were identified, and this knowledge can be used to assist others undertaking similar projects.

Training on domestic violence and child safeguarding in general practice: a mixed method evaluation of a pilot intervention.

PubMed

Lewis, Natalia V; Larkins, Cath; Stanley, Nicky; Szilassy, Eszter; Turner, William; Drinkwater, Jessica; Feder, Gene S

2017-03-04

Children's exposure to domestic violence is a type of child maltreatment, yet many general practice clinicians remain uncertain of their child safeguarding responsibilities in the context of domestic violence. We developed an evidence-based pilot training on domestic violence and child safeguarding for general practice teams. The aim of this study was to test and evaluate its feasibility, acceptability and the direction of change in short-term outcome measures. We used a mixed method design which included a pre-post questionnaire survey, qualitative analysis of free-text comments, training observations, and post-training interviews with trainers and participants. The questionnaire survey used a validated scale to measure participants' knowledge, confidence/ self-efficacy, and beliefs/ attitudes towards domestic violence and child safeguarding in the context of domestic violence. Eleven UK general practices were recruited (response rate 55%) and 88 clinicians attended the pilot training. Thirty-seven participants (42%) completed all pre-post questionnaires and nine were interviewed. All training sessions were observed. All six trainers were interviewed. General practice clinicians valued the training materials and teaching styles, opportunities for reflection and delivery by local trainers from both health and children's social services. The training elicited positive changes in total outcome score and knowledge and confidence/ self-efficacy sub scores which remained at 3-month follow up. However, the mean sub score of beliefs and attitudes did not change and the qualitative results were mixed. Two interviewees described changes in their clinical practice. Participants' suggestions for improving the training included incorporating more ethnic and class diversity in the material, using cases with multiple socio economic disadvantages, and addressing multi-agency collaboration in the context of changing and under-resourced services for children. The pilot training for general practice on child safeguarding in the context of domestic violence was feasible and acceptable. It elicited positive changes in clinicians' knowledge and confidence/ self-esteem. The extent to which clinical behaviour changed is unclear, but there are indications of changes in practice by some clinicians. The pilot training requires further refinement and evaluation before implementation.

A multi-institutional quality improvement initiative to transform education for chronic illness care in resident continuity practices.

PubMed

Stevens, David P; Bowen, Judith L; Johnson, Julie K; Woods, Donna M; Provost, Lloyd P; Holman, Halsted R; Sixta, Constance S; Wagner, Ed H

2010-09-01

There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care. To improve training for residents who provide chronic illness care in teaching practice settings. US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure

A Multi-Institutional Quality Improvement Initiative to Transform Education for Chronic Illness Care in Resident Continuity Practices

PubMed Central

Bowen, Judith L.; Johnson, Julie K.; Woods, Donna M.; Provost, Lloyd P.; Holman, Halsted R.; Sixta, Constance S.; Wagner, Ed H.

2010-01-01

BACKGROUND There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care. OBJECTIVE To improve training for residents who provide chronic illness care in teaching practice settings. DESIGN US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives—either a national Collaborative, or a subsequent California Collaborative—to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures—HbA1c <7%, LDL <100 mg/dL, and blood pressure ≤130/80—and three process measures—retinal and foot examinations, and patient self-management goals—were tracked. PARTICIPANTS Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives. INTERVENTIONS Teaching-practice teams—faculty, residents and staff—participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly. RESULTS Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives. CONCLUSIONS These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable. PMID:20737232

Nature and Scope of Certified Nurse-Midwifery Practice in One Large State in the United States.

PubMed

Hastings-Tolsma, Marie; Wilcox Foster, Sarah; Brucker, Mary C; Nodine, Priscilla; Burpo, Rebecca; Camune, Barbara; Griggs, Jackie; Callahan, Tiffany J

2018-04-21

To describe the nature and scope of nurse-midwifery practice in Texas and to determine legislative priorities and practice barriers. Across the globe, midwives are the largest group of maternity care providers despite little known about midwifery practice. With a looming shortage of midwives, there is a pressing need to understand midwives' work environment and scope of practice. Mixed methods research utilizing prospective descriptive survey and interview. An online survey was administered to nurse-midwives practicing in the state of Texas (N=449) with a subset (n=10) telephone interviewed. Descriptive and inferential statistics and content analysis was performed. The survey was completed by 141 midwives with 8 interviewed. Most were older, Caucasian, and held a master's degree. A majority worked full-time, were in clinical practice in larger urban areas, and were employed by a hospital or physician-group. Care was most commonly provided for Hispanic and white women; approximately a quarter could care for greater numbers of patients. Most did not clinically teach midwifery students. Physician practice agreements were believed unnecessary and prescriptive authority requirements restrictive. Legislative issues were typically followed through the professional organization or social media sites; most felt a lack of competence to influence health policy decisions. While most were satisfied with current clinical practice, a majority planned a change in the next 3 to 5 years. An aging midwifery workforce, not representative of the race/ethnicity of the populations served, is underutilized with practice requirements that limit provision of services. Health policy changes are needed to ensure unrestricted practice. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Clinical nurse specialists as entrepreneurs: constrained or liberated.

PubMed

Austin, Lynn; Luker, Karen; Roland, Martin; Ronald, Martin

2006-12-01

This qualitative study explored the experiences of two groups of clinical nurse specialists--continence advisors and tissue viability nurses--working in primary care in the UK. In particular, the study focused on how clinical nurse specialists' relationships with other health-care professionals had an impact on their role. Clinical nurse specialists are recognized worldwide as having expertise in a given field, which they use to develop the practice of others. Additionally, clinical nurse specialists share many of the characteristics of entrepreneurs, which they use to develop services related to their speciality. However, little research has been conducted in relation to clinical nurse specialists' experiences as they attempt to diversify nursing practice. An ethnographic approach was adopted comprising many elements of Glaserian grounded theory. Data were collected via participant observation and face-to-face interviews with 22 clinical nurse specialists. Services provided by clinical nurse specialists were not static, clinical nurse specialists being the main drivers for service developments. However, clinical nurse specialists encountered difficulties when introducing new ideas. Given their role as advisors, clinical nurse specialists lacked authority to bring about change and were dependent on a number of mechanisms to bring about change, including 'cultivating relationships' with more powerful others, most notably the speciality consultant. The UK government has pledged to 'liberate the talents of nurses' so that their skills can be used to progress patient services. This study highlights the fact that a lack of collaborative working practices between health-care professionals led to clinical nurse specialists being constrained. Health-care organizations need to provide an environment in which the entrepreneurial skills of clinical nurse specialists may be capitalized on. In the absence of an outlet for their ideas regarding service developments, clinical nurse specialists may remain dependent on the mechanisms witnessed in this study for some time.

Accelerating what works: using qualitative research methods in developing a change package for a learning collaborative.

PubMed

Sorensen, Asta V; Bernard, Shulamit L

2012-02-01

Learning (quality improvement) collaboratives are effective vehicles for driving coordinated organizational improvements. A central element of a learning collaborative is the change package-a catalogue of strategies, change concepts, and action steps that guide participants in their improvement efforts. Despite a vast literature describing learning collaboratives, little to no information is available on how the guiding strategies, change concepts, and action items are identified and developed to a replicable and actionable format that can be used to make measurable improvements within participating organizations. The process for developing the change package for the Health Resources and Services Administration's (HRSA) Patient Safety and Clinical Pharmacy Services Collaborative entailed environmental scan and identification of leading practices, case studies, interim debriefing meetings, data synthesis, and a technical expert panel meeting. Data synthesis involved end-of-day debriefings, systematic qualitative analyses, and the use of grounded theory and inductive data analysis techniques. This approach allowed systematic identification of innovative patient safety and clinical pharmacy practices that could be adopted in diverse environments. A case study approach enabled the research team to study practices in their natural environments. Use of grounded theory and inductive data analysis techniques enabled identification of strategies, change concepts, and actionable items that might not have been captured using different approaches. Use of systematic processes and qualitative methods in identification and translation of innovative practices can greatly accelerate the diffusion of innovations and practice improvements. This approach is effective whether or not an individual organization is part of a learning collaborative.

Why Ineffective Psychotherapies Appear to Work: A Taxonomy of Causes of Spurious Therapeutic Effectiveness.

PubMed

Lilienfeld, Scott O; Ritschel, Lorie A; Lynn, Steven Jay; Cautin, Robin L; Latzman, Robert D

2014-07-01

The past 40 years have generated numerous insights regarding errors in human reasoning. Arguably, clinical practice is the domain of applied psychology in which acknowledging and mitigating these errors is most crucial. We address one such set of errors here, namely, the tendency of some psychologists and other mental health professionals to assume that they can rely on informal clinical observations to infer whether treatments are effective. We delineate four broad, underlying cognitive impediments to accurately evaluating improvement in psychotherapy-naive realism, confirmation bias, illusory causation, and the illusion of control. We then describe 26 causes of spurious therapeutic effectiveness (CSTEs), organized into a taxonomy of three overarching categories: (a) the perception of client change in its actual absence, (b) misinterpretations of actual client change stemming from extratherapeutic factors, and (c) misinterpretations of actual client change stemming from nonspecific treatment factors. These inferential errors can lead clinicians, clients, and researchers to misperceive useless or even harmful psychotherapies as effective. We (a) examine how methodological safeguards help to control for different CSTEs, (b) delineate fruitful directions for research on CSTEs, and (c) consider the implications of CSTEs for everyday clinical practice. An enhanced appreciation of the inferential problems posed by CSTEs may narrow the science-practice gap and foster a heightened appreciation of the need for the methodological safeguards afforded by evidence-based practice. © The Author(s) 2014.

The Clinical Learning Spiral: A Model to Develop Reflective Practitioners.

ERIC Educational Resources Information Center

Stockhausen, Lynette

1994-01-01

The Clinical Learning Spiral incorporates reflective processes into undergraduate nursing education. It entails successive cycles of four phases: preparative (briefing, planning), constructive (practice development), reflective (debriefing), and reconstructive (planning for change and commitment to action). (SK)

Blurring the boundaries: using institutional ethnography to inquire into health professions education and practice.

PubMed

Ng, Stella L; Bisaillon, Laura; Webster, Fiona

2017-01-01

Qualitative, social science approaches to research have surged in popularity within health professions education (HPE) over the past decade. Institutional ethnography (IE) offers the field another sociological approach to inquiry. Although widely used in nursing and health care research, IE remains relatively uncommon in the HPE research community. This article provides a brief introduction to IE and suggests why HPE researchers may wish to consider it for future studies. Part 1 of this paper presents IE's conceptual grounding in: (i) the entry point to inquiry ('materiality'), (ii) a generous definition of 'work' and (iii) a focus on how 'texts' such as policies, forms and written protocols influence activity. Part 2 of this paper outlines the method's key features through exemplars from our own research. Part 3 discusses the ways in which research that blurs the lines between educational and clinical practice can be both generative for HPE and accomplished using IE. The authors demonstrate the usefulness of IE for studying complex social issues in HPE. It is posited that a key added value of IE is that it goes beyond individual-level explanations of problems and phenomena, yet also closely studies individuals' activities, rather than remaining at an abstract or distant level of analysis. Thereby, IE can result in feasible and meaningful social change at the nexus of health professions education and other social systems such as clinical practice. IE adds to the growing qualitative research toolkit for HPE researchers. It is worth considering because it may enable change through the study of HPE in relation to other social processes, structures and systems, including the clinical practice world. A particular benefit may be found in blending HPE research with research on clinical practice, toward changing practice and policy through IE, given the interrelated nature of these fields. © 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

Hospital culture--why create one?

PubMed

Sovie, M D

1993-01-01

Hospitals, to survive, must be transformed into responsive, participative organizations capable of new practices that produce improved results in both quality of care and service at reduced costs. Creating, managing, and changing the culture are critical leadership functions that will enable the hospital to succeed. Strategic planning and effective implementation of planned change will produce the desired culture. Work restructuring, a focus on quality management along with changes in clinical practices, as well as the care and support processes, are all a part of the necessary hospital cultural revolution.

Caring for individual patients and beyond: enhancing care through secondary use of data in a general practice setting.

PubMed

Tolar, Marianne; Balka, Ellen

2012-07-01

It is argued that with the introduction of electronic medical record (EMR) systems into the primary care sector, data collected can be used for secondary purposes which extend beyond individual patient care (e.g., for chronic disease management, prevention and clinical performance evaluation). However, EMR systems are primarily designed to support clinical tasks, and data entry practices of clinicians focus on the treatment of individual patients. Hence data collected through EMRs is not always useful in meeting these ends. In this paper we follow a community health centre (CHC), and document the changes in work practices of the personnel that were necessary in order to make EMR data useful for secondary purposes. This project followed an action research approach, in which ethnographic data were collected mainly by participant observations, by a researcher who also acted as an IT support person for the clinic's secondary usage of EMR data. Additionally, interviews were carried out with the clinical and administrative personnel of the CHC. The case study demonstrates that meaningful use of secondary data occurs only after a long process, aimed at creating the pre-conditions for meaningful use of secondary data, has taken place. PRECONDITIONS: Specific areas of focus have to be chosen for secondary data use, and initiatives have to be continuously evaluated and adapted to the workflow through a team approach. Collaboration between IT support and physicians is necessary to tailor the software to allow for the collection of clinically relevant data. Data entry procedures may have to be changed to encourage the usage of an agreed-upon coding scheme, required for meaningful use of secondary data. And finally resources in terms of additional personnel or dedicated time are necessary to keep up with data collection and other tasks required as a pre-condition to secondary use of data, communication of the results to the clinic, and eventual re-evaluation. Changes in the work practices observed in this case which were required to support secondary data use from the EMR included completion of additional tasks by clinical and administrative personnel related to the organization of follow-up tasks. Among physicians increased awareness of specific initiatives and guideline compliance in terms of chronic disease management and prevention was noticed. Finally, the clinic was able to evaluate their own practice and present the results to varied stakeholders. The case describes the secondary usage of data by a clinic aimed at improving management of the clinic's patients. It illustrates that creating the pre-conditions for secondary use of data from EMRs is a complex process which can be seen as a shift in paradigms from a focus on individual patient care to chronic disease management and performance measurement. More research is needed about how to best support clinics in the process of change management necessitated by emerging clinical management goals. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

[Approaches, knowledge and capabilities of nurses and physicians regarding evidence-based clinical practice in the Imbadura province (Ecuador)].

PubMed

Molina Mula, Jesús; Muñoz Navarro, Paulina; Vaca Auz, Janeth; Cabascango Cabascango, Carmita; Cabascango Cabascango, Katty

2015-01-01

The research raises the need to increase understanding of organizational and personal factors that influence the attitude and aptitude of each professional, with respect to evidence-based clinical practice. The aim of this study is to describe the transfer of knowledge into clinical practice in hospital units in Imbabura (Ecuador) identifying the obstacles to implementing evidence-based clinical practice validated questionnaire EBPQ-19. A cross-sectional observational study was conducted in hospitals of the Ministry of Public Health of Imbabura of Ecuador took place, including a total of 281 nurses and physicians. Nurses and physicians showed positive attitudes toward evidence-based clinical practice (EBCP) and their use to support clinical decision-making. This research evidences perceptions of professionals on strategies for knowledge transfer and obstacles to carry it out. Significant differences between the perception of the use of EBCP strategies between nurses and physicians are observed. Physicians consider they use them frequently, while nurses acknowledge using them less (chi-square: 105.254, P=.018). In conclusion, we can say that these factors should be considered as necessary to improve the quality of care that is provided to users based on the best available evidence. It is necessary to start developing change interventions in this regard to remedy the current situation of clinical practice based not on evidence, but rather on experience only. Experimental studies demonstrating the effectiveness of strategies to eliminate barriers to scientific evidence-based clinical practice should be conducted. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

Adherence to COPD guidelines in general practice: impact of an educational programme delivered on location in Danish general practices.

PubMed

Ulrik, Charlotte Suppli; Sørensen, Tina Brandt; Højmark, Torben Brunse; Olsen, Kim Rose; Vedsted, Peter

2013-03-01

The general practitioner (GP) is often the first healthcare contact for patients with chronic obstructive pulmonary disease (COPD). To determine whether participating in a standardised educational programme delivered in the GP's own practice is associated with adherence to COPD guidelines. A nationwide register-based observational before and after study was undertaken with a control group of propensity-matched practices (follow-up period 6 months). COPD was defined as age 40+ years and at least two prescriptions for inhaled medication. The educational programme consisted of a 3-hr teaching lesson with a respiratory specialist and five visits by a representative from the sponsoring pharmaceutical company focusing on assessment and management of patients including written algorithms. A one-to-one propensity-matched control group of practices was selected. Register data were used to compare the rate of spirometry testing, preventive consultations, and influenza vaccinations provided to COPD patients and the rate of spirometry testing in non-COPD individuals, assumed to reflect diagnostic activity. Data for 102 participating GP practices were analysed. Participating clinics had a significant increase in preventive consultations and influenza vaccinations (p<0.05). For the control group, a significant change was observed only for influenza vaccinations. No significant change was found when comparing participating and control clinics in the difference-in-difference estimator. However, a significant improvement was observed for the subgroup of 48 clinics with the lowest starting point of spirometry testing. Focused education of GPs and their staff delivered in the GPs' own practices may improve adherence to COPD guidelines, not least for clinics with a high potential for improvement.

Implications of pharmacogenomics for drug development and clinical practice.

PubMed

Ginsburg, Geoffrey S; Konstance, Richard P; Allsbrook, Jennifer S; Schulman, Kevin A

2005-11-14

Pharmacogenomics is likely to be among the first clinical applications of the Human Genome Project and is certain to have an enormous impact on the clinical practice of medicine. Herein, we discuss the potential implications of pharmacogenomics on the drug development process, including drug safety, productivity, market segmentation, market expansion, differentiation, and personalized health care. We also review 3 challenges facing the translation of pharmacogenomics into clinical practice: dependence on information technology, limited health care financing, and the scientific uncertainty surrounding validation of specific applications of the technology. To our knowledge, there is currently no formal agenda to promote and cultivate innovation, to develop progressive information technology, or to obtain the financing that would be required to advance the use of pharmacogenomic technologies in patient care. Although the potential of these technologies is driving change in the development of clinical sciences, it remains to be seen which health care systems level needs will be addressed.

GP Networks as enablers of quality of care: implementing a practice engagement framework in a General Practice Network.

PubMed

Pearce, Christopher; Shearer, Marianne; Gardner, Karina; Kelly, Jill; Xu, Tony Baixian

2012-01-01

This paper describes how the Melbourne East General Practice Network supports general practice to enable quality of care, it describes the challenges and enablers of change, and the evidence of practice capacity building and improved quality of care. Primary care is well known as a place where quality, relatively inexpensive medical care occurs. General practice is made up of multiple small sites with fragmented systems and a funding system that challenges a whole-of-practice approach to clinical care. General Practice Networks support GPs to synthesise complexity and crystallise solutions that enhance general practice beyond current capacity. Through a culture of change management, GP Networks create the link between the practice and the big picture of the whole health system and reduce the isolation of general practice. They distribute information (evidence-based learning and resources) and provide individualised support, responding to practice need and capacity.

Exploring the role of children's dreams in psychoanalytic practice today: a pilot study.

PubMed

Lempen, Olivia; Midgley, Nick

2006-01-01

The aim of this research study was to investigate the role of children's dreams in the practice of child psychoanalysis today, and to explore contemporary psychoanalytic understanding of children's dreams. This pilot study consisted of two stages. The first involved a document analysis of published articles in The Psychoanalytic Study of the Child, making a comparison between those of the early 1950s and the 1990s, in order to see in what way the discourse around children's dreams within the psychoanalytic literature has changed over time. The second stage, based on questionnaires and in-depth interviews, attempted to understand in more detail the way contemporary child analysts, working in the Anna Freudian tradition, think about dreams and use them in their clinical practice. Results suggest that there has been a decreased focus on dreams in a clinical context over time, and that this may partly be a consequence of changing theoretical models and changes in training. When work with dreams does take place, it appears that child analysts have

Study protocol for "Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET)": a pragmatic trial comparing implementation strategies.

PubMed

Gold, Rachel; Hollombe, Celine; Bunce, Arwen; Nelson, Christine; Davis, James V; Cowburn, Stuart; Perrin, Nancy; DeVoe, Jennifer; Mossman, Ned; Boles, Bruce; Horberg, Michael; Dearing, James W; Jaworski, Victoria; Cohen, Deborah; Smith, David

2015-10-16

Little research has directly compared the effectiveness of implementation strategies in any setting, and we know of no prior trials directly comparing how effectively different combinations of strategies support implementation in community health centers. This paper outlines the protocol of the Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET), a trial designed to compare the effectiveness of several common strategies for supporting implementation of an intervention and explore contextual factors that impact the strategies' effectiveness in the community health center setting. This cluster-randomized trial compares how three increasingly hands-on implementation strategies support adoption of an evidence-based diabetes quality improvement intervention in 29 community health centers, managed by 12 healthcare organizations. The strategies are as follows: (arm 1) a toolkit, presented in paper and electronic form, which includes a training webinar; (arm 2) toolkit plus in-person training with a focus on practice change and change management strategies; and (arm 3) toolkit, in-person training, plus practice facilitation with on-site visits. We use a mixed methods approach to data collection and analysis: (i) baseline surveys on study clinic characteristics, to explore how these characteristics impact the clinics' ability to implement the tools and the effectiveness of each implementation strategy; (ii) quantitative data on change in rates of guideline-concordant prescribing; and (iii) qualitative data on the "how" and "why" underlying the quantitative results. The outcomes of interest are clinic-level results, categorized using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, within an interrupted time-series design with segmented regression models. This pragmatic trial will compare how well each implementation strategy works in "real-world" practices. Having a better understanding of how different strategies support implementation efforts could positively impact the field of implementation science, by comparing practical, generalizable methods for implementing clinical innovations in community health centers. Bridging this gap in the literature is a critical step towards the national long-term goal of effectively disseminating and implementing effective interventions into community health centers. ClinicalTrials.gov, NCT02325531.

Building a Knowledge to Action Program in Stroke Rehabilitation.

PubMed

Janzen, Shannon; McIntyre, Amanda; Richardson, Marina; Britt, Eileen; Teasell, Robert

2016-09-01

The knowledge to action (KTA) process proposed by Graham et al (2006) is a framework to facilitate the development and application of research evidence into clinical practice. The KTA process consists of the knowledge creation cycle and the action cycle. The Evidence Based Review of Stroke Rehabilitation is a foundational part of the knowledge creation cycle and has helped guide the development of best practice recommendations in stroke. The Rehabilitation Knowledge to Action Project is an audit-feedback process for the clinical implementation of best practice guidelines, which follows the action cycle. The objective of this review was to: (1) contextualize the Evidence Based Review of Stroke Rehabilitation and Rehabilitation Knowledge to Action Project within the KTA model and (2) show how this process led to improved evidence-based practice in stroke rehabilitation. Through this process, a single centre was able to change clinical practice and promote a culture that supports the use of evidence-based practices in stroke rehabilitation.

Achieving organizational change in pediatric pain management

PubMed Central

Dowden, Stephanie; McCarthy, Maria; Chalkiadis, George

2008-01-01

BACKGROUND: Pain in hospitalized children is often under-treated. Little information exists to guide the process of organizational change with a view to improving pain management practices. OBJECTIVES: To describe the process and results of a hospital-wide review of pain management practices designed to identify deficiencies in service provision and recommend directions for change in a pediatric hospital. DESIGN: Prospective consultation of the clinical staff of a specialist pediatric hospital, using qualitative research methodology involving semistructured individual and group interviews. Recommendations based on the interview findings were made by a hospital-appointed working party. RESULTS: A total of 454 staff (27% of all clinical staff) from a variety of professional backgrounds, representing almost every hospital unit or department, were interviewed. Procedural and persistent (chronic) pain was identified as the area needing the most improvement. Barriers to improving pain management included variability in practice, outmoded beliefs and inadequate knowledge, factors which were seen to contribute to a culture of slow or no change. Recommendations of the working party and changes achieved after the review are described. CONCLUSION: The review process identified deficiencies in the management of pain in children, and barriers to its effective management. With institutional support, the present review has guided improvement. PMID:18719714

Context and contingency in the history of post World War II nursing scholarship in the United States.

PubMed

Fairman, Julie

2008-01-01

To examine the context for the development of nursing scholarship post World War II. Historiographical analysis of the social, political, and cultural context of nursing scholarship in the postwar period, with an understanding of how this context shaped nursing scholarship. The development of nursing scholarship was influenced by three contextual strands: Nurses' use of experiential clinical knowledge to situate practice questions in the changing clinical care milieu of the 1950s to the 1970s; The development of an intellectual genealogy through new educational opportunities at the baccalaureate and graduate level from the 1960s to the 1980s that provided the foundation for reintegrating practice and education; and the creation of a growing cadre of nurse scholars and their political influence on the relationship between power, knowledge, and clinical practice. These formulations are critical for understanding how scholarship changed over time and help us understand contemporary clinical practice, its authority structure, how it helps us define a body of knowledge from which practice proceeds, and then, how it responds to public demands. Nursing scholarship is nested in a particular social, political, economic, and cultural context. This context also determines how and why it is generated, debated, and used. Its production does not always follow a rational, logical pattern. Nursing knowledge development is influenced as much by the political underpinnings of health care as it is by social, economic, cultural, and scientific foundations.

Use of Anthropometry for the Prediction of Regional Body Tissue Distribution in Adults: Benefits and Limitations in Clinical Practice

PubMed Central

Scafoglieri, Aldo; Clarys, Jan Pieter; Cattrysse, Erik; Bautmans, Ivan

2014-01-01

Regional body composition changes with aging. Some of the changes in composition are considered major risk factors for developing obesity related chronic diseases which in turn may lead to increased mortality in adults. The role of anthropometry is well recognized in the screening, diagnosis and follow-up of adults for risk classification, regardless of age. Regional body composition is influenced by a number of intrinsic and extrinsic factors. Therapeutic measures recommended to lower cardiovascular disease risk include lifestyle changes. The aim of this review is to systematically summarize studies that assessed the relationships between anthropometry and regional body composition. The potential benefits and limitations of anthropometry for use in clinical practice are presented and suggestions for future research given. PMID:25489489

Looking good or doing better? Patterns of decoupling in the implementation of clinical directorates.

PubMed

Mascia, Daniele; Morandi, Federica; Cicchetti, Americo

2014-01-01

The interest toward hospital restructuring has risen significantly in recent years. In spite of its potential benefits, often organizational restructuring in health care produces unexpected consequences. Extant research suggests that institutional theory provides a powerful theoretical lens through which hospital restructuring can be described and explained. According to this perspective, the effectiveness of change is strongly related to the extent to which innovative arrangements, tools, or practices are adopted and implemented within hospitals. Whenever these new arrangements require a substantial modification of internal processes and practices, resistance to implementation emerges and organizational change is likely to become neutralized. This study analyzes how hospital organizations engage in decoupling by adopting but not implementing a new organizational model named clinical directorate. We collected primary data on the diffusion of the clinical directorate model, which was mandated by law in the Italian National Health Service to improve hospital services. We surveyed the adoption and implementation of the clinical directorate model by monitoring the presence of clinical governance tools (measures for the quality improvement of hospital services) within single directorates. In particular, we compared hospitals that adopted the model before (early adopters) or after (later adopters) the mandate was introduced. Hospitals were engaged in decoupling by adopting the new arrangement but not implementing internal practices and tools for quality improvement. The introduction of the law significantly affected the decoupling, with late-adopter hospitals being less likely to implement the adopted model. The present research shows that changes in quality improvement processes may vary in relation to policy makers' interventions aimed at boosting the adoption of new hospital arrangements. Hospital administrators need to be aware and identify the institutional changes that might be driven by law to be able to react consistently with expectations of policymakers.

Evaluation of learning from Practical Obstetric Multi-Professional Training and its impact on patient outcomes in Australia using Kirkpatrick's framework: a mixed methods study.

PubMed

Kumar, Arunaz; Sturrock, Sam; Wallace, Euan M; Nestel, Debra; Lucey, Donna; Stoyles, Sally; Morgan, Jenny; Neil, Peter; Schlipalius, Michelle; Dekoninck, Philip

2018-02-17

The aim of this study was to evaluate the implementation of the Practical Obstetric Multi-Professional Training (PROMPT) simulation using the Kirkpatrick's framework. We explored participants' acquisition of knowledge and skills, its impact on clinical outcomes and organisational change to integrate the PROMPT programme as a credentialing tool. We also aimed to assess participants' perception of usefulness of PROMPT in their clinical practice. Mixed methods approach with a pre-test/post-test design. Healthcare network providing obstetric care in Victoria, Australia. Medical and midwifery staff attending PROMPT between 2013 and 2015 (n=508); clinical outcomes were evaluated in two cohorts: 2011-2012 (n=15 361 births) and 2014-2015 (n=12 388 births). Attendance of the PROMPT programme, a simulation programme taught in multidisciplinary teams to facilitate teaching emergency obstetric skills. Clinical outcomes compared before and after embedding PROMPT in educational practice. Assessment of knowledge gained by participants through a qualitative analysis and description of process of embedding PROMPT in educational practice. There was a change in the management of postpartum haemorrhage by early recognition and intervention. The key learning themes described by participants were being prepared with a prior understanding of procedures and equipment, communication, leadership and learning in a safe, supportive environment. Participants reported a positive learning experience and increase in confidence in managing emergency obstetric situations through the PROMPT programme, which was perceived as a realistic demonstration of the emergencies. Participants reported an improvement of both clinical and non-technical skills highlighting principles of teamwork, communication, leadership and prioritisation in an emergency situation. An improvement was observed in management of postpartum haemorrhage, but no significant change was noted in clinical outcomes over a 2-year period after PROMPT. However, the skills acquired by medical and midwifery staff justify embedding PROMPT in educational programmes. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

A Comparison of the Concurrent and Predictive Validity of Three Measures of Readiness to Change Alcohol Use in a Clinical Sample of Adolescents

ERIC Educational Resources Information Center

Maisto, Stephen A.; Krenek, Marketa; Chung, Tammy; Martin, Christopher S.; Clark, Duncan; Cornelius, Jack

2011-01-01

The authors compared 3 measures of readiness to change alcohol use commonly used in clinical research and practice with adolescents: the Readiness Ruler, the SOCRATES (subscales of Recognition and Taking Steps), and a Staging Algorithm. The analysis sample consisted of 161 male and female adolescents presenting for intensive outpatient…

Managing the clinical setting for best nursing practice: a brief overview of contemporary initiatives.

PubMed

Henderson, Amanda; Winch, Sarah

2008-01-01

Leadership strategies are important in facilitating the nursing profession to reach their optimum standards in the practice environment. To compare and contrast the central tenets of contemporary quality initiatives that are commensurate with enabling the environment so that best practice can occur. Democratic leadership, accessible and relevant education and professional development, the incorporation of evidence into practice and the ability of facilities to be responsive to change are core considerations for the successful maintenance of practice standards that are consistent with best nursing practice. While different concerns of management drive the adoption of contemporary approaches, there are many similarities in the how these approaches are translated into action in the clinical setting. Managers should focus on core principles of professional nursing that add value to practice rather than business processes.

Clinical leadership and prevention in practice: is a needs led preventive approach to the delivery of care to improve quality, outcomes and value in primary dental care practice a realistic concept?

PubMed Central

2015-01-01

Background There is a need to improve access to, and the quality of, service delivery in NHS primary dental care. Building public health thinking and leadership capacity in clinicians from primary care teams was seen as an underpinning component to achieving this goal. Clinical teams contributed to service redesign concepts and were contractually supported to embrace a preventive approach. Methods Improvement in quality and preventive focus of dental practice care delivery was explored through determining the impact of several projects, to share how evidence, skill mix and clinical leadership could be utilised in design, implementation and measurement of care outcomes in general dental practice in order to champion and advocate change, during a period of substantial change within the NHS system. The projects were: 1. A needs-led, evidence informed preventive care pathway approach to primary dental care delivery with a focus on quality and outcomes. 2. Building clinical leadership to influence and advocate for improved quality of care; and spread of learning through local professional networks. This comprised two separate projects: improved access for very young children called “Baby Teeth DO Matter” and the production of a clinically led, evidence-based guidance for periodontyal treatment in primary care called “Healthy Gums DO Matter”. Results What worked and what hindered progress, is described. The projects developed understanding of how working with ‘local majorities’ of clinicians influenced, adoption and spread of learning, and the impact in prompting wider policy and contract reform in England. Conclusions The projects identified issues that required change to meet population need. Clinicians were allowed to innovate in an evironment working together with commissioners, patients and public health colleagues. Communication and the development of clinical leadership led to the development of an infrastructure to define care pathways and decision points in the patient's journey. PMID:26392019

Clinical leadership and prevention in practice: is a needs led preventive approach to the delivery of care to improve quality, outcomes and value in primary dental care practice a realistic concept?

PubMed

Bridgman, Colette; McGrady, Michael G

2015-01-01

There is a need to improve access to, and the quality of, service delivery in NHS primary dental care. Building public health thinking and leadership capacity in clinicians from primary care teams was seen as an underpinning component to achieving this goal. Clinical teams contributed to service redesign concepts and were contractually supported to embrace a preventive approach. Improvement in quality and preventive focus of dental practice care delivery was explored through determining the impact of several projects, to share how evidence, skill mix and clinical leadership could be utilised in design, implementation and measurement of care outcomes in general dental practice in order to champion and advocate change, during a period of substantial change within the NHS system. The projects were: 1. A needs-led, evidence informed preventive care pathway approach to primary dental care delivery with a focus on quality and outcomes. 2. Building clinical leadership to influence and advocate for improved quality of care; and spread of learning through local professional networks. This comprised two separate projects: improved access for very young children called “Baby Teeth DO Matter” and the production of a clinically led, evidence-based guidance for periodontyal treatment in primary care called "Healthy Gums DO Matter". What worked and what hindered progress, is described. The projects developed understanding of how working with 'local majorities' of clinicians influenced, adoption and spread of learning, and the impact in prompting wider policy and contract reform in England. The projects identified issues that required change to meet population need. Clinicians were allowed to innovate in an environment working together with commissioners, patients and public health colleagues. Communication and the development of clinical leadership led to the development of an infrastructure to define care pathways and decision points in the patient's journey.

Development and integration of pharmacist clinical services into the patient-centered medical home.

PubMed

Berdine, Hildegarde J; Skomo, Monica L

2012-01-01

To describe the development of pharmacist clinical services within a primary care physician practice using a standardized business plan, the extent of clinical pharmacy service integration into the patient-centered medical home (PCMH), and the clinical changes in the pharmacist's patient cohort. A two-physician primary care/occupational care practice in Pittsburgh, PA, from May 2007 to December 2011. Pharmacist-led clinic receives physician referrals for medication management, adherence, and disease management services. Pharmacist practice in a primary care setting with emphasis on integration of clinical services into the medical home model designed by the American Academy of Family Physicians. Characterization of the patient's pharmacist and services provided by the pharmacist. Glycosylated hemoglobin (A1C), body mass index (BMI), low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, total cholesterol, triglycerides, and blood pressure. The top five primary referral reasons were diabetes self-management, weight management, medication adherence, hypertension, and dyslipidemia management. Improvements in clinical parameters were demonstrated for lipids and A1C at 1 and 2 years after baseline. Statistically significant improvements in BMI also were observed. The pharmacist developed and integrated clinical services into a primary care practice, became an integral member of the clinical team in the two-physician PCMH, and improved patient outcomes.

Clinician-led improvement in cancer care (CLICC) - testing a multifaceted implementation strategy to increase evidence-based prostate cancer care: phased randomised controlled trial - study protocol

PubMed Central

2014-01-01

Background Clinical practice guidelines have been widely developed and disseminated with the aim of improving healthcare processes and patient outcomes but the uptake of evidence-based practice remains haphazard. There is a need to develop effective implementation methods to achieve large-scale adoption of proven innovations and recommended care. Clinical networks are increasingly being viewed as a vehicle through which evidence-based care can be embedded into healthcare systems using a collegial approach to agree on and implement a range of strategies within hospitals. In Australia, the provision of evidence-based care for men with prostate cancer has been identified as a high priority. Clinical audits have shown that fewer than 10% of patients in New South Wales (NSW) Australia at high risk of recurrence after radical prostatectomy receive guideline recommended radiation treatment following surgery. This trial will test a clinical network-based intervention to improve uptake of guideline recommended care for men with high-risk prostate cancer. Methods/Design In Phase I, a phased randomised cluster trial will test a multifaceted intervention that harnesses the NSW Agency for Clinical Innovation (ACI) Urology Clinical Network to increase evidence-based care for men with high-risk prostate cancer following surgery. The intervention will be introduced in nine NSW hospitals over 10 months using a stepped wedge design. Outcome data (referral to radiation oncology for discussion of adjuvant radiotherapy in line with guideline recommended care or referral to a clinical trial of adjuvant versus salvage radiotherapy) will be collected through review of patient medical records. In Phase II, mixed methods will be used to identify mechanisms of provider and organisational change. Clinicians’ knowledge and attitudes will be assessed through surveys. Process outcome measures will be assessed through document review. Semi-structured interviews will be conducted to elucidate mechanisms of change. Discussion The study will be one of the first randomised controlled trials to test the effectiveness of clinical networks to lead changes in clinical practice in hospitals treating patients with high-risk cancer. It will additionally provide direction regarding implementation strategies that can be effectively employed to encourage widespread adoption of clinical practice guidelines. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910. PMID:24884877

Implementing evidence in an onco-haematology nursing unit: a process of change using participatory action research.

PubMed

Abad-Corpa, Eva; Delgado-Hito, Pilar; Cabrero-García, Julio; Meseguer-Liza, Cristobal; Zárate-Riscal, Carmen Lourdes; Carrillo-Alcaraz, Andrés; Martínez-Corbalán, José Tomás; Caravaca-Hernández, Amor

2013-03-01

To implement evidence in a nursing unit and to gain a better understanding of the experience of change within a participatory action research. Study design of a participatory action research type was use from the constructivist paradigm. The analytical-methodological decisions were inspired by Checkland Flexible Systems for evidence implementation in the nursing unit. The study was carried out between March and November 2007 in the isolation unit section for onco-haematological patients in a tertiary level general university hospital in Spain. Accidental sampling was carried out with the participation of six nurses. Data were collected using five group meetings and individual reflections in participants' dairies. The participant observation technique was also carried out by researchers. Data analysis was carried out by content analysis. The rigorous criteria were used: credibility, confirmability, dependence, transferability and reflexivity. A lack of use of evidence in clinical practice is the main problem. The factors involved were identified (training, values, beliefs, resources and professional autonomy). Their daily practice (complexity in taking decisions, variability, lack of professional autonomy and safety) was compared with an ideal situation (using evidence it will be possible to normalise practice and to work more effectively in teams by increasing safety and professional recognition). It was decided to create five working areas about several clinical topics (mucositis, pain, anxiety, satisfaction, nutritional assessment, nauseas and vomiting, pressure ulcers and catheter-related problems) and seven changes in clinical practice were agreed upon together with 11 implementation strategies. Some reflections were made about the features of the study: the changes produced; the strategies used and how to improve them; the nursing 'subculture'; attitudes towards innovation; and the commitment as participants in the study and as healthcare professionals. The findings throw light on the process of change in the healthcare sector. The results are useful to modify nursing practice based on evidence. © 2013 The Authors. International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute.

Bridging the gaps between research, policy and practice in low- and middle-income countries: a survey of health care providers

PubMed Central

Guindon, G. Emmanuel; Lavis, John N.; Becerra-Posada, Francisco; Malek-Afzali, Hossein; Shi, Guang; Yesudian, C. Ashok K.; Hoffman, Steven J.

2010-01-01

Background Gaps continue to exist between research-based evidence and clinical practice. We surveyed health care providers in 10 low- and middle-income countries about their use of research-based evidence and examined factors that may facilitate or impede such use. Methods We surveyed 1499 health care providers practising in one of four areas relevant to the Millennium Development Goals (prevention of malaria, care of women seeking contraception, care of children with diarrhea and care of patients with tuberculosis) in each of China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania. Results The proportion of respondents who reported that research was likely to change their clinical practice if performed and published in their own country (84.6% and 86.0% respectively) was higher than the proportion who reported the same about research and publications from their region (66.4% and 63.1%) or from high-income countries (55.8% and 55.5%). Respondents who were most likely to report that the use of research-based evidence led to changes in their practice included those who reported using clinical practice guidelines in paper format (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.03–2.28), using scientific journals from their own country in paper format (OR 1.70, 95% CI 1.26–2.28), viewing the quality of research performed in their country as above average or excellent (OR 1.93, 95% CI 1.16–3.22); trusting systematic reviews of randomized controlled trials (OR 1.59, 95% CI 1.08–2.35); and having easy access to the Internet (OR 1.90, 95% CI 1.19–3.02). Interpretation Locally conducted or published research has played an important role in changing the professional practice of health care providers surveyed in low- and middle-income countries. Increased investments in local research, or at least in locally adapted publications of research-based evidence from other settings, are therefore needed. Although access to the Internet was viewed as a significant factor in whether research-based evidence led to concrete changes in practice, few respondents reported having easy access to the Internet. Therefore, efforts to improve Internet access in clinical settings need to be accelerated. PMID:20439448

A naturalistic study of changes in pharmacological prescription for borderline personality disorder in clinical practice: from APA to NICE guidelines.

PubMed

Pascual, Juan C; Martín-Blanco, Ana; Soler, Joaquim; Ferrer, Alicia; Tiana, Thais; Alvarez, Enrique; Pérez, Víctor

2010-11-01

Although no psychotropic agents are specifically licensed for the management of borderline personality disorder (BPD), pharmacological treatment appears to be common. This study aimed to examine the drug prescriptions for patients with BPD in clinical practice, analyze the prescription patterns from the appearance of the American Psychiatric Association guidelines in 2001 until the National Institute for Health and Clinical Excellence guidelines in 2009, and identify the factors associated with such prescription of each type of drug. Naturalistic study on 226 consecutive BPD patients admitted to an outpatient BPD program. Socio-demographic, clinical and pharmacological treatment information was collected; factors associated with drug prescription were examined using logistic regression analyses for dichotomous outcomes measures. Changes in prescription patterns over time were also evaluated. Patients received an average of 2.7 drugs; only 6% were drug-free; 56% were taking ≥3 drugs and 30% ≥4 drugs. Over the past 8 years, prescription of antidepressants has remained stable; there has been a significant reduction in prescription of benzodiazepines and an increase in the use of mood stabilizers and atypical antipsychotics. Comorbidity with Axis I disorders was the main factor associated with drug prescription. Drug prescription and polypharmacy are common in the management of BPD in clinical practice.

Educational Value of an Ambulatory Care Experience for Medical Students.

ERIC Educational Resources Information Center

Dutton, Cynthia B.; And Others

1984-01-01

A study to determine whether the conversion of a clinic to a hospital-based internal medicine group practice was associated with changes in medical students' evaluations of their educational experience in the modified clinical setting is described. (MLW)

Body composition analysis techniques in adult and pediatric patients: how reliable are they? How useful are they clinically?

PubMed

Woodrow, Graham

2007-06-01

Complex abnormalities of body composition occur in peritoneal dialysis (PD). These abnormalities reflect changes in hydration, nutrition, and body fat, and they are of major clinical significance. Clinical assessment of these body compartments is insensitive and inaccurate. Frequently, simultaneous changes of hydration, wasting, and body fat content can occur, confounding clinical assessment of each component. Body composition can be described by models of varying complexity that use one or more measurement techniques. "Gold standard" methods provide accurate and precise data, but are not practical for routine clinical use. Dual energy X-ray absorptiometry allows for measurement of regional as well as whole-body composition, which can provide further information of clinical relevance. Simpler techniques such as anthropometry and bioelectrical impedance analysis are suited to routine use in clinic or at the bedside, but may be less accurate. Body composition methodology sometimes makes assumptions regarding relationships between components, particularly in regard to hydration, which may be invalid in pathologic states. Uncritical application of these methods to the PD patient may result in erroneous interpretation of results. Understanding the foundations and limitations of body composition techniques allows for optimal application in clinical practice.

Is the Cognitive Complexity of Commitment-to-Change Statements Associated With Change in Clinical Practice? An Application of Bloom's Taxonomy.

PubMed

Armson, Heather; Elmslie, Tom; Roder, Stefanie; Wakefield, Jacqueline

2015-01-01

This study categorizes 4 practice change options, including commitment-to-change (CTC) statements using Bloom's taxonomy to explore the relationship between a hierarchy of CTC statements and implementation of changes in practice. Our hypothesis was that deeper learning would be positively associated with implementation of planned practice changes. Thirty-five family physicians were recruited from existing practice-based small learning groups. They were asked to use their usual small-group process while exploring an educational module on peripheral neuropathy. Part of this process included the completion of a practice reflection tool (PRT) that incorporates CTC statements containing a broader set of practice change options-considering change, confirmation of practice, and not convinced a change is needed ("enhanced" CTC). The statements were categorized using Bloom's taxonomy and then compared to reported practice implementation after 3 months. Nearly all participants made a CTC statement and successful practice implementation at 3 months. By using the "enhanced" CTC options, additional components that contribute to practice change were captured. Unanticipated changes accounted for one-third of all successful changes. Categorizing statements on the PRT using Bloom's taxonomy highlighted the progression from knowledge/comprehension to application/analysis to synthesis/evaluation. All PRT statements were classified in the upper 2 levels of the taxonomy, and these higher-level (deep learning) statements were related to higher levels of practice implementation. The "enhanced" CTC options captured changes that would not otherwise be identified and may be worthy of further exploration in other CME activities. Using Bloom's taxonomy to code the PRT statements proved useful in highlighting the progression through increasing levels of cognitive complexity-reflecting deep learning. © 2015 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education.

General practice: the DREEM attachment? Comparing the educational environment of hospital and general practice placements.

PubMed

Kelly, Martina; Bennett, Deirdre; O'Flynn, Siun

2012-01-01

The clinical learning environment is changing. General practice placements are now a fundamental part of undergraduate medical education. There is growing recognition that changes in hospital work practices are altering the breadth of exposure available to students. Surprisingly little work has been done comparing the quality of clinical placements between the hospital and community using validated tools. Such comparisons inform curriculum planning and resource allocation. The aim of this study was to compare the quality of the educational environment experienced by junior medical students during hospital and general practice placements using a widely used tool. Following the introduction of a new integrated curriculum, all Year 3 students (n=108) completed a standardised evaluation instrument, the Dundee Ready Education Environment Measure (DREEM) at the end of each of their clinical attachments (two different hospital sites and one in general practice), giving a total of 324 questionnaires. All forms were analysed and input into Graphpad INSTAT version 3. Total DREEM scores as well as subscale scores were calculated for each site. These were compared across sites using a Mann-Whitney U non-parametric test. By comparison with international standards, clinical attachments in our new integrated curriculum were rated highly. In particular, attachments in general practice scored highly with a mean score of 156.6 and perform significantly better (P < 0.01) when compared with the mean score for hospital rotations of 149.0. Significant differences between general practice and hospital rotations exist in the domains of students' perceptions of atmosphere and students' social self-perceptions. Finally, significant differences also emerged in students' perceptions of teachers in general practice when compared to those in the hospital setting. These findings provide evidence of the high-quality educational environment afforded students in primary care. They challenge the traditional emphasis on hospital-based teaching and preempt the question - Is the community a better place for junior students to learn?

Negotiating multiple roles: link teachers in clinical nursing practice.

PubMed

Ramage, Charlotte

2004-02-01

The background to this study was a concern about the teacher's role in clinical practice. Experience suggested that teachers believed that their role in practice was important but that there were significant forces which impeded their ability to move with ease between education and practice. A discrepancy between previous research findings and theoretical discussions, and the reality experienced by teachers, led to the adoption of grounded theory as a way of exploring uncertainties in the situation. Data were gathered over a period of 7 years and involved 28 in-depth interviews with nurses with a range of educational roles, employed in educational institutions and practice settings in inner city and provincial areas in the South of England. The data revealed four categories, 'gaining access', 'negotiating credibility', 'being effective' and the core category 'negotiating multiple roles'. The core category is addressed in this article. Experiences of moving from a position of clinical practitioner to link teacher involved: 'disassembling the self' through leaving behind old identities; 'reconstructing the self' through clarifying new ways of being; and, finally, 'realizing the self' through reciprocal interpersonal activity with students, educational and nursing colleagues. It is inevitable that an individual with a remit for change entering an established social group will experience difficulties in establishing their role. It is also clear that an individual who changes their role within a group to reflect behaviours not congruent with the primary activity in that setting will experience dimensions of social exclusion. Further work needs to address how educational roles can make a significant impact on the everyday lives of students and nurses working in practice. The findings of this study are as relevant for the new roles of practice educator, clinical facilitator and practice placement co-ordinator as they are for link teachers and lecturer practitioners. Several suggestions are made to improve links with practice.

The medicalization of addiction treatment professionals.

PubMed

Roy, A Kenison; Miller, Michael M

2012-01-01

In a previous article, the authors described the changes initiated by recent health care legislation, and how those changes might affect the practice of medicine and the delivery of addiction services. This article reviews the same changes with respect to how they have the potential to change the practice activities of addiction physicians, addiction therapists, addiction counselors and addiction nurses, as well as the activities of administrators and service delivery financial personnel. Developments in delivery systems and the impact of those developments on professionals who work in addiction treatment are considered; current problems, potential solutions, and opportunities for clinicians under health reform are addressed. The goals envisioned for health system reform and the potential for realization of those goals via changes in addiction service delivery design and clinical practice are discussed.

Primary Care Practice Transformation Is Hard Work

PubMed Central

Crabtree, Benjamin F.; Nutting, Paul A.; Miller, William L.; McDaniel, Reuben R.; Stange, Kurt C.; Jaén, Carlos Roberto; Stewart, Elizabeth

2010-01-01

Background Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches. Methods Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change. Results A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with “agents” who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice. Conclusions It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change. PMID:20856145

Clinical decision support provided within physician order entry systems: a systematic review of features effective for changing clinician behavior.

PubMed

Kawamoto, Kensaku; Lobach, David F

2003-01-01

Computerized physician order entry (CPOE) systems represent an important tool for providing clinical decision support. In undertaking this systematic review, our objective was to identify the features of CPOE-based clinical decision support systems (CDSSs) most effective at modifying clinician behavior. For this review, two independent reviewers systematically identified randomized controlled trials that evaluated the effectiveness of CPOE-based CDSSs in changing clinician behavior. Furthermore, each included study was assessed for the presence of 14 CDSS features. We screened 10,023 citations and included 11 studies. Of the 10 studies comparing a CPOE-based CDSS intervention against a non-CDSS control group, 7 reported a significant desired change in professional practice. Moreover, meta-regression analysis revealed that automatic provision of the decision support was strongly associated with improved professional practice (adjusted odds ratio, 23.72; 95% confidence interval, 1.75-infiniti). Thus, we conclude that automatic provision of decision support is a critical feature of successful CPOE-based CDSS interventions.

Information and Communication Technologies for the Dissemination of Clinical Practice Guidelines to Health Professionals: A Systematic Review.

PubMed

De Angelis, Gino; Davies, Barbara; King, Judy; McEwan, Jessica; Cavallo, Sabrina; Loew, Laurianne; Wells, George A; Brosseau, Lucie

2016-11-30

The transfer of research knowledge into clinical practice can be a continuous challenge for researchers. Information and communication technologies, such as websites and email, have emerged as popular tools for the dissemination of evidence to health professionals. The objective of this systematic review was to identify research on health professionals' perceived usability and practice behavior change of information and communication technologies for the dissemination of clinical practice guidelines. We used a systematic approach to retrieve and extract data about relevant studies. We identified 2248 citations, of which 21 studies met criteria for inclusion; 20 studies were randomized controlled trials, and 1 was a controlled clinical trial. The following information and communication technologies were evaluated: websites (5 studies), computer software (3 studies), Web-based workshops (2 studies), computerized decision support systems (2 studies), electronic educational game (1 study), email (2 studies), and multifaceted interventions that consisted of at least one information and communication technology component (6 studies). Website studies demonstrated significant improvements in perceived usefulness and perceived ease of use, but not for knowledge, reducing barriers, and intention to use clinical practice guidelines. Computer software studies demonstrated significant improvements in perceived usefulness, but not for knowledge and skills. Web-based workshop and email studies demonstrated significant improvements in knowledge, perceived usefulness, and skills. An electronic educational game intervention demonstrated a significant improvement from baseline in knowledge after 12 and 24 weeks. Computerized decision support system studies demonstrated variable findings for improvement in skills. Multifaceted interventions demonstrated significant improvements in beliefs about capabilities, perceived usefulness, and intention to use clinical practice guidelines, but variable findings for improvements in skills. Most multifaceted studies demonstrated significant improvements in knowledge. The findings suggest that health professionals' perceived usability and practice behavior change vary by type of information and communication technology. Heterogeneity and the paucity of properly conducted studies did not allow for a clear comparison between studies and a conclusion on the effectiveness of information and communication technologies as a knowledge translation strategy for the dissemination of clinical practice guidelines. ©Gino De Angelis, Barbara Davies, Judy King, Jessica McEwan, Sabrina Cavallo, Laurianne Loew, George A Wells, Lucie Brosseau. Originally published in JMIR Medical Education (http://mededu.jmir.org), 30.11.2016.

Practical perspectives of personalized healthcare in oncology.

PubMed

Hodgson, Darren R; Wellings, Robert; Harbron, Christopher

2012-09-15

There is an increasing prevalence of drug-diagnostic combinations in oncology. This has placed diagnostic stakeholders directly into the complex benefit-risk, cost, value and uncertainty-driven development paradigm traditionally the preserve of the drug development community. In this review we focus on the delivery of the clinical data required to advance such drug-diagnostic combination development programmes and ultimately satisfy regulators and payors of the value of contemporaneous changes in diagnostic and treatment practice. Ideally all stakeholders would like to initially estimate, and ultimately specify, the comparative benefit-risk for a new treatment option with and without changing diagnostic practice. Hence, in an ideal world clinical trial design is focused on acquiring biomarker treatment interaction data. In this review we describe the key scientific and feasibility inputs required to design and deliver such trials and the drivers, advantages and disadvantages associated with departing from this model. We do not discuss the discovery of new biomarkers nor the analytical validation and marketing of diagnostic products. Following on from trial design we describe how subsequent success then depends upon the concepts that guide trial design being driven into the complex world of large, multinational clinical trial delivery. For every aspect of a traditional clinical drug trial such as supply, recruitment and adherence, there is a corresponding concept for the diagnostic element. In practice, this means that each patient's contribution to the decision making data-set is subject to double jeopardy (attrition on clinical outcome and biomarker status). Historically, this has led to significantly reduced power for detecting biomarker-treatment interactions, reduced decision making confidence and a waste of valuable human and financial resources. We describe recent practice changes and experience that have led to the successful delivery of such trials focusing on both pre- and on trial aspects. The former includes the pivotal role of tissue banks in accurate estimation of evaluability and prevalence for biomarker assays and the latter several practices designed to engage and incentivize key stakeholders particularly CRAs and pathologists. The result is that in the new world of developing personalized treatments for cancer patients the real-time acquisition and monitoring of biomarker data receives similar support to that traditionally reserved for clinical outcome data and far more patients contribute to the testing of personalized medicine hypotheses. Copyright © 2012 Elsevier B.V. All rights reserved.

Using data to improve medical practice by measuring processes and outcomes of care.

PubMed

Nelson, E C; Splaine, M E; Godfrey, M M; Kahn, V; Hess, A; Batalden, P; Plume, S K

2000-12-01

The purpose of this article is to help clinicians expand their use of data to improve medical practice performance and to do improvement research. Clinical practices can be viewed as small, complex organizations (microsystems) that produce services for specific patient populations. These services can be greatly improved by embedding measurement into the flow of daily work in the practice. WHY DO IT?: Four good reasons to build measures into daily medical practice are to (1) diagnose strengths and weaknesses in practice performance; (2) improve and innovate in providing care and services using improvement research; (3) manage patients and the practice; and (4) evaluate changes in results over time. It is helpful to have a "physiological" model of a medical practice to analyze the practice, to manage it, and to improve it. One model views clinical practices as microsystems that are designed to generate desired health outcomes for specific subsets of patients and to use resources efficiently. This article provides case study examples to show what an office-based practice might look like if it were using front-line measurement to improve care and services most of the time and to conduct clinical improvement research some of the time. WHAT ARE THE PRINCIPLES FOR USING DATA TO IMPROVE PROCESSES AND OUTCOMES OF CARE?: Principles reflected in the case study examples--such as "Keep Measurement Simple. Think Big and Start Small" and "More Data Is Not Necessarily Better Data. Seek Usefulness, Not Perfection, in Your Measures"--may help guide the development of data to study and improve practice. HOW CAN A PRACTICE START TO USE DATA TO IMPROVE CARE AND CONDUCT IMPROVEMENT RESEARCH?: Practical challenges are involved in starting to use data for enhancing care and improvement research. To increase the odds for success, it would be wise to use a change management strategy to launch the startup plan. Other recommendations include "Establish a Sense of Urgency. (Survival Is Not Mandatory)" and "Create the Guiding Coalition. (A Small, Devoted Group of People Can Change the World)." Over the long term, we must transform thousands of local practice cultures so that useful data are used every day in countless ways to assist clinicians, support staff, patients, families, and communities.

'A good fit?' Bringing the sociology of footwear to the clinical encounter in podiatry services: a narrative review.

PubMed

Nicholls, Emily; Robinson, Victoria; Farndon, Lisa; Vernon, Wesley

2018-01-01

This narrative review explores the ways in which drawing on theories and methods used in sociological work on footwear and identity can contribute to healthcare research with podiatrists and their patients, highlighting recent research in this field, implications for practice and potential areas for future development.Traditionally, research within Podiatry Services has tended to adopt a quantitative, positivist focus, developing separately from a growing body of sociological work exploring the importance of shoes in constructing identity and self-image. Bringing qualitative research drawing on sociological theory and methods to the clinical encounter has real potential to increase our understanding of patient values, motivations and - crucially - any barriers to adopting 'healthier' footwear that they may encounter. Such work can help practitioners to understand why patients may resist making changes to their footwear practices, and help us to devise new ways for practitioners to explore and ultimately break down individual barriers to change (including their own preconceptions as practitioners). This, in turn, may lead to long-term, sustainable changes to footwear practices and improvements in foot health for those with complex health conditions and the wider population. A recognition of the complex links between shoes and identity is opening up space for discussion of patient resistance to footwear changes, and paving the way for future research in this field beyond the temporary 'moment' of the clinical encounter.

Effect of European Clinical Trials Directive on academic drug trials in Denmark: retrospective study of applications to the Danish Medicines Agency 1993-2006.

PubMed

Berendt, Louise; Håkansson, Cecilia; Bach, Karin Friis; Dalhoff, Kim; Andreasen, Per Buch; Petersen, Lene Grejs; Andersen, Elin; Poulsen, Henrik Enghusen

2008-01-05

To determine the impact of the European Union's Clinical Trials Directive on the number of academic drug trials carried out in Denmark. Retrospective review of applications for drug trials to the Danish Medicines Agency, 1993-2006. Applications for drug trials for alternate years were classified as academic or commercial trials. A random subset of academic trials was reviewed for number of participants in and intended monitoring of the trials. Academic and commercial drug trials showed an identical steady decline from 1993 to 2006 and no noticeable change after 2004 when good clinical practice became mandatory for academic trials. The Clinical Trials Directive introduced in May 2004 to ensure good clinical practice for academic drug trials was not associated with a decline in research activity in Denmark; presumably because good clinical practice units had already been in place in Danish universities since 1999. With such an infrastructure academic researchers can do drug trials under the same regulations as drug companies.

Modeling the value for money of changing clinical practice change: a stochastic application in diabetes care.

PubMed

Hoomans, Ties; Abrams, Keith R; Ament, Andre J H A; Evers, Silvia M A A; Severens, Johan L

2009-10-01

Decision making about resource allocation for guideline implementation to change clinical practice is inevitably undertaken in a context of uncertainty surrounding the cost-effectiveness of both clinical guidelines and implementation strategies. Adopting a total net benefit approach, a model was recently developed to overcome problems with the use of combined ratio statistics when analyzing decision uncertainty. To demonstrate the stochastic application of the model for informing decision making about the adoption of an audit and feedback strategy for implementing a guideline recommending intensive blood glucose control in type 2 diabetes in primary care in the Netherlands. An integrated Bayesian approach to decision modeling and evidence synthesis is adopted, using Markov Chain Monte Carlo simulation in WinBUGs. Data on model parameters is gathered from various sources, with effectiveness of implementation being estimated using pooled, random-effects meta-analysis. Decision uncertainty is illustrated using cost-effectiveness acceptability curves and frontier. Decisions about whether to adopt intensified glycemic control and whether to adopt audit and feedback alter for the maximum values that decision makers are willing to pay for health gain. Through simultaneously incorporating uncertain economic evidence on both guidance and implementation strategy, the cost-effectiveness acceptability curves and cost-effectiveness acceptability frontier show an increase in decision uncertainty concerning guideline implementation. The stochastic application in diabetes care demonstrates that the model provides a simple and useful tool for quantifying and exploring the (combined) uncertainty associated with decision making about adopting guidelines and implementation strategies and, therefore, for informing decisions about efficient resource allocation to change clinical practice.

Effectiveness of risk minimization measures for cabergoline-induced cardiac valve fibrosis in clinical practice in Italy.

PubMed

Italiano, Domenico; Bianchini, Elisa; Ilardi, Maura; Cilia, Roberto; Pezzoli, Gianni; Zanettini, Renzo; Vacca, Laura; Stocchi, Fabrizio; Bramanti, Placido; Ciurleo, Rosella; Di Lorenzo, Giuseppe; Polimeni, Giovanni; de Luise, Cynthia; Ross, Douglas; Rijnbeek, Peter; Sturkenboom, Miriam; Trifirò, Gianluca

2015-06-01

On June 2008, the European Medicines Agency (EMA) introduced changes to the Summary of Product Characteristics (SPC) for cabergoline and pergolide, to reduce the risk of cardiac valvulopathy in users of these drugs. To assess the effectiveness of EMA recommendations in Italian clinical practice, we retrospectively reviewed medical charts of patients with degenerative Parkinsonism treated with cabergoline in three large Italian clinics between January 2006 and June 2012. The prevalence and the severity of cardiac valve regurgitation were assessed in patients who stopped cabergoline therapy prior to June 2008 or continued therapy after that date. In addition, the proportion of patients undergoing echocardiographic examination in each cohort was evaluated. A total of 61 patients were available for evaluation. The proportion of patients who underwent a baseline echocardiographic examination increased from 64 % in the period before the 2008 SPC changes to 71 % among those who continued treatment after that date. However, only 18 and 29 % of patients underwent at least two echocardiographic examinations during the pre-SPC and cross-SPC change period, respectively. No severe cardiac valve regurgitation was documented in any of the study patients using cabergoline either prior or after 26th June 2008. Our findings show that the 2008 changes to the SPC resulted in an increase in physicians' awareness of cabergoline-induced valvulopathy risk in Italy. However, only a small percentage of patients underwent serial echocardiography. Further efforts are needed to achieve better compliance with the prescribing guidelines for cabergoline treated patients in clinical practice.

Primary Care Practices' Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement.

PubMed

Cohen, Deborah J; Dorr, David A; Knierim, Kyle; DuBard, C Annette; Hemler, Jennifer R; Hall, Jennifer D; Marino, Miguel; Solberg, Leif I; McConnell, K John; Nichols, Len M; Nease, Donald E; Edwards, Samuel T; Wu, Winfred Y; Pham-Singer, Hang; Kho, Abel N; Phillips, Robert L; Rasmussen, Luke V; Duffy, F Daniel; Balasubramanian, Bijal A

2018-04-01

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.

Physician perspective on incorporation of oncology patient quality-of-life, fatigue, and pain assessment into clinical practice.

PubMed

Hubbard, Joleen M; Grothey, Axel F; McWilliams, Robert R; Buckner, Jan C; Sloan, Jeff A

2014-07-01

Patient-reported outcomes (PROs) such as pain, fatigue, and quality of life (QOL) are important for morbidity and mortality in patients with cancer. Systematic approaches to collect and incorporate PROs into clinical practice are still evolving. We set out to determine the impact of PRO assessment on routine clinical practice. Beginning in July 2010, the symptom assessment questionnaire (SAQ) was administered to every patient in a solid tumor oncology practice at an academic center. The SAQ measures pain, fatigue, and QOL, each on a scale of 0 to 10 points. Results were available to providers before each visit in the electronic medical record. Eighteen months after the SAQ was implemented, an online survey was sent to 83 oncology care providers regarding the use of the SAQ and how it affected their clinical practice, including discussion with patients, duration of visits, and work burden. A total of 53% of care providers completed the online survey, producing 44 evaluable surveys. Of these, 86% of care providers reported using information from the SAQ; > 90% of care providers indicated the SAQ did not change the length of clinic visits or contribute to increased work burden. A majority of care providers felt that the SAQ had helped or enhanced their practice. Providers endorsed the SAQ for facilitating communication with their patients. This study indicates that simple single-item measures of pain, fatigue, and QOL can be incorporated into oncology clinical practice with positive implications for both patients and physicians without increasing duration of visits or work burden. Copyright © 2014 by American Society of Clinical Oncology.

A Learning Collaborative Model to Improve Human Papillomavirus Vaccination Rates in Primary Care.

PubMed

Rand, Cynthia M; Tyrrell, Hollyce; Wallace-Brodeur, Rachel; Goldstein, Nicolas P N; Darden, Paul M; Humiston, Sharon G; Albertin, Christina S; Stratbucker, William; Schaffer, Stanley J; Davis, Wendy; Szilagyi, Peter G

2018-03-01

Human papillomavirus (HPV) vaccination rates remain low, in part because of missed opportunities (MOs) for vaccination. We used a learning collaborative quality improvement (QI) model to assess the effect of a multicomponent intervention on reducing MOs. Study design: pre-post using a QI intervention in 33 community practices and 14 pediatric continuity clinics over 9 months to reduce MOs for HPV vaccination at all visit types. outcome measures comprised baseline and postproject measures of 1) MOs (primary outcome), and 2) HPV vaccine initiation and completion. Process measures comprised monthly chart audits of MOs for HPV vaccination for performance feedback, monthly Plan-Do-Study-Act surveys and pre-post surveys about office systems. providers were trained at the start of the project on offering a strong recommendation for HPV vaccination. Practices implemented provider prompts and/or standing orders and/or reminder/recall if desired, and were provided monthly feedback on MOs to assess their progress. chi-square tests were used to assess changes in office practices, and logistic regression used to assess changes in MOs according to visit type and overall, as well as HPV vaccine initiation and completion. MOs overall decreased (from 73% to 53% in community practices and 62% to 55% in continuity clinics; P < .01, and P = .03, respectively). HPV vaccine initiation increased for both genders in community practices (from 66% to 74% for female, 57% to 65% for male; P < .01), and for male patients in continuity clinics (from 68% to 75%; P = .05). Series completion increased overall in community practices (39% to 43%; P = .04) and for male patients in continuity clinics (from 36% to 44%; P = .03). Office systems changes using a QI model and multicomponent interventions decreased rates of MO for HPV vaccination and increased initiation and completion rates among some gender subgroups. A learning collaborative model provides an effective forum for practices to improve HPV vaccine delivery. Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Implementing clinical governance in English primary care groups/trusts: reconciling quality improvement and quality assurance.

PubMed

Campbell, S M; Sheaff, R; Sibbald, B; Marshall, M N; Pickard, S; Gask, L; Halliwell, S; Rogers, A; Roland, M O

2002-03-01

To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care. Qualitative case studies using semi-structured interviews and documentation review. Twelve purposively sampled PCG/Ts in England. Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members. Participants' perceptions of the role of clinical governance in PCG/Ts. PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment). PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance.

Introducing guidelines into clinical practice.

PubMed

Fowkes, F G; Roberts, C J

1984-04-01

The impetus for guidelines of practice has been accelerated by a worldwide trend towards insurance based systems of health care. In the past it has been the tradition for the clinician to order all the diagnostic procedures that conceivably might help to clarify what is wrong with a patient, or what course of treatment should be followed. This traditional view ignores the stubborn economic reality that resources are finite and that it is no longer possible to be both endlessly generous and continually fair. Making judgements about the need for, and value of, services now forms an important part of coping with this problem. Clinical practice has to strive to be as safe as possible and to produce a given benefit at a socially acceptable cost. Guidelines are recommendations, preferably developed by clinicians themselves, which describe how and when individual clinical activities should be offered in order to achieve these objectives. Utilisation review of current practice is a valuable source of information for the development of guidelines. In the United Kingdom the Royal College of Radiologists attempted to do this in connection with the use of pre-operative chest X-rays. In 1979 they published the findings of a multicentre review of 10,619 consecutive cases of elective non-cardiopulmonary surgery undertaken in 8 centres throughout the United Kingdom. Substantial variations were found in national practice. Use of pre-operative chest X-rays varied from 11.5% of patients in one centre to 54.2% of patients in another centre. The study also found that the chest X-ray report did not seem to have much influence on the decision to operate nor on the decision to use inhalation anaesthesia. The College study failed to find "any evidence at all for the effectiveness of pre-operative chest X-ray when used routinely" and it was estimated that even if the procedure was 10% effective the costs of avoiding one death would be approximately 1 million pounds. These findings provided the impetus for the College to develop guidelines for the use of pre-operative chest X-rays in hospitals in the United Kingdom. Creating a change in clinical practice through the introduction of guidelines is a three stage process: Stage I: introducing the idea of a change in practice. Stage II: introduction of guidelines into clinical practice. Stage III: sustained implementation of guidelines in clinical practice.(ABSTRACT TRUNCATED AT 400 WORDS)

Strategies to translate knowledge related to common musculoskeletal conditions into physiotherapy practice: a systematic review.

PubMed

Bérubé, Marie-Ève; Poitras, Stéphane; Bastien, Marc; Laliberté, Lydie-Anne; Lacharité, Anyck; Gross, Douglas P

2018-03-01

Many physiotherapists underuse evidence-based practice guidelines or recommendations when treating patients with musculoskeletal disorders, yet synthesis of knowledge translation interventions used within the field of physiotherapy fails to offer clear conclusions to guide the implementation of clinical practice guidelines. To evaluate the effectiveness of various knowledge translation interventions used to implement changes in the practice of current physiotherapists treating common musculoskeletal issues. A computerized literature search of MEDLINE, CINHAL and ProQuest of systematic reviews (from inception until May 2016) and primary research studies (from January 2010 until June 2016). Eligibility criteria specified articles evaluating interventions for translating knowledge into physiotherapy practice. Two reviewers independently screened the titles and abstracts, reviewed full-text articles, performed data extraction, and performed quality assessment. Of a total of 13014 articles located and titles and abstracts screened, 34 studies met the inclusion criteria, including three overlapping publications, resulting in 31 individual studies. Knowledge translation interventions appear to have resulted in a positive change in physiotherapist beliefs, attitudes, skills and guideline awareness. However, no consistent improvement in clinical practice, patient and economic outcomes were observed. The studies included had small sample sizes and low methodological quality. The heterogeneity of the studies was not conducive to pooling the data. The intensity and type of knowledge translation intervention seem to have an effect on practice change. More research targeting financial, organizational and regulatory knowledge translation interventions is needed. Copyright © 2017 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Practice-based learning for improvement: the pursuit of clinical excellence.

PubMed

Staker, L V

2000-10-01

Physicians often seem to be paralyzed waiting for a health plan, a health maintenance organization, or an integrated health care system to bring about change or improvement in health care. But small changes in individual practices (microsystems) can have a profound impact on outcomes in an organization (microsystem). With simple graphical measurement tools, physicians can teach patients to measure and empower themselves to learn to improve both their health and their health care. At the same time, physicians can learn a great deal from their patient population data. When these measurement tools and a well-known and widely accepted method for clinical practice improvement called rapid cycle testing were used in a population of patients with diabetes, the average fasting blood sugar changed from 187 to 110 and the average hemoglobin A1c from 10.5 to 7.2. This article shows that measurement using specification charts and control charts in patient care can have a profound impact on patients, physicians, and organizations. Understanding these principles and using time-sequence measurement with graphical data feedback, physicians can engage in practice-based learning and can participate in improvement in the microsystems over which they have control.

Less Therapy Okay for Some with Wilms Tumor?

Cancer.gov

Some children with advanced Wilms tumor, a form of kidney cancer, may be able to skip radiation therapy, findings from an NCI-funded clinical trial show. It’s unclear if the finding will change clinical practice, as this Cancer Currents post reports.

[Factors influencing the course and duration of inpatient child and adolescent psychiatric treatment: between empiricism and clinical reality].

PubMed

Branik, Emil

2003-09-01

In the last two decades considerable changes influenced the scope of inpatient treatment in child and adolescent psychiatry. Proceeding from a literature review dilemmas between available research data and clinical practice will be pointed out. Proposals will be made to take into account the complex developmental processes, the individuality and the social context by psychic impaired children and adolescents requiring hospitalisation. This could improve the transfer of research findings into the clinical practice. It will be argued against a confusion of economical interests with research findings.

Implications of Preparing School Administrators for Knowledge Work Organizations: A Case Study.

ERIC Educational Resources Information Center

Mulkeen, Thomas A.; Cooper, Bruce S.

1992-01-01

The Executive Leadership Program at Fordham University presents a model for practicing school administrators' continuing education that reflects a changing society and schools' changing needs. The program is based on four innovations: an intellectual/change agent approach; a clinical, field-based research experience; an instructional agenda…

Name Changes in Medically Important Fungi and Their Implications for Clinical Practice

PubMed Central

de Hoog, G. Sybren; Chaturvedi, Vishnu; Denning, David W.; Dyer, Paul S.; Frisvad, Jens Christian; Geiser, David; Gräser, Yvonne; Guarro, Josep; Haase, Gerhard; Kwon-Chung, Kyung-Joo; Meyer, Wieland; Pitt, John I.; Samson, Robert A.; Tintelnot, Kathrin; Vitale, Roxana G.; Walsh, Thomas J.

2014-01-01

Recent changes in the Fungal Code of Nomenclature and developments in molecular phylogeny are about to lead to dramatic changes in the naming of medically important molds and yeasts. In this article, we present a widely supported and simple proposal to prevent unnecessary nomenclatural instability. PMID:25297326

The origins of the modern pain clinic at the Mayo Clinic.

PubMed

Weingarten, Toby N; Martin, David P; Bacon, Douglas R

2011-07-01

In the 1970s the practice of pain management evolved from the isolated anesthesiologist practicing pain "on the side" to a multi-disciplinary model. The impetus behind this change remains obscure. To understand how this national trend occurred locally and to examine national institutional challenges which should be reflected at the Mayo Clinic that stimulated the establishment of a modern academic pain practice, we interviewed appropriate staff members and reviewed relevant departmental meeting notes. Following the 1959 departure of Dr. John Lundy from Mayo, Dr. Robert Jones became the primary practitioner of pain procedures in addition to his anesthesiology practice. In 1973, close to his retirement, Jones wrote a letter to the department chairman, Dr. Richard Theye, expressing frustration because this divided practice hindered patient care, education, and research opportunities. In 1974 Dr. Lee Nauss joined Mayo upon residency completion at Virginia Mason where he received training in regional anesthesia and met Dr. John Bonica. Nauss introduced epidural steroid injections, which became in such great demand that other anesthesiologists needed to cover his rooms. Within two months, Theye asked Nauss to create a stand-alone pain clinic. Nauss recruited Dr. Tony Wang and opened the clinic that year. This pain clinic increased patient access, improved resident education, allowed for the establishment of a fellowship program, and produced ground-breaking research (e.g., the human administration of intrathecal morphine). The establishment of the pain clinic addressed the deficiencies of a mixed pain and anesthesia practice. The pain specialist could now focus attention on and provide better access for pain patients, keep current with clinical practice, engage in research, and educate future pain specialists.

The role of clinical governance as a strategy for quality improvement in primary care.

PubMed Central

Campbell, Stephen M; Sweeney, Grace M

2002-01-01

This power considers the process of implementing clinical governance in primary care and its impact on quality improvement. It discuss how clinical governance is being implemented both at the level of Primary Care Organisations and general practices, and the challenges to implementing clinical governance. It also suggests a model for promoting the factors that will help clinical governance improve quality of care. The experience of implementing clinical governance is broadly positive to date. However, the government needs to match its commitment to a ten-year programme of change with realistic timetables to secure the cultural and organisational changes needed to improve quality of care. PMID:12389764

Common Factor Mechanisms in Clinical Practice and Their Relationship with Outcome.

PubMed

Gaitan-Sierra, Carolina; Hyland, Michael E

2015-01-01

This study investigates three common factor mechanisms that could affect outcome in clinical practice: response expectancy, the affective expectation model and motivational concordance. Clients attending a gestalt therapy clinic (30 clients), a sophrology (therapeutic technique) clinic (33 clients) and a homeopathy clinic (31 clients) completed measures of expectancy and the Positive Affect and Negative Affect Schedule (PANAS) before their first session. After 1 month, they completed PANAS and measures of intrinsic motivation, perceived effort and empowerment. Expectancy was not associated with better outcome and was no different between treatments. Although some of the 54 clients who endorsed highest expectations showed substantial improvement, others did not: 19 had no change or deteriorated in positive affect, and 18 had the same result for negative affect. Intrinsic motivation independently predicted changes in negative affect (β = -0.23). Intrinsic motivation (β = 0.24), effort (β = 0.23) and empowerment (β = 0.20) independently predicted positive affect change. Expectancy (β = -0.17) negatively affected changes in positive affect. Clients found gestalt and sophrology to be more intrinsically motivating, empowering and effortful compared with homeopathy. Greater improvement in mood was found for sophrology and gestalt than for homeopathy clients. These findings are inconsistent with response expectancy as a common factor mechanism in clinical practice. The results support motivational concordance (outcome influenced by the intrinsic enjoyment of the therapy) and the affective expectation model (high expectations can lead for some clients to worse outcome). When expectancy correlates with outcome in some other studies, this may be due to confound between expectancy and intrinsic enjoyment. Common factors play an important role in outcome. Intrinsic enjoyment of a therapeutic treatment is associated with better outcome. Active engagement with a therapeutic treatment improves outcome. Unrealistic expectations about a therapeutic treatment can have a negative impact on outcome. Copyright © 2014 John Wiley & Sons, Ltd.

Delineating advanced practice nursing in New Zealand: a national survey.

PubMed

Carryer, J; Wilkinson, J; Towers, A; Gardner, G

2018-03-01

A variety of advanced practice nursing roles and titles have proliferated in response to the changing demands of a population characterized by increasing age and chronic illness. Whilst similarly identified as advanced practice roles, they do not share a common practice profile, educational requirements or legislative direction. The lack of clarity limits comparative research that can inform policy and health service planning. To identify advanced practice roles within nursing titles employed in New Zealand and practice differences between advanced practice and other roles. Replicating recent Australian research, 3255 registered nurses/nurse practitioners in New Zealand completed the amended Advanced Practice Delineation survey tool. The mean domain scores of the predominant advanced practice position were compared with those of other positions. Differences between groups were explored using one-way ANOVA and post hoc between group comparisons. Four nursing position bands were identified: nurse practitioner, clinical nurse specialist, domain-specific and registered nurse. Significant differences between the bands were found on many domain scores. The nurse practitioner and clinical nurse specialist bands had the most similar practice profiles, nurse practitioners being more involved in direct care and professional leadership. Similar to the position of clinical nurse consultant in Australia, those practicing as clinical nurse specialists were deemed to reflect the threshold for advanced practice nursing. The results identified different practice patterns for the identified bands and distinguish the advanced practice nursing roles. By replicating the Australian study of Gardener et al. (2016), this NZ paper extends the international data available to support more evidence-based nursing workforce planning and policy development. © 2017 International Council of Nurses.

Understanding general practice: a conceptual framework developed from case studies in the UK NHS

PubMed Central

Checkland, Kath

2007-01-01

Background General practice in the UK is undergoing a period of rapid and profound change. Traditionally, research into the effects of change on general practice has tended to regard GPs as individuals or as members of a professional group. To understand the impact of change, general practices should also be considered as organisations. Aim To use the organisational studies literature to build a conceptual framework of general practice organisations, and to test and develop this empirically using case studies of change in practice. This study used the implementation of National Service Frameworks (NSFs) and the new General Medical Services (GMS) contract as incidents of change. Design of study In-depth, qualitative case studies. The design was iterative: each case study was followed by a review of the theoretical ideas. The final conceptual framework was the result of the dynamic interplay between theory and empirical evidence. Setting Five general practices in England, selected using purposeful sampling. Method Semi-structured interviews with all clinical and managerial personnel in each practice, participant and non-participant observation, and examination of documents. Results A conceptual framework was developed that can be used to understand how and why practices respond to change. This framework enabled understanding of observed reactions to the introduction of NSFs and the new GMS contract. Important factors for generating responses to change included the story that the practice members told about their practice, beliefs about what counted as legitimate work, the role played by the manager, and previous experiences of change. Conclusion Viewing general practices as small organisations has generated insights into factors that influence responses to change. Change tends to occur from the bottom up and is determined by beliefs about organisational reality. The conceptual framework suggests some questions that can be asked of practices to explain this internal reality. PMID:17244426

Barriers for integrating personalized medicine into clinical practice: a qualitative analysis.

PubMed

Najafzadeh, Mehdi; Davis, Jennifer C; Joshi, Pamela; Marra, Carlo

2013-04-01

Personalized medicine-tailoring interventions based on individual's genetic information-will likely change routine clinical practice in the future. Yet, how practitioners plan to apply genetic information to inform medical decision making remains unclear. We aimed to investigate physician's perception about the future role of personalized medicine, and to identify the factors that influence their decision in using genetic testing in their practice. We conducted three semi-structured focus groups in three health regions (Fraser, Vancouver coastal, and Interior) in British Columbia, Canada. In the focus groups, participants discussed four topics on personalized medicine: (i) physicians' general understanding, (ii) advantages and disadvantages, (iii) potential impact and role in future clinical practice, and (iv) perceived barriers to integrating personalized medicine into clinical practice. Approximately 36% (n = 9) of physicians self-reported that they were not familiar with the concept of personalized medicine. After introducing the concept, the majority of physicians (68%, n = 19 of 28) were interested in incorporating personalized medicine in their practice, provided they have access to the necessary knowledge and tools. Participants mostly believed that genetic developments will directly affect their practice in the future. The key concerns highlighted were physician's access to clinical guidelines and training opportunities for the use of genetic testing and data interpretation. Despite the challenges that personalized medicine can create, in general, physicians in the focus groups expressed strong interest in using genetic information in their practice if they have access to the necessary knowledge and tools. Copyright © 2013 Wiley Periodicals, Inc.

Has evidence-based medicine ever been modern? A Latour-inspired understanding of a changing EBM.

PubMed

Wieringa, Sietse; Engebretsen, Eivind; Heggen, Kristin; Greenhalgh, Trish

2017-10-01

Evidence-based health care (EBHC), previously evidence-based medicine (EBM), is considered by many to have modernized health care and brought it from an authority-based past to a more rationalist, scientific grounding. But recent concerns and criticisms pose serious challenges and urge us to look at the fundamentals of a changing EBHC. In this paper, we present French philosopher Bruno Latour's vision on modernity as a framework to discuss current changes in the discourse on EBHC/EBM. Drawing on Latour's work, we argue that the early EBM movement had a strong modernist agenda with an aim to "purify" clinical reality into a dichotomy of objective "evidence" from nature and subjective "preferences" from human society and culture. However, we argue that this shift has proved impossible to achieve in reality. Several recent developments appear to point to a demise of purified evidence in the EBHC discourse and a growing recognition-albeit implicit and undertheorized-that evidence in clinical decision making is relentlessly situated and contextual. The unique, individual patient, not abstracted truths from distant research studies, must be the starting point for clinical practice. It follows that the EBHC community needs to reconsider the assumption that science should be abstracted from culture and acknowledge that knowledge from human culture and nature both need translation and interpretation. The implications for clinical reasoning are far reaching. We offer some preliminary principles for conceptualizing EBHC as a "situated practice" rather than as a sequence of research-driven abstract decisions. © 2017 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.

COMPARISON OF METHODS FOR ESTIMATING CONTEMPORARY COSTS: AN APPLICATION TO LIVER TRANSPLANTATION IN THE UNITED KINGDOM.

PubMed

Singh, Jeshika; Longworth, Louise

2017-01-01

Our study addresses the important issue of estimating treatment costs from historical data. It is a problem frequently faced by health technology assessment analysts. We compared four approaches used to estimate current costs when good quality contemporary data are not available using liver transplantation as an example. First, the total cost estimates extracted for patients from a cohort study, conducted in the 1990s, were inflated using a published inflation multiplier. Second, resource use estimates from the cohort study were extracted for hepatitis C patients and updated using current unit costs. Third, expert elicitation was carried out to identify changes in clinical practice over time and quantify current resource use. Fourth, routine data on resource use were obtained from National Health Service Blood and Transplant (NHSBT). The first two methods did not account for changes in clinical practice. Also the first was not specific to hepatitis patients. The use of experts confirmed significant changes in clinical practice. However, the quantification of resource use using experts is challenging as clinical specialists may not have a complete overview of clinical pathway. The NHSBT data are the most accurate reflection of transplantation and posttransplantation phase; however, data were not available for the whole pathway of care. The best estimate of total cost, combining NHSBT data and expert elicitation, is £121,211. Observational data from routine care are potentially the most reliable reflection of current resource use. Efforts should be made to make such data readily available and accessible to researchers. Expert elicitation provided reasonable estimates.

Theoretical and practical considerations for teaching diagnostic electronic-nose technologies to clinical laboratory technicians

Treesearch

Alphus D. Wilson

2012-01-01

The rapid development of new electronic technologies and instruments, utilized to perform many current clinical operations in the biomedical field, is changing the way medical health care is delivered to patients. The majority of test results from laboratory analyses, performed with these analytical instruments often prior to clinical examinations, are frequently used...

Changes in Residents' Self-Efficacy Beliefs in a Clinically Rich Graduate Teacher Education Program

ERIC Educational Resources Information Center

Reynolds, Heather M.; Wagle, A. Tina; Mahar, Donna; Yannuzzi, Leigh; Tramonte, Barbara; King, Joseph

2016-01-01

Increasing the clinical preparation of teachers in the United States to meet greater rigor in K-12 education has become a goal of institutions of higher education, especially since the publication of the National Council for the Accreditation of Teacher Education Blue Ribbon Panel Report on Clinical Practice. Using a theoretical framework grounded…

'They've invited me into their world': a focus group with clinicians delivering a behaviour change intervention in a UK contraceptive service.

PubMed

Martin, Jilly; Sheeran, Paschal; Slade, Pauline

2017-02-01

Although teenage conceptions rates in the United Kingdom (UK) have seen a downward trend recently, it remains imperative that contraceptive services for young people continue to improve. To ensure that evidence-based interventions are sustained in clinical practice, it is useful to assess the experiences of those delivering them. This study explores the experiences of sexual health clinicians who were trained to deliver a one-to-one behaviour change intervention aiming to improve contraceptive use in young women. The intervention was set in a UK NHS contraceptive and sexual health service and involved clinicians' facilitating (within one-to-one consultations) the formation of implementation intentions (or 'if-then' plans) that specified when, where and how young women would use contraception. A focus group was conducted with seven clinicians who had delivered the intervention. A thematic analysis of the focus group revealed three overall themes: (1) How the intervention worked in practice; (2) barriers and benefits to delivering the intervention; and (3) positive changes to individual consultation style and wider 'best practice' within the clinic. Our findings show that, with support, clinical staff would be in favour of incorporating if-then planning as a strategy to help promote contraceptive adherence in young women.

Hospice nurses' views on single nurse administration of controlled drugs.

PubMed

Taylor, Vanessa; Middleton-Green, Laura; Carding, Sally; Perkins, Paul

2015-07-01

The involvement of two nurses to dispense and administer controlled drugs is routine practice in most clinical areas despite there being no legal or evidence-based rationale. Indeed, evidence suggests this practice enhances neither safety nor care. Registered nurses at two hospices agreed to change practice to single nurse dispensing and administration of controlled drugs (SNAD). Participants' views on SNAD were evaluated before and after implementation. The aim of this study was to explore the views and experiences of nurses who had implemented SNAD and to identify the views and concerns of those who had not yet experienced SNAD. Data was obtained through semi-structured interviews. Qualitative thematic analysis of interview transcripts identified three key themes: practice to enhance patient benefit and care; practice to enhance nursing care and satisfaction; and practice to enhance organisational safety. The findings have implications for the understanding of influences on medicines safety in clinical practice and for hospice policy makers.

Obstructive sleep apnea among commercial motor vehicle drivers: using evidence-based practice to identify risk factors.

PubMed

Olszewski, Kimberly; Wolf, Debra

2013-11-01

Commercial motor vehicle driving is a hazardous occupation, having the third highest fatality rate among common U.S. jobs. Among the estimated 14 million U.S. commercial motor vehicle drivers, the prevalence of obstructive sleep apnea is reported to be 17% to 28%. Despite the identified increased prevalence of obstructive sleep apnea among commercial motor vehicle drivers, federal law does not require that they be screened for obstructive sleep apnea. This article presents an evidence-based practice change project; the authors developed, implemented, and evaluated a screening program to identify commercial motor vehicle drivers' risk for obstructive sleep apnea during commercial driver medical examinations. The results of this practice change indicated screening for obstructive sleep apnea during the commercial driver medical examination led to improved identification of obstructive sleep apnea risk among commercial motor vehicle drivers and should be a clinical standard in occupational health clinics. Copyright 2013, SLACK Incorporated.

Improvement in Diagnosis and Treat-to-Target Management of Hyperuricemia in Gout: Results from the GEMA-2 Transversal Study on Practice.

PubMed

Perez Ruiz, Fernando; Sanchez-Piedra, Carlos A; Sanchez-Costa, Jesus T; Andrés, Mariano; Diaz-Torne, Cesar; Jimenez-Palop, Mercedes; De Miguel, Eugenio; Moragues, Carmen; Sivera, Francisca

2018-06-01

The objective of the study was to evaluate changes regarding main European League Against Rheumatism (EULAR) recommendations on diagnosis and treatment of gout compared to a previous assessment. The GEMA-2 (Gout Evaluation and MAnagement) is a transversal assessment of practice for gout by rheumatologists. Main outcome variables were improvement of the previous GEMA assessment regarding the rate of crystal-proven diagnosis and that reaching therapeutic serum urate target below 6 mg/dl at last visit. Other management variables (prophylaxis, treatment of flares, lifestyle change advice) were also evaluated along with general characteristics. The sample was powered to include at least 483 patients for up to 50% change. Data on management of 506 patients were retrieved from 38 out of 41 rheumatology units that participated in the previous GEMA audit. Crystal-proved diagnosis rate increased from 26% to 32% (31% improvement) and was higher in gout-dedicated practices; ultrasonography contributed to diagnosis in less than 1% of cases. Therapeutic serum urate at last visit improved from 41% to 64% of all patients (66% of patients on urate-lowering medications), in any case over 50% improvement from the previous assessment. The use of any urate-lowering medication available was not prescribed as per label dosing in patients who failed to achieve target serum urate. Clinical inertia to increase doses of either allopurinol or febuxostat was still present in clinical practice. Over 50% improvement in targeting therapeutic serum urate has been observed, but clinical inertia is still present. Diagnosis is still mostly clinically based, ultrasonography not being commonly contributive. Menarini España.

Socrates was not a pimp: changing the paradigm of questioning in medical education.

PubMed

Kost, Amanda; Chen, Frederick M

2015-01-01

The slang term "pimping" is widely recognized by learners and educators in the clinical learning environment as the act of more senior members of the medical team publicly asking questions of more junior members. Although questioning as a pedagogical practice has many benefits, pimping, as described in the literature, evokes negative emotions in learners and leads to an environment that is not conducive to adult learning. Medical educators may employ pimping as a pedagogic technique because of beliefs that it is a Socratic teaching method. Although problems with pimping have previously been identified, no alternative techniques for questioning in the clinical environment were suggested. The authors posit that using the term "pimping" to describe questioning in medical education is harmful and unprofessional, and they propose clearly defining pimping as "questioning with the intent to shame or humiliate the learner to maintain the power hierarchy in medical education." Explicitly separating pimping from the larger practice of questioning allows the authors to make three recommendations for improving questioning practices. First, educators should examine the purpose of each question they pose to learners. Second, they should apply historic and modern interpretations of Socratic teaching methods that promote critical thinking skills. Finally, they should consider adult learning theories to make concrete changes to their questioning practices. These changes can result in questioning that is more learner centered, aids in the acquisition of knowledge and skills, performs helpful formative and summative assessments of the learner, and improves community in the clinical learning environment.

Eight years' experience of regional audit: an assessment of its value as a clinical governance tool.

PubMed

John, H; Paskins, Z; Hassell, A; Rowe, I F

2010-02-01

Strengthening clinical audit is crucial for improving the quality of healthcare provision. The West Midlands Rheumatology Service and Training Committee coordinates an innovative programme of regional audits and the experience of rheumatology healthcare professionals involved was surveyed. This was a questionnaire-based study in which respondents rated statements relating to regional audit on Likert scales. Out of 105 staff, 70 replied. There was consensus that results of regional audit have been robust, valid and reliable; regional audits benefit patients and units; provide educational opportunities for specialist registrars (SpRs); and are more efficient than local audit by allowing comparison between units. Opinion was divided about how well informed respondents were and how effective they are at closing the audit loop. Many units reported changes in practice. Regional audit is widely perceived to be a valuable clinical governance tool supporting significant changes to clinical practice, and an excellent training opportunity for SpRs. Recommendations for a successful regional audit scheme are described in this article.

Impact of clinical trial findings on Bell's palsy management in general practice in the UK 2001–2012: interrupted time series regression analysis

PubMed Central

Morales, Daniel R; Donnan, Peter T; Daly, Fergus; Staa, Tjeerd Van; Sullivan, Frank M

2013-01-01

Objectives To measure the incidence of Bell's palsy and determine the impact of clinical trial findings on Bell's palsy management in the UK. Design Interrupted time series regression analysis and incidence measures. Setting General practices in the UK contributing to the Clinical Practice Research Datalink (CPRD). Participants Patients ≥16 years with a diagnosis of Bell's palsy between 2001 and 2012. Interventions (1) Publication of the 2004 Cochrane reviews of clinical trials on corticosteroids and antivirals for Bell's palsy, which made no clear recommendation on their use and (2) publication of the 2007 Scottish Bell's Palsy Study (SBPS), which made a clear recommendation that treatment with prednisolone alone improves chances for complete recovery. Main outcome measures Incidence of Bell's palsy per 100 000 person-years. Changes in the management of Bell's palsy with either prednisolone therapy, antiviral therapy, combination therapy (prednisolone with antiviral therapy) or untreated cases. Results During the 12-year period, 14 460 cases of Bell's palsy were identified with an overall incidence of 37.7/100 000 person-years. The 2004 Cochrane reviews were associated with immediate falls in prednisolone therapy (−6.3% (−11.0 to −1.6)), rising trends in combination therapy (1.1% per quarter (0.5 to 1.7)) and falling trends for untreated cases (−0.8% per quarter (−1.4 to −0.3)). SBPS was associated with immediate increases in prednisolone therapy (5.1% (0.9 to 9.3)) and rising trends in prednisolone therapy (0.7% per quarter (0.4 to 1.2)); falling trends in combination therapy (−1.7% per quarter (−2.2 to −1.3)); and rising trends for untreated cases (1.2% per quarter (0.8 to 1.6)). Despite improvements, 44% still remain untreated. Conclusions SBPS was clearly associated with change in management, but a significant proportion of patients failed to receive effective treatment, which cannot be fully explained. Clarity and uncertainty in clinical trial recommendations may change clinical practice. However, better ways are needed to understand and circumvent barriers in implementing clinical trial findings. PMID:23864211

Impact of clinical trial findings on Bell's palsy management in general practice in the UK 2001-2012: interrupted time series regression analysis.

PubMed

Morales, Daniel R; Donnan, Peter T; Daly, Fergus; Staa, Tjeerd Van; Sullivan, Frank M

2013-01-01

To measure the incidence of Bell's palsy and determine the impact of clinical trial findings on Bell's palsy management in the UK. Interrupted time series regression analysis and incidence measures. General practices in the UK contributing to the Clinical Practice Research Datalink (CPRD). Patients ≥16 years with a diagnosis of Bell's palsy between 2001 and 2012. (1) Publication of the 2004 Cochrane reviews of clinical trials on corticosteroids and antivirals for Bell's palsy, which made no clear recommendation on their use and (2) publication of the 2007 Scottish Bell's Palsy Study (SBPS), which made a clear recommendation that treatment with prednisolone alone improves chances for complete recovery. Incidence of Bell's palsy per 100 000 person-years. Changes in the management of Bell's palsy with either prednisolone therapy, antiviral therapy, combination therapy (prednisolone with antiviral therapy) or untreated cases. During the 12-year period, 14 460 cases of Bell's palsy were identified with an overall incidence of 37.7/100 000 person-years. The 2004 Cochrane reviews were associated with immediate falls in prednisolone therapy (-6.3% (-11.0 to -1.6)), rising trends in combination therapy (1.1% per quarter (0.5 to 1.7)) and falling trends for untreated cases (-0.8% per quarter (-1.4 to -0.3)). SBPS was associated with immediate increases in prednisolone therapy (5.1% (0.9 to 9.3)) and rising trends in prednisolone therapy (0.7% per quarter (0.4 to 1.2)); falling trends in combination therapy (-1.7% per quarter (-2.2 to -1.3)); and rising trends for untreated cases (1.2% per quarter (0.8 to 1.6)). Despite improvements, 44% still remain untreated. SBPS was clearly associated with change in management, but a significant proportion of patients failed to receive effective treatment, which cannot be fully explained. Clarity and uncertainty in clinical trial recommendations may change clinical practice. However, better ways are needed to understand and circumvent barriers in implementing clinical trial findings.

American Society of Clinical Oncology National Census of Oncology Practices: Preliminary Report

PubMed Central

Forte, Gaetano J.; Hanley, Amy; Hagerty, Karen; Kurup, Anupama; Neuss, Michael N.; Mulvey, Therese M.

2013-01-01

In response to reports of increasing financial and administrative burdens on oncology practices and a lack of systematic information related to these issues, American Society of Clinical Oncology (ASCO) leadership started an effort to collect key practice-level data from all oncology practices in the United States. The result of the effort is the ASCO National Census of Oncology Practices (Census) launched in June 2012. The initial Census work involved compiling an inventory of oncology practices from existing lists of oncology physicians in the United States. A comprehensive, online data collection instrument was developed, which covered a number of areas, including practice characteristics (staffing configuration, organizational structure, patient mix and volume, types of services offered); organizational, staffing, and service changes over the past 12 months; and an assessment of the likelihood that the practice would experience organizational, staffing, and service changes in the next 12 months. More than 600 practices participated in the Census by providing information. In this article, we present preliminary highlights from the data gathered to date. We found that practice size was related to having experienced practice mergers, hiring additional staff, and increasing staff pay in the past 12 months, that geographic location was related to having experienced hiring additional staff, and that practices in metropolitan areas were more likely to have experienced practice mergers in the past 12 months than those in nonmetropolitan areas. We also found that practice size and geographic location were related to higher likelihoods of anticipating practice mergers, sales, and purchases in the future. PMID:23633966

The Diabetes Care Project: an Australian multicentre, cluster randomised controlled trial [study protocol

PubMed Central

2013-01-01

Background Diabetes mellitus is an increasingly prevalent metabolic disorder that is associated with substantial disease burden. Australia has an opportunity to improve ways of caring for the growing number of people with diabetes, but this may require changes to the way care is funded, organised and delivered. To inform how best to care for people with diabetes, and to identify the extent of change that is required to achieve this, the Diabetes Care Project (DCP) will evaluate the impact of two different, evidence-based models of care (compared to usual care) on clinical quality, patient and provider experience, and cost. Methods/Design The DCP uses a pragmatic, cluster randomised controlled trial design. Accredited general practices that are situated within any of the seven Australian Medicare Locals/Divisions of General Practice that have agreed to take part in the study were invited to participate. Consenting practices will be randomly assigned to one of three treatment groups for approximately 18 to 22 months: (a) control group (usual care); (b) Intervention 1 (which tests improvements that could be made within the current funding model, facilitated through the use of an online chronic disease management network); or (c) Intervention 2 (which includes the same components as Intervention 1, as well as altered funding to support voluntary patient registration with their practice, incentive payments and a care facilitator). Adult patients who attend the enrolled practices and have established (≥12 month’s duration) type 1 diabetes mellitus or newly diagnosed or established type 2 diabetes mellitus are invited to participate. Multiple outcomes will be studied, including changes in glycosylated haemoglobin (primary outcome), changes in other biochemical and clinical metrics, incidence of diabetes-related complications, quality of life, clinical depression, success of tailored care, patient and practitioner satisfaction, and budget sustainability. Discussion This project responds to a need for robust evidence of the clinical and economic effectiveness of coordinated care for the management of diabetes in the Australian primary care setting. The outcomes of the study will have implications not only for diabetes management, but also for the management of other chronic diseases, both in Australia and overseas. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12612000363886); World Health Organisation (U1111-1128-0481). PMID:24359432

An education and motivation intervention to change clinical management of the third stage of labor - the GIRMMAHP Initiative.

PubMed

Figueras, Albert; Narváez, Edgar; Valsecia, Mabel; Vásquez, Susana; Rojas, Germán; Camilo, Angiolina; del Valle, José-María; Aguilera, Cristina

2008-12-01

Hemorrhage and hypertensive disorders are major contributors to death after delivery in developing countries. The GIRMMAHP Initiative was designed to describe the actual delivery care in five Latin American countries and to educate and motivate clinical staff at 17 hospitals with the purpose of implementing their own clinical practice guidelines to prevent postpartum hemorrhage. A multicountry education intervention was developed in four consecutive stages, using two analyses: (a) an observational study of the clinical records in eight teaching and nine nonteaching hospitals and (b) a study of the long-term changes measured 12 months after completion of an education intervention and writing a local clinical guideline. Data from 2,247 pregnant women showed that only 23.3 percent had an active management of the third stage of labor and that 22.7 percent received no prenatal care visit. These data were used to prepare local clinical practice guidelines in each participant hospital. The proportion of active management increased to 72.6 percent of deliveries at 3 months and 58.7 percent 1 year later. Use of oxytocin during the third stage of labor increased to 85.9 percent of included deliveries. The proportion of women who had postpartum hemorrhage decreased from 12.7 percent at baseline to 5 percent at 1 year after the intervention. An education intervention and discussion of actual clinical practice problems with health professionals and their involvement in drafting clinical guidelines helped improve health care quality and practitioners' adherence to these guidelines.

Interpretation of lung cancer study outcomes.

PubMed

Cortinovis, Diego; Abbate, Marida; Bidoli, Paolo; Pelizzoni, Davide; Canova, Stefania

2015-11-01

Lung cancer is the leading cause of cancer death in developed countries. However, in the last few years we observed an important acceleration in drug development due to oncogenic driver tumors discovery. Sharing and putting together preclinical data from benchmark and data from clinical research is the scientific paradigm that allows real breakthrough in clinical practice in this field, but only a few targeted agents are worthy and practice changing. The clinical research and proper use of statistical methodology are the pillars to continue to achieve important goals like improvement of overall survival. A good medical oncologist should be able to critically read a scientific paper and move from the observed outcomes into clinical perspective. Despite clinical improvements, sometimes the union of promising targeted agents and optimistic expectations misrepresent the reality and the value of clinical research. In this article, we try to analyze the meaning of statistical assumptions from clinical trials, especially in lung cancer, through a critical review of the concept of value-based medicine. We also attempt to give the reader some practical tools to weigh scientific value of literature reports.

SAFETY: an integrated clinical reasoning and reflection framework for undergraduate nursing students.

PubMed

Hicks Russell, Bedelia; Geist, Melissa J; House Maffett, Jenny

2013-01-01

Nurse educators can no longer focus on imparting to students knowledge that is merely factual and content specific. Activities that provide students with opportunities to apply concepts in real-world scenarios can be powerful tools. Nurse educators should take advantage of student-patient interactions to model clinical reasoning and allow students to practice complex decision making throughout the entire curriculum. In response to this change in nursing education, faculty in a pediatric course designed a reflective clinical reasoning activity based on the SAFETY template, which is derived from the National Council of State Boards of Nursing RN practice analysis. Students were able to prioritize key components of nursing care, as well as integrate practice issues such as delegation, Health Insurance Portability and Accountability Act violations, and questioning the accuracy of orders. SAFETY is proposed as a framework for integration of content knowledge, clinical reasoning, and reflection on authentic professional nursing concerns. Copyright 2012, SLACK Incorporated.

Values-based practice in mental health and psychiatry.

PubMed

Woodbridge-Dodd, Kim

2012-11-01

Values-based practice (VBP) challenges traditions of clinical practice and moral decision-making and the literature published over the last 18 months demonstrates a growing momentum for its use. The VBP model has become part of the narrative of health and social care practice. It features in a range of publications and has been subject to philosophical analysis in relation to its theoretical rigour, and applied to clinical practice through education and training, implementation in the field and policy development. From a philosophical perspective the model faces several challenges; from a practice perspective it is welcomed as a necessary partner to Evidence-Based Practice. Both perspectives suggest VBP requires significant adjustment to professional ideas of good practice, expectations of the clinician service user relationship and notions of what constitutes good care. VBP is both a solution and a problem for clinicians. Whether VBP is seen as providing a much needed clinical skill for working with the complexity of mental health and psychiatry which is steeped in values or a solution to a dominant sociopolitical neoliberal ideology demand for choice and personalization of care, VBP will require clinicians to make personal changes to their values base that reach to the depths of their professional identity.

Simulation and Advanced Practice Nursing Education

ERIC Educational Resources Information Center

Blue, Dawn I.

2016-01-01

This quantitative study compared changes in level of confidence resulting from participation in simulation or traditional instructional methods for BSN (Bachelor of Science in Nursing) to DNP (Doctor of Nursing Practice) students in a nurse practitioner course when they entered the clinical practicum. Simulation has been used in many disciplines…

The 2017 World Health Organization classification of tumors of the pituitary gland: a summary.

PubMed

Lopes, M Beatriz S

2017-10-01

The 4th edition of the World Health Organization (WHO) classification of endocrine tumors has been recently released. In this new edition, major changes are recommended in several areas of the classification of tumors of the anterior pituitary gland (adenophypophysis). The scope of the present manuscript is to summarize these recommended changes, emphasizing a few significant topics. These changes include the following: (1) a novel approach for classifying pituitary neuroendocrine tumors according to pituitary adenohypophyseal cell lineages; (2) changes to the histological grading of pituitary neuroendocrine tumors with the elimination of the term "atypical adenoma;" and (3) introduction of new entities like the pituitary blastoma and re-definition of old entities like the null-cell adenoma. This new classification is very practical and mostly based on immunohistochemistry for pituitary hormones, pituitary-specific transcription factors, and other immunohistochemical markers commonly used in pathology practice, not requiring routine ultrastructural analysis of the tumors. Evaluation of tumor proliferation potential, by mitotic count and Ki-67 labeling index, and tumor invasion is strongly recommended on individual case basis to identify clinically aggressive adenomas. In addition, the classification offers the treating clinical team information on tumor prognosis by identifying specific variants of adenomas associated with an elevated risk for recurrence. Changes in the classification of non-neuroendocrine tumors are also proposed, in particular those tumors arising in the posterior pituitary including pituicytoma, granular cell tumor of the posterior pituitary, and spindle cell oncocytoma. These changes endorse those previously published in the 2016 WHO classification of CNS tumors. Other tumors arising in the sellar region are also reviewed in detail including craniopharyngiomas, mesenchymal and stromal tumors, germ cell tumors, and hematopoietic tumors. It is hoped that the 2017 WHO classification of pituitary tumors will establish more biologically and clinically uniform groups of tumors, make it possible for practicing pathologists to better diagnose these tumors, and contribute to our understanding of clinical outcomes for patients harboring pituitary tumors.

The leadership role of nurse educators in mental health nursing.

PubMed

Sayers, Jan; Lopez, Violeta; Howard, Patricia B; Escott, Phil; Cleary, Michelle

2015-01-01

Leadership behaviors and actions influence others to act, and leadership in clinical practice is an important mediator influencing patient outcomes and staff satisfaction. Indeed, positive clinical leadership has been positioned as a crucial element for transformation of health care services and has led to the development of the Practice Doctorate Movement in the United States. Nurse educators in health care have a vital leadership role as clinical experts, role models, mentors, change agents, and supporters of quality projects. By enacting these leadership attributes, nurse educators ensure a skilled and confident workforce that is focused on optimizing opportunities for students and graduates to integrate theory and practice in the workplace as well as developing more holistic models of care for the consumer. Nurse educators need to be active in supporting staff and students in health care environments and be visible leaders who can drive policy and practice changes and engage in professional forums, research, and scholarship. Although nurse educators have always been a feature of the nursing workplace, there is a paucity of literature on the role of nurse educators as clinical leaders. This discursive article describes the role and attributes of nurse educators with a focus on their role as leaders in mental health nursing. We argue that embracing the leadership role is fundamental to nurse educators and to influencing consumer-focused care in mental health. We also make recommendations for developing the leadership role of nurse educators and provide considerations for further research such as examining the impact of clinical leaders on client, staff, and organizational outcomes.

Defending the solo and small practice neurologist.

PubMed

Jones, Elaine C; Evans, David A

2015-04-01

Changes in health care are having a dramatic effect on the practice of medicine. In 2005, a National Center for Health Statistics survey showed that 55%-70% of physicians are in small/solo practices. These data also demonstrated that 70% of physicians identified themselves as owners. Since passage of the Affordable Care Act (ACA) in 2010, neurologists report an 8% increase in academic practice settings, a 2% decrease in private practice settings, and a 5% decrease in solo practice settings. Surveys of family physicians showed that 60% are now employees of hospitals or larger groups. A survey by The Physicians Foundation showed that 89% of physicians believed that the traditional model of independent private practice is either "on shaky ground" or "a dinosaur soon to go extinct." With the changes expected from the ACA, solo/small practices will continue to face challenges and therefore must pay close attention to business and clinical metrics.

Increasing confidence and changing behaviors in primary care providers engaged in genetic counselling.

PubMed

Wilkes, Michael S; Day, Frank C; Fancher, Tonya L; McDermott, Haley; Lehman, Erik; Bell, Robert A; Green, Michael J

2017-09-13

Screening and counseling for genetic conditions is an increasingly important part of primary care practice, particularly given the paucity of genetic counselors in the United States. However, primary care physicians (PCPs) often have an inadequate understanding of evidence-based screening; communication approaches that encourage shared decision-making; ethical, legal, and social implication (ELSI) issues related to screening for genetic mutations; and the basics of clinical genetics. This study explored whether an interactive, web-based genetics curriculum directed at PCPs in non-academic primary care settings was superior at changing practice knowledge, attitudes, and behaviors when compared to a traditional educational approach, particularly when discussing common genetic conditions. One hundred twenty one PCPs in California and Pennsylvania physician practices were randomized to either an Intervention Group (IG) or Control Group (CG). IG physicians completed a 6 h interactive web-based curriculum covering communication skills, basics of genetic testing, risk assessment, ELSI issues and practice behaviors. CG physicians were provided with a traditional approach to Continuing Medical Education (CME) (clinical review articles) offering equivalent information. PCPs in the Intervention Group showed greater increases in knowledge compared to the Control Group. Intervention PCPs were also more satisfied with the educational materials, and more confident in their genetics knowledge and skills compared to those receiving traditional CME materials. Intervention PCPs felt that the web-based curriculum covered medical management, genetics, and ELSI issues significantly better than did the Control Group, and in comparison with traditional curricula. The Intervention Group felt the online tools offered several advantages, and engaged in better shared decision making with standardized patients, however, there was no difference in behavior change between groups with regard to increases in ELSI discussions between PCPs and patients. While our intervention was deemed more enjoyable, demonstrated significant factual learning and retention, and increased shared decision making practices, there were few differences in behavior changes around ELSI discussions. Unfortunately, barriers to implementing behavior change in clinical genetics is not unique to our intervention. Perhaps the missing element is that busy physicians need systems-level support to engage in meaningful discussions around genetics issues. The next step in promoting active engagement between doctors and patients may be to put into place the tools needed for PCPs to easily access the materials they need at the point-of-care to engage in joint discussions around clinical genetics.

Ideology, psychiatric practice and professionalism.

PubMed

Bouras, N; Ikkos, G

2013-01-01

Psychiatry, associated as it is with social and cultural factors, has undergone profound changes over the last 50 years. Values, attitudes, beliefs and ideology all influence psychiatry. Deinstitutionalisation, the normalization principle, advocacy, empowerment and the recovery model are ideologies that have been closely associated with policy, service developments and clinical practice in psychiatry. A "new professionalism" is emerging as a consequence of a number of changes in mental health care that needs to be guided by the highest standards of care which are best epitomized in psychiatry as a social contract with society. Looking to the future it is important that the profession recognises the impact ideology can make, if it is not to remain constantly on the defensive. In order to engage proactively and effectively with ideology as well as clinical science and evidence based service development, psychiatry as a profession will do best to approach significant future policy, practice and service changes by adopting an ethical approach, as a form a social contract. Psychiatrists must pay increasing attention to understanding values as expressed by ideologies, working in a collaborative way with other mental health professionals, involve service users and manage systems as well as be competent in clinical assessment and treatment. Whether in time of plenty or in times of deprivation, ideology produces effects on practice and in the context of constantly changing knowledge and the current financial stress this is likely to be more the case (and not less) in the foreseeable future. Psychiatrists must take into consideration the new social problems seen in some high income countries with the increased availability of highly potent "street drugs", perceived threats from various immigrant and minority communities and breakdown of "social capital" such as the decline of the nuclear family.

Impact of the Canadian Diabetes Association guideline dissemination strategy on clinician knowledge and behaviour change outcomes.

PubMed

Yu, Catherine H; Lillie, Erin; Mascarenhas-Johnson, Alekhya; Gall Casey, Carolyn; Straus, Sharon E

2018-04-04

Implementation of clinical practice guideline (CPG) into clinical practice remains limited. Using the Knowledge-To-Action framework, a guideline dissemination and implementation strategy for the Canadian Diabetes Association's 2013 CPG was developed and launched to clinicians and people with diabetes. The RE-AIM framework guided evaluation of this strategy clinician; we report here one aspect of the effectiveness dimension using mixed methods. We measured impact of the strategy on clinican knowledge and behaviour change constructs using evaluation forms, national online survey and individual interviews. After attending a lecture, clinician confidence (n = 915) increased (3.7(SD 0.7) to 4.5 (SD 0.6) on a 5-point scale (p < 0.001)), with 55% (n = 505) intending to make a practice change (e.g. clinical management regarding glycemic control). Ninety-four percent of survey respondents (n = 907) were aware of the guidelines, attributed to communications from professional associations, continuing professional development events, and colleagues. Forty to 98% of respondents (total n 462-485) were correct in their interpretation of CPG messages, and 33-65%(total n 351-651) reported that they had made changes to their practice. Interviews with 28 clinicians revealed that organizational credibility, online access to tools, clarity of tool content, and education sessions facilitated uptake; lack of time, team-based consensus, and seamless integration into care and patient complexity were barriers. The complexity of diabetes care requires systemic adoption of organization of care interventions, including interprofessional collaboration and consensus. Augmenting our strategy to include scalable models for professional development, integration of guidelines into electronic medical records, and expansion of our target audience to include health care teams and patients, may optimize guideline uptake. Copyright © 2018 Elsevier B.V. All rights reserved.

National continuous surveys on internal quality control for HbA1c in 306 clinical laboratories of China from 2012 to 2016: Continual improvement.

PubMed

Li, Tingting; Wang, Wei; Zhao, Haijian; He, Falin; Zhong, Kun; Yuan, Shuai; Wang, Zhiguo

2017-09-01

This study aimed to evaluate whether the quality performance of clinical laboratories in China has been greatly improved and whether Internal Quality Control (IQC) practice of HbA1c has also been changed since National Center for Clinical Laboratories (NCCL) of China organized laboratories to report IQC data for HbA1c in 2012. Internal Quality Control information of 306 External Quality Assessment (EQA) participant laboratories which kept reporting IQC data in February from 2012 to 2016 were collected by Web-based EQA system. Then percentages of laboratories meeting four different imprecision specifications for current coefficient of variations (CVs) of HbA1c measurements were calculated. Finally, we comprehensively analyzed analytical systems and IQC practice of HbA1c measurements. The current CVs of HbA1c tests have decreased significantly from 2012 to 2016. And percentages of laboratories meeting four imprecision specifications for CVs all showed the increasing tendency year by year. As for analytical system, 52.1% (159/306) laboratories changed their systems with the change in principle of assay. And many laboratories began to use cation exchange high-performance liquid chromatography (CE-HPLC) instead of Immunoturbidimetry, because CE-HPLC owed a lower intra-laboratory CVs. The data of IQC practice, such as IQC rules and frequency, also showed significant variability among years with overall tendency of meeting requirements. The imprecision performance of HbA1c tests has been improved in these 5 years with the change in IQC practice, but it is still disappointing in China. Therefore, laboratories should actively find existing problems and take action to promote performance of HbA1c measurements. © 2016 Wiley Periodicals, Inc.

Primary-Care Weight-Management Strategies: Parental Priorities and Preferences.

PubMed

Turer, Christy Boling; Upperman, Carla; Merchant, Zahra; Montaño, Sergio; Flores, Glenn

2016-04-01

To examine parental perspectives/rankings of the most important weight-management clinical practices and to determine whether preferences/rankings differ when parents disagree that their child is overweight. We performed mixed-methods analysis of a 32-question survey of parents of 2- to 18-year-old overweight children assessing parental agreement that their child is overweight, the single most important thing providers can do to improve weight status, ranking American Academy of Pediatrics-recommended clinical practices, and preferred follow-up interval. Four independent reviewers analyzed open-response data to identify qualitative themes/subthemes. Multivariable analyses examined parental rankings, preferred follow-up interval, and differences by agreement with their child's overweight assessment. Thirty-six percent of 219 children were overweight, 42% obese, and 22% severely obese; 16% of parents disagreed with their child's overweight assessment. Qualitative analysis of the most important practice to help overweight children yielded 10 themes; unique to parents disagreeing with their children's overweight assessments was "change weight-status assessments." After adjustment, the 3 highest-ranked clinical practices included, "check for weight-related problems," "review growth chart," and "recommend general dietary changes" (all P < .01); parents disagreeing with their children's overweight assessments ranked "review growth chart" as less important and ranked "reducing screen time" and "general activity changes" as more important. The mean preferred weight-management follow-up interval (10-12 weeks) did not differ by agreement with children's overweight assessments. Parents prefer weight-management strategies that prioritize evaluating weight-related problems, growth-chart review, and regular follow-up. Parents who disagree that their child is overweight want changes in how overweight is assessed. Using parent-preferred weight-management strategies may prove useful in improving child weight status. Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Advanced practice nurse entrepreneurs in a multidisciplinary surgical-assisting partnership.

PubMed

DeCarlo, Linda

2005-09-01

CHANGES IN THE HEALTH CARE environment and reimbursement practices are creating opportunities for nurse entrepreneurs to be partners with other professional nurses and physicians. Advanced practice nurses (APNs) who want to step into an entrepreneurial role must have strong clinical expertise, specific personal characteristics, interpersonal skills, and business acumen. ESTABLISHING A MULTIDISCIPLINARY partnership for providing surgical assisting services has many benefits and presents many challenges.

Implementation of clinical practice guidelines on lifestyle interventions in Swedish primary healthcare - a two-year follow up.

PubMed

Kardakis, Therese; Jerdén, Lars; Nyström, Monica E; Weinehall, Lars; Johansson, Helene

2018-04-02

Implementation of interventions concerning prevention and health promotion in health care has faced particular challenges resulting in a low frequency and quality of these services. In November 2011, the Swedish National Board of Health and Welfare released national clinical practice guidelines to counteract patients' unhealthy lifestyle habits. Drawing on the results of a previous study as a point of departure, the aim of this two-year follow up was to assess the progress of work with lifestyle interventions in primary healthcare as well as the uptake and usage of the new guidelines on lifestyle interventions in clinical practice. Longitudinal study among health professionals with survey at baseline and 2 years later. Development over time and differences between professional groups were calculated with Pearson chi-square test. Eighteen percent of the physicians reported to use the clinical practice guidelines, compared to 58% of the nurses. Nurses were also more likely to consider them as a support in their work than physicians did. Over time, health professionals usage of methods to change patients' tobacco habits and hazardous use of alcohol had increased, and the nurses worked to a higher extent than before with all four lifestyles. Knowledge on methods for lifestyle change was generally high; however, there was room for improvement concerning methods on alcohol, unhealthy eating and counselling. Forty-one percent reported to possess thorough knowledge of counselling skills. Even if the uptake and usage of the CPGs on lifestyle interventions so far is low, the participants reported more frequent counselling on patients' lifestyle changes concerning use of tobacco and hazardous use of alcohol. However, these findings should be evaluated acknowledging the possibility of selection bias in favour of health promotion and lifestyle guidance, and the loss of one study site in the follow up. Furthermore, this study indicates important differences in physicians and nurses' attitudes to and use of the guidelines, where the nurses reported working to a higher extent with all four lifestyles compared to the first study. These findings suggest further investigations on the implementation process in clinical practice, and the physicians' uptake and use of the CPGs.

Video observation in HIT development: lessons learned on benefits and challenges.

PubMed

Høstgaard, Anna Marie; Bertelsen, Pernille

2012-08-22

Experience shows that the precondition for the development of successful health information technologies is a thorough insight into clinical work practice. In contemporary clinical work practice, clinical work and health information technology are integrated, and part of the practice is tacit. When work practice becomes routine, it slips to the background of the conscious awareness and becomes difficult to recognize without the context to support recall. This means that it is difficult to capture with traditional ethnographic research methods or in usability laboratories or clinical set ups. Observation by the use of the video technique within healthcare settings has proven to be capable of providing a thorough insight into the complex clinical work practice and its context - including parts of the tacit practice. The objective of this paper is 1) to argue for the video observation technique to inform and improve health-information-technology development and 2) to share insights and lessons learned on benefits and challenges when using the video observation technique within healthcare settings. A multiple case study including nine case studies conducted by DaCHI researchers 2004-2011 using audio-visual, non-participant video observation for data collection within different healthcare settings. In HIT development, video observation is beneficial for 1) informing and improving system design 2) studying changes in work practice 3) identifying new potentials and 4) documenting current work practices. The video observation technique used within healthcare settings is superior to other ethnographic research methods when it comes to disclosing the complexity in clinical work practice. The insights gained are far more realistic compared to traditional ethnographic studies or usability studies and studies in clinical set ups. Besides, the data generated through video recordings provide a solid basis for dialog between the health care professionals involved. The most important lessons learned are that a well considered methodology and clear formulated objectives are imperative, in order to stay focused during the data rich analysis phase. Additionally, the video observation technique is primarily recommended for studies of specific clinical work practices within delimited clinical settings. Overall, the video observation technique has proven to be capable of improving our understanding of the interwoven relation between clinical work practice and HIT and to inform us about user requirements and needs for HIT, which is a precondition for the development of more successful HIT systems in the future.

Translating Life Course Theory to Clinical Practice to Address Health Disparities

PubMed Central

Solomon, Barry S.

2013-01-01

Life Course Theory (LCT) is a framework that explains health and disease across populations and over time and in a powerful way, conceptualizes health and health disparities to guide improvements. It suggests a need to change priorities and paradigms in our healthcare delivery system. In “Rethinking Maternal and Child Health: The Life Course Model as an Organizing Framework,” Fine and Kotelchuck identify three areas of rethinking that have relevance to clinical care: (1) recognition of context and the “whole-person, whole-family, whole-community systems approach;” (2) longitudinal approach with “greater emphasis on early (“upstream”) determinants of health”; and (3) need for integration and “developing integrated, multi-sector service systems that become lifelong “pipelines” for healthy development”. This paper discusses promising clinical practice innovations in these three areas: addressing social influences on health in clinical practice, longitudinal and vertical integration of clinical services and horizontal integration with community services and resources. In addition, barriers and facilitators to implementation are reviewed. PMID:23677685

Does the Internet promote the unregulated use of fecal microbiota transplantation: a potential public health issue?

PubMed

Segal, Jonathan Philip; Abbasi, Faisal; Kanagasundaram, Cynthia; Hart, Ailsa

2018-01-01

The Internet has become an increasingly popular resource for medical information. Fecal microbiota transplantation (FMT) has changed the treatment of Clostridium difficile with cure rates of 81% following one infusion of FMT, further studies have since validated these findings. The Medicines and Health care Products Regulatory Agency has classified FMT as a medicine and hence should be only utilized in strict clinical settings. We searched Facebook, Twitter, Google, and YouTube using the words "Faecal Microbiota Transplantation" and "FMT". We utilized the first 50 hits on each site. We analyzed the percentage of articles that fell outside regulated medical practice. We searched how many clinics in the UK advertised practice that falls outside suggested guidelines. Google, YouTube, and Facebook had a variety of information regarding FMT available. Nine out of 50 (18%) of the top 50 google searches can be considered articles that fall outside regulated practice. YouTube highlighted four videos describing how to self-administer FMT, one of these was for ulcerative colitis. Fourteen percent of the top 50 YouTube videos fall outside regulated practice and 8% of the top 50 Facebook searches fall outside regulated clinical practice. There were two clinics in the UK advertising FMT for uses that fall outside regulated practice. Clinicians and patients need to be aware of the resources available through social media and the Internet. It should be appreciated that some websites fall outside regulated clinical practice. Private clinics offering FMT need to ensure that they are offering FMT within a regulated framework.

Practice Facilitator Strategies for Addressing Electronic Health Record Data Challenges for Quality Improvement: EvidenceNOW.

PubMed

Hemler, Jennifer R; Hall, Jennifer D; Cholan, Raja A; Crabtree, Benjamin F; Damschroder, Laura J; Solberg, Leif I; Ono, Sarah S; Cohen, Deborah J

2018-01-01

Practice facilitators ("facilitators") can play an important role in supporting primary care practices in performing quality improvement (QI), but they need complete and accurate clinical performance data from practices' electronic health records (EHR) to help them set improvement priorities, guide clinical change, and monitor progress. Here, we describe the strategies facilitators use to help practices perform QI when complete or accurate performance data are not available. Seven regional cooperatives enrolled approximately 1500 small-to-medium-sized primary care practices and 136 facilitators in EvidenceNOW, the Agency for Healthcare Research and Quality's initiative to improve cardiovascular preventive services. The national evaluation team analyzed qualitative data from online diaries, site visit field notes, and interviews to discover how facilitators worked with practices on EHR data challenges to obtain and use data for QI. We found facilitators faced practice-level EHR data challenges, such as a lack of clinical performance data, partial or incomplete clinical performance data, and inaccurate clinical performance data. We found that facilitators responded to these challenges, respectively, by using other data sources or tools to fill in for missing data, approximating performance reports and generating patient lists, and teaching practices how to document care and confirm performance measures. In addition, facilitators helped practices communicate with EHR vendors or health systems in requesting data they needed. Overall, facilitators tailored strategies to fit the individual practice and helped build data skills and trust. Facilitators can use a range of strategies to help practices perform data-driven QI when performance data are inaccurate, incomplete, or missing. Support is necessary to help practices, particularly those with EHR data challenges, build their capacity for conducting data-driven QI that is required of them for participating in practice transformation and performance-based payment programs. It is questionable how practices with data challenges will perform in programs without this kind of support. © Copyright 2018 by the American Board of Family Medicine.

Organizational Readiness for Change in Correctional and Community Substance Abuse Programs

ERIC Educational Resources Information Center

Lehman, Wayne E. K.; Greener, Jack M.; Rowan-Szal, Grace A.; Flynn, Patrick M.

2012-01-01

Significant needs exist for increased and better substance abuse treatment services in our nation's prisons. The TCU Organizational Readiness for Change (ORC) survey has been widely used in community-based treatment programs and evidence is accumulating for relationships between readiness for change and implementation of new clinical practices.…

The business case as a strategic tool for change.

PubMed

Weaver, Diana J; Sorrells-Jones, Jean

2007-09-01

The authors discuss the clinically focused business case, when it is and is not needed, and the knowledge and skills the nurse executive must master to use the business case effectively as a strategic tool. Necessary skills include translating nursing practice proposals into cost-effective change initiatives and marketing those changes to colleagues.

The minimally important difference for the fatigue visual analog scale in patients with rheumatoid arthritis followed in an academic clinical practice.

PubMed

Khanna, Dinesh; Pope, Janet E; Khanna, Puja P; Maloney, Michelle; Samedi, Nooshin; Norrie, Debbie; Ouimet, Gillian; Hays, Ron D

2008-12-01

To estimate the minimally important difference (MID) for a fatigue visual analog scale (VAS) using patient-reported anchors (fatigue, pain, and overall health). Patients with rheumatoid arthritis (RA; n = 307) had 2 clinic visits at a median of 5.9 months apart. They completed a fatigue VAS (0-10 scale) and the retrospective anchor items, "How would you describe your overall fatigue/pain/overall health since the last visit?" with response options: Much worsened, Somewhat worsened, Same, Somewhat better, or Much better. The fatigue anchor was used for primary analysis and the pain/overall health anchors for sensitivity analyses. The minimally changed group was defined by those reporting they were somewhat better or somewhat worsened. The mean [standard deviation (SD)] age was 59.4 (13.2) years, disease duration was 14.1 (11.5) years, and 83% of patients were women. The baseline mean (SD) Health Assessment Questionnaire-Disability Index score was 0.84 (0.75). The baseline fatigue VAS score was 4.2 (2.9) and at followup was 4.3 (2.8) [mean change of -0.07 (2.5); p = not significant]. The fatigue change score (0-10 scale) for Somewhat better and Somewhat worsened for the fatigue anchor averaged -1.12 and 1.26, respectively. Using the pain anchor, the fatigue change score for Somewhat better and Somewhat worsened averaged -0.87 and 1.13; and using the global anchor, the fatigue change score for Somewhat better and Somewhat worsened averaged -0.82 and 1.17, respectively. Effect size estimates using 3 anchors were small for the Somewhat better (range 0.27-0.39) and Somewhat worsened (0.40-0.44) groups, but larger than for the no-change group (0.03-0.08). The MID for fatigue VAS is between -0.82 for -1.12 for improvement and is 1.13 to 1.26 for worsening on a 0-10 scale in a large RA clinical practice, and is similar to that seen in RA clinical trials. This information can aid in interpreting fatigue VAS in day-to-day care in clinical practice.

The impact of clinical nurse specialists on clinical pathways in the application of evidence-based practice.

PubMed

Gurzick, Martha; Kesten, Karen S

2010-01-01

The purpose of this article was to address the call for evidence-based practice through the development of clinical pathways and to assert the role of the clinical nurse specialist (CNS) as a champion in clinical pathway implementation. In the current health care system, providing quality of care while maintaining cost-effectiveness is an ever-growing battle that institutions face. The CNS's role is central to meeting these demands. An extensive literature review has been conducted to validate the use of clinical pathways as a means of improving patient outcomes. This literature also suggests that clinical pathways must be developed, implemented, and evaluated utilizing validated methods including the use of best practice standards. Execution of clinical pathways should include a clinical expert, who has the ability to look at the system as a whole and can facilitate learning and change by employing a multitude of competencies while maintaining a sphere of influence over patient and families, nurses, and the system. The CNS plays a pivotal role in influencing effective clinical pathway development, implementation, utilization, and ongoing evaluation to ensure improved patient outcomes and reduced costs. This article expands upon the call for evidence-based practice through the utilization of clinical pathways to improve patient outcomes and reduce costs and stresses the importance of the CNS as a primary figure for ensuring proper pathway development, implementation, and ongoing evaluation. Copyright 2010 Elsevier Inc. All rights reserved.

Using Gemba Boards to Facilitate Evidence-Based Practice in Critical Care.

PubMed

Bourgault, Annette M; Upvall, Michele J; Graham, Alison

2018-06-01

Tradition-based practices lack supporting research evidence and may be harmful or ineffective. Engagement of key stakeholders is a critical step toward facilitating evidence-based practice change. Gemba , derived from Japanese, refers to the real place where work is done. Gemba boards (visual management tools) appear to be an innovative method to engage stakeholders and facilitate evidence-based practice. To explore the use of gemba boards and gemba huddles to facilitate practice change. Twenty-two critical care nurses participated in interviews in this qualitative, descriptive study. Thematic analysis was used to code and categorize interview data. Two researchers reached consensus on coding and derived themes. Data were managed with qualitative analysis software. The code gemba occurred most frequently; a secondary analysis was performed to explore its impact on practice change. Four themes were derived from the gemba code: (1) facilitation of staff, leadership, and interdisciplinary communication, (2) transparency of outcome data, (3) solicitation of staff ideas and feedback, and (4) dissemination of practice changes. Gemba boards and gemba huddles became part of the organizational culture for promoting and disseminating evidence-based practices. Unit-based, publicly located gemba boards and huddles have become key components of evidence-based practice culture. Gemba is both a tool and a process to engage team members and the public to generate clinical questions and to plan, implement, and evaluate practice changes. Future research on the effectiveness of gemba boards to facilitate evidence-based practice is warranted. ©2018 American Association of Critical-Care Nurses.

Implementation of a two-part unit-based multiple intervention: moving evidence-based practice into action.

PubMed

Rashotte, Judy; Thomas, Margot; Grégoire, Diane; Ledoux, Sheila

2008-06-01

This study examined the impact of a 2-part unit-based multiple intervention on the use by pediatric critical care nurses of best practice guidelines for pressure-ulcer prevention. A total of 23 nurses participated in a repeated-measures design pre- and post-intervention to address 2 questions: Is there a difference in nurses' evidence-based practices following implementation of an educational intervention only versus implementation of both an educational and an innovative intervention? Are the changes sustained 6 months after completion of the intervention? A significant change occurred in the implementation of 2 of 11 recommended practices following both interventions: assessment of risk of pressure ulcers using an age-appropriate tool (p < or = 0.001), and the documentation of same (p < or = 0.001). These changes may have been sustained. The findings bring to light the real challenges encountered when attempting to implement and evaluate multiple knowledge translation strategies associated with complex best practice guidelines in clinical practice.

New graduate nurses' experiences in a clinical specialty: a follow up study of newcomer perceptions of transitional support.

PubMed

Hussein, Rafic; Everett, Bronwyn; Ramjan, Lucie M; Hu, Wendy; Salamonson, Yenna

2017-01-01

Given the increasing complexity of acute care settings, high patient acuity and demanding workloads, new graduate nurses continue to require greater levels of support to manage rising patient clinical care needs. Little is known about how change in new graduate nurses' satisfaction with clinical supervision and the practice environment impacts on their transitioning experience and expectations during first year of practice. This study aimed to examine change in new graduate nurses' perceptions over the 12-month Transitional Support Program, and identify how organizational factors and elements of clinical supervision influenced their experiences. Using a convergent mixed methods design, a prospective survey with open-ended questions was administered to new graduate nurses' working in a tertiary level teaching hospital in Sydney, Australia. Nurses were surveyed at baseline (8-10 weeks) and follow-up (10-12 months) between May 2012 and August 2013. Two standardised instruments: the Manchester Clinical Supervision Scale (MCSS-26) and the Practice Environment Scale Australia (PES-AUS) were used. In addition to socio-demographic data, single -item measures were used to rate new graduate nurses' confidence, clinical capability and support received. Participants were also able to provide open-ended comments explaining their responses. Free-text responses to the open-ended questions were initially reviewed for emergent themes, then coded as either positive or negative aspects of these preliminary themes. Descriptive and inferential statistics were used to analyse the quantitative data and the qualitative data was analysed using conventional content analysis (CCA). The study was approved by the relevant Human Research Ethics Committees. Eighty seven new graduate nurses completed the follow-up surveys, representing a 76% response rate. The median age was 23 years (Range: 20 to 53). No change was seen in new graduate nurses' satisfaction with clinical supervision (mean MCSS-26 scores: 73.2 versus 72.2, p  = 0.503), satisfaction with the clinical practice environment (mean PES-AUS scores: 112.4 versus 110.7, p  = 0.298), overall satisfaction with the transitional support program (mean: 7.6 versus 7.8, p  = 0.337), satisfaction with the number of study days received, orientation days received (mean: 6.4 versus 6.6, p  = 0.541), unit orientation (mean: 4.4 versus 4.8, p  = 0.081), confidence levels (mean: 3.6 versus 3.5, p  = 0.933) and not practising beyond personal clinical capability (mean: 3.9 versus 4.0, p  = 0.629). Negative responses to the open-ended questions were associated with increasing workload, mismatch in the level of support against clinical demands and expectations. Emergent themes from qualitative data included i) orientation and Transitional Support Program as a foundation for success; and ii) developing clinical competence. While transitional support programs are helpful in supporting new graduate nurses in their first year of practice, there are unmet needs for clinical, social and emotional support. Understanding new graduate nurses' experiences and their unmet needs during their first year of practice will enable nurse managers, educators and nurses to better support new graduate nurses' and promote confidence and competence to practice within their scope.

Implementing clinical governance in English primary care groups/trusts: reconciling quality improvement and quality assurance

PubMed Central

Campbell, S; Sheaff, R; Sibbald, B; Marshall, M; Pickard, S; Gask, L; Halliwell, S; Rogers, A; Roland, M

2002-01-01

Objectives: To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care. Design: Qualitative case studies using semi-structured interviews and documentation review. Setting: Twelve purposively sampled PCG/Ts in England. Participants: Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members. Main outcome measures: Participants' perceptions of the role of clinical governance in PCG/Ts. Results: PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment). Conclusion: PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance. PMID:12078380

Applying self-determination theory for improved understanding of physiotherapists' rationale for using research in clinical practice: a qualitative study in Sweden.

PubMed

Dannapfel, Petra; Peolsson, Anneli; Ståhl, Christian; Öberg, Birgitta; Nilsen, Per

2014-01-01

Physiotherapists are generally positive to evidence-based practice (EBP) and the use of research in clinical practice, yet many still base clinical decisions on knowledge obtained during their initial education and/or personal experience. Our aim was to explore motivations behind physiotherapists' use of research in clinical practice. Self-Determination Theory was applied to identify the different types of motivation for use of research. This theory posits that all behaviours lie along a continuum of relative autonomy, reflecting the extent to which a person endorses their actions. Eleven focus group interviews were conducted, involving 45 physiotherapists in various settings in Sweden. Data were analysed using qualitative content analysis and the findings compared with Self-Determination Theory using a deductive approach. Motivations underlying physiotherapists use of research in clinical practice were identified. Most physiotherapists expressed autonomous forms of motivation for research use, but some exhibited more controlled motivation. Several implications about how more evidence-based physiotherapy can be achieved are discussed, including the potential to tailor educational programs on EBP to better account for differences in motivation among participants, using autonomously motivated physiotherapists as change agents and creating favourable conditions to encourage autonomous motivation by way of feelings of competence, autonomy and a sense of relatedness.

Development and evaluation of an interactive dental video game to teach dentin bonding.

PubMed

Amer, Rafat S; Denehy, Gerald E; Cobb, Deborah S; Dawson, Deborah V; Cunningham-Ford, Marsha A; Bergeron, Cathia

2011-06-01

Written and clinical tests compared the change in clinical knowledge and practical clinical skill of first-year dental students watching a clinical video recording of the three-step etch-and-rinse resin bonding system to those using an interactive dental video game teaching the same procedure. The research design was a randomized controlled trial with eighty first-year dental students enrolled in the preclinical operative dentistry course. Students' change in knowledge was measured through written examination using a pre-test and a post-test, as well as clinical tests in the form of a benchtop shear bond strength test. There was no statistically significant difference between teaching methods in regards to change in either knowledge or clinical skills, with one minor exception relating to the wetness of dentin following etching. Students expressed their preference for an interactive self-paced method of teaching.

Practice development 'without walls' and the quandary of corporate practice.

PubMed

Graham, Iain; Fielding, Carol; Rooke, Debbie; Keen, Steven

2006-08-01

The context of this study is a group of clinical nurse specialists from across a Trust seeking accreditation as a practice development unit. The university was asked to facilitate the accreditation process via 11 2-hour learning sessions (including a one-hour focus group). During initial discussions between the university and practice development unit, the overarching research question for this study was set as: 'what are the main roles and responsibilities of clinical nurse specialists?' Although there is no known study of a practice development unit based beyond a ward or speciality, the central tenet of the practice development unit literature is that units must demonstrate their worth if they are to survive and harness senior management support in doing so. Data gleaned from the transcribed audio tape-recordings of the learning sessions were studied at least three times to ensure transcription accuracy and produce detailed charts. Ethical approval was granted by the appropriate Local Research Ethics Committee and written informed consent obtained from clinical nurse specialists. The study lasted 30 months and ended in October 2004. The four crucial statements that give meaning to specialist practice are: quality care giver; expert; information giver and initiator of change. Further analysis reveals the area of corporate and political practice as being missing from this and other lists of clinical nurse specialist attributes found in the literature. Clinical nurse specialists characterize their relationship with the Trust in terms of dichotomy--differing agendas and perceptions of value. The specialist role requires professional development in the areas of corporate and political acumen and professional business management. While the findings of this study relate to one Trust and a group of 16 clinical nurse specialists, with careful application they may be transferable to other settings and groups of senior nurses.

Reliable change indices and standardized regression-based change score norms for evaluating neuropsychological change in children with epilepsy.

PubMed

Busch, Robyn M; Lineweaver, Tara T; Ferguson, Lisa; Haut, Jennifer S

2015-06-01

Reliable change indices (RCIs) and standardized regression-based (SRB) change score norms permit evaluation of meaningful changes in test scores following treatment interventions, like epilepsy surgery, while accounting for test-retest reliability, practice effects, score fluctuations due to error, and relevant clinical and demographic factors. Although these methods are frequently used to assess cognitive change after epilepsy surgery in adults, they have not been widely applied to examine cognitive change in children with epilepsy. The goal of the current study was to develop RCIs and SRB change score norms for use in children with epilepsy. Sixty-three children with epilepsy (age range: 6-16; M=10.19, SD=2.58) underwent comprehensive neuropsychological evaluations at two time points an average of 12 months apart. Practice effect-adjusted RCIs and SRB change score norms were calculated for all cognitive measures in the battery. Practice effects were quite variable across the neuropsychological measures, with the greatest differences observed among older children, particularly on the Children's Memory Scale and Wisconsin Card Sorting Test. There was also notable variability in test-retest reliabilities across measures in the battery, with coefficients ranging from 0.14 to 0.92. Reliable change indices and SRB change score norms for use in assessing meaningful cognitive change in children following epilepsy surgery are provided for measures with reliability coefficients above 0.50. This is the first study to provide RCIs and SRB change score norms for a comprehensive neuropsychological battery based on a large sample of children with epilepsy. Tables to aid in evaluating cognitive changes in children who have undergone epilepsy surgery are provided for clinical use. An Excel sheet to perform all relevant calculations is also available to interested clinicians or researchers. Copyright © 2015 Elsevier Inc. All rights reserved.

Towards changing healthcare workers' behaviour: a qualitative study exploring non-compliance through appraisals of infection prevention and control practices.

PubMed

Shah, N; Castro-Sánchez, E; Charani, E; Drumright, L N; Holmes, A H

2015-06-01

Improving behaviour in infection prevention and control (IPC) practice remains a challenge, and understanding the determinants of healthcare workers' (HCWs) behaviour is fundamental to develop effective and sustained behaviour change interventions. To identify behaviours of HCWs that facilitated non-compliance with IPC practices, focusing on how appraisals of IPC duties and social and environmental circumstances shaped and influenced non-compliant behaviour. This study aimed to: (1) identify how HCWs rationalized their own behaviour and the behaviour of others; (2) highlight challenging areas of IPC compliance; and (3) describe the context of the working environment that may explain inconsistencies in IPC practices. Clinical staff at a National Health Service hospital group in London, UK were interviewed between December 2010 and July 2011 using qualitative methods. Responses were analysed using a thematic framework. Three ways in which HCWs appraised their behaviour were identified through accounts of IPC policies and practices: (1) attribution of responsibilities, with ambiguity about responsibility for certain IPC practices; (2) prioritization and risk appraisal, which demonstrated a divergence in values attached to some IPC policies and practices; and (3) hierarchy of influence highlighted that traditional clinical roles challenged work relationships. Overall, behaviours are not entirely independent of policy rules, but often an amalgamation of local normative practices, individual preferences and a degree of professional isolation. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

Clinical trials and the new good clinical practice guideline in Japan. An economic perspective.

PubMed

Ono, S; Kodama, Y

2000-08-01

Japanese clinical trials have been drastically changing in response to the implementation of the International Conference on Harmonisation-Good Clinical Practice (ICH-GCP) guideline in 1997. The most important aim of the new guideline is to standardise the quality of clinical trials in the US, European Union and Japan, but it inevitably imposes substantial costs on investigators, sponsors and even patients in Japan. The study environment in Japan differs from that in the US in several ways: (i) historical lack of a formal requirement for informed consent; (ii) patients' attitudes to clinical trials in terms of expectation of positive outcomes; (iii) the implications of universal health insurance for trial participation; (iv) the historical absence of on-site monitoring by the sponsor, with the attendant effects on study quality; and (v) the lack of adequate financial and personnel support for the conduct of trials. Implementation of the new GCP guideline will improve the ethical and scientific quality of trials conducted in Japan. It may also lead to an improved relationship between medical professionals and patients if the requirement for explicit informed consent in clinical trials leads to the provision of a similar level of patient information in routine care and changes the traditional paternalistic attitude of physicians to patients. The initial response of the Japanese 'market' for clinical trials to the implementation of the ICH-GCP guideline has been clinical trial price increases and a decrease in the number of study contracts. These changes can be explained by applying a simple demand-supply scheme. Whether clinical trials undertaken in Japan become more or less attractive to the industry in the long term will depend on other factors such as international regulations on the acceptability of foreign clinical trials and the reform of domestic healthcare policies.

Essential features influencing collaboration in team-based non-specific back pain rehabilitation: Findings from a mixed methods study

PubMed Central

Hellman, Therese; Jensen, Irene; Bergström, Gunnar; Brämberg, Elisabeth Björk

2016-01-01

ABSTRACT The aim of the study presented in this article was to explore how professionals, without guidelines for implementing interprofessional teamwork, experience the collaboration within team-based rehabilitation for people with back pain and how this collaboration influences their clinical practice. This study employed a mixed methods design. A questionnaire was answered by 383 participants and 17 participants were interviewed. The interviews were analysed using content analysis. The quantitative results showed that the participants were satisfied with their team-based collaboration. Thirty percent reported that staff changes in the past year had influenced their clinical practice, of which 57% reported that these changes had had negative consequences. The qualitative findings revealed that essential features for an effective collaboration were shared basic values and supporting each other. Furthermore, aspects such as having enough time for reflection, staff continuity, and a shared view of the team members’ roles were identified as aspects which influenced the clinical practice. Important clinical implications for nurturing and developing a collaboration in team-based rehabilitation are to create shared basic values and a unified view of all team members’ roles and their contributions to the team. These aspects need to be emphasised on an ongoing basis and not only when the team is formed. PMID:27152534

Do the clinical competencies of musculoskeletal outpatient physiotherapists improve after they have participated in a bespoke in-service education programme designed around individual and service continuing professional development needs?

PubMed

Banks, Kevin; Meaburn, Anthony; Phelan, Elaine

2013-01-01

To determine whether the clinical competencies of musculoskeletal outpatient physiotherapists improve if they participate in an annual in-service education programme designed around clinical practice needs. A within-subject, without-control, experimental, pre-test post-test study. Clinical and educational facilities of Doncaster and Bassetlaw Hospitals NHS Foundation Trust and locality-based outpatient facilities. Participants were 37 specialist musculoskeletal outpatient physiotherapists (band 6 and 7), working for Doncaster and Bassetlaw Hospitals NHS Foundation Trust. Participants completed three separate modules of in-service education through an academic year, based on learning outcomes identified from observation and performance rating of their clinical competencies. Each module lasted 7 hours, with supporting clinical assistance sessions and self-directed learning time. The primary outcome measure was a (participant) performance rating (from novice to expert) of 20 clinical competencies scored by experienced clinical educators before and after completion of the in-service education programme. A secondary, qualitative outcome measure (a purpose-made, semi-structured questionnaire) given after the programme explored participants' experiences and perceptions of the in-service education programme. Seven competencies were identified as the focus of the programme because their performance ratings were the lowest. All seven of these competencies improved following the programme. Communication scores improved by 6%, clinical reasoning by 4%, functional analysis of movement by 6%, use of research in practice by 4%, and critical appraisal of evidence by 4.6%. Performance of structural differentiation and the range of manual handling skills demonstrated were the only competencies to show a statistically significant improvement of 14.6% and 12%, respectively (p≤0.025(. Thematic analysis of the questionnaires revealed that 96% of respondents felt that their practice had changed positively over the year because of the programme. Providing a structured and bespoke in-service education programme over an academic year may help to improve the rating of clinical competencies and give participants the perception that their clinical practice has changed because of the programme.

The safety net medical home initiative: transforming care for vulnerable populations.

PubMed

Sugarman, Jonathan R; Phillips, Kathryn E; Wagner, Edward H; Coleman, Katie; Abrams, Melinda K

2014-11-01

Despite findings that medical homes may reduce or eliminate health care disparities among underserved and minority populations, most previous medical home pilot and demonstration projects have focused on health care delivery systems serving commercially insured patients and Medicare beneficiaries. To develop a replicable approach to support medical home transformation among diverse practices serving vulnerable and underserved populations. Facilitated by a national program team, convening organizations in 5 states provided coaching and learning community support to safety net practices over a 4-year period. To guide transformation, we developed a framework of change concepts aligned with supporting tools including implementation guides, activity checklists, and measurement instruments. Sixty-five health centers, homeless clinics, private practices, residency training centers, and other safety net practices in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. We evaluated implementation of the change concepts using the Patient-Centered Medical Home-Assessment, and conducted a survey of participating practices to assess perceptions of the impact of the technical assistance. All practices implemented key features of the medical home model, and nearly half (47.6%) implemented the 33 identified key changes to a substantial degree as evidenced by level A Patient-Centered Medical Home-Assessment scores. Two thirds of practices that achieved substantial implementation did so only after participating in the initiative for >2 years. By the end of the initiative, 83.1% of sites achieved external recognition as medical homes. Despite resource constraints and high-need populations, safety net clinics made considerable progress toward medical home implementation when provided robust, multimodal support over a 4-year period.

Development of a theory- and evidence-based intervention to enhance implementation of physical therapy guidelines for the management of low back pain

PubMed Central

2014-01-01

Background Systematic planning could improve the generally moderate effectiveness of interventions to enhance adherence to clinical practice guidelines. The aim of our study was to demonstrate how the process of Intervention Mapping was used to develop an intervention to address the lack of adherence to the national CPG for low back pain by Dutch physical therapists. Methods We systematically developed a program to improve adherence to the Dutch physical therapy guidelines for low back pain. Based on multi-method formative research, we formulated program and change objectives. Selected theory-based methods of change and practical applications were combined into an intervention program. Implementation and evaluation plans were developed. Results Formative research revealed influential determinants for physical therapists and practice quality managers. Self-regulation was appropriate because both the physical therapists and the practice managers needed to monitor current practice and make and implement plans for change. The program stimulated interaction between practice levels by emphasizing collective goal setting. It combined practical applications, such as knowledge transfer and discussion-and-feedback, based on theory-based methods, such as consciousness raising and active learning. The implementation plan incorporated the wider environment. The evaluation plan included an effect and process evaluation. Conclusions Intervention Mapping is a useful framework for formative data in program planning in the field of clinical guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process. PMID:24428945

Development of a theory- and evidence-based intervention to enhance implementation of physical therapy guidelines for the management of low back pain.

PubMed

Rutten, Geert M; Harting, Janneke; Bartholomew, Leona K; Braspenning, Jozé C; van Dolder, Rob; Heijmans, Marcel Fgj; Hendriks, Erik Jm; Kremers, Stef Pj; van Peppen, Roland Ps; Rutten, Steven Tj; Schlief, Angelique; de Vries, Nanne K; Oostendorp, Rob Ab

2014-01-15

Systematic planning could improve the generally moderate effectiveness of interventions to enhance adherence to clinical practice guidelines. The aim of our study was to demonstrate how the process of Intervention Mapping was used to develop an intervention to address the lack of adherence to the national CPG for low back pain by Dutch physical therapists. We systematically developed a program to improve adherence to the Dutch physical therapy guidelines for low back pain. Based on multi-method formative research, we formulated program and change objectives. Selected theory-based methods of change and practical applications were combined into an intervention program. Implementation and evaluation plans were developed. Formative research revealed influential determinants for physical therapists and practice quality managers. Self-regulation was appropriate because both the physical therapists and the practice managers needed to monitor current practice and make and implement plans for change. The program stimulated interaction between practice levels by emphasizing collective goal setting. It combined practical applications, such as knowledge transfer and discussion-and-feedback, based on theory-based methods, such as consciousness raising and active learning. The implementation plan incorporated the wider environment. The evaluation plan included an effect and process evaluation. Intervention Mapping is a useful framework for formative data in program planning in the field of clinical guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process.

Serum Bicarbonate in Acute Heart Failure: Relationship to Treatment Strategies and Clinical Outcomes.

PubMed

Cooper, Lauren B; Mentz, Robert J; Gallup, Dianne; Lala, Anuradha; DeVore, Adam D; Vader, Justin M; AbouEzzeddine, Omar F; Bart, Bradley A; Anstrom, Kevin J; Hernandez, Adrian F; Felker, G Michael

2016-09-01

Though commonly noted in clinical practice, it is unknown if decongestion in acute heart failure (AHF) results in increased serum bicarbonate. For 678 AHF patients in the DOSE-AHF, CARRESS-HF, and ROSE-AHF trials, we assessed change in bicarbonate (baseline to 72-96 hours) according to decongestion strategy, and the relationship between bicarbonate change and protocol-defined decongestion. Median baseline bicarbonate was 28 mEq/L. Patients with baseline bicarbonate ≥28 mEq/L had lower ejection fraction, worse renal function and higher N-terminal pro-B-type natriuretic peptide than those with baseline bicarbonate <28 mEq/L. There were no differences in bicarbonate change between treatment groups in DOSE-AHF or ROSE-AHF (all P > .1). In CARRESS-HF, bicarbonate increased with pharmacologic care but decreased with ultrafiltration (median +3.3 vs -0.9 mEq/L, respectively; P < .001). Bicarbonate change was not associated with successful decongestion (P > .2 for all trials). In AHF, serum bicarbonate is most commonly elevated in patients with more severe heart failure. Despite being used in clinical practice as an indicator for decongestion, change in serum bicarbonate was not associated with significant decongestion. Copyright © 2016 Elsevier Inc. All rights reserved.

Modifying physician behavior to improve cost-efficiency in safety-net ambulatory settings.

PubMed

Borkowski, Nancy; Gumus, Gulcin; Deckard, Gloria J

2013-01-01

Change interventions in one form or another are viewed as important tools to reduce variation in medical services, reduce costs, and improve quality of care. With the current focus on efficient resource use, the successful design and implementation of change strategies are of utmost importance for health care managers. We present a case study in which macro and micro level change strategies were used to modify primary care physicians' practice patterns of prescribing diagnostic services in a safety-net's ambulatory clinics. The findings suggest that health care managers using evidence-based strategies can create a practice environment that reduces barriers and facilitates change.

Identifying the domains of context important to implementation science: a study protocol.

PubMed

Squires, Janet E; Graham, Ian D; Hutchinson, Alison M; Michie, Susan; Francis, Jill J; Sales, Anne; Brehaut, Jamie; Curran, Janet; Ivers, Noah; Lavis, John; Linklater, Stefanie; Fenton, Shannon; Noseworthy, Thomas; Vine, Jocelyn; Grimshaw, Jeremy M

2015-09-28

There is growing recognition that "context" can and does modify the effects of implementation interventions aimed at increasing healthcare professionals' use of research evidence in clinical practice. However, conceptual clarity about what exactly comprises "context" is lacking. The purpose of this research program is to develop, refine, and validate a framework that identifies the key domains of context (and their features) that can facilitate or hinder (1) healthcare professionals' use of evidence in clinical practice and (2) the effectiveness of implementation interventions. A multi-phased investigation of context using mixed methods will be conducted. The first phase is a concept analysis of context using the Walker and Avant method to distinguish between the defining and irrelevant attributes of context. This phase will result in a preliminary framework for context that identifies its important domains and their features according to the published literature. The second phase is a secondary analysis of qualitative data from 13 studies of interviews with 312 healthcare professionals on the perceived barriers and enablers to their application of research evidence in clinical practice. These data will be analyzed inductively using constant comparative analysis. For the third phase, we will conduct semi-structured interviews with key health system stakeholders and change agents to elicit their knowledge and beliefs about the contextual features that influence the effectiveness of implementation interventions and healthcare professionals' use of evidence in clinical practice. Results from all three phases will be synthesized using a triangulation protocol to refine the context framework drawn from the concept analysis. The framework will then be assessed for content validity using an iterative Delphi approach with international experts (researchers and health system stakeholders/change agents). This research program will result in a framework that identifies the domains of context and their features that can facilitate or hinder: (1) healthcare professionals' use of evidence in clinical practice and (2) the effectiveness of implementation interventions. The framework will increase the conceptual clarity of the term "context" for advancing implementation science, improving healthcare professionals' use of evidence in clinical practice, and providing greater understanding of what interventions are likely to be effective in which contexts.

Impact of Patient Protection and Affordable Care Act on academic radiology departments' clinical, research, and education missions.

PubMed

Mansoori, Bahar; Vidal, Lorenna L; Applegate, Kimberly; Rawson, James V; Novak, Ronald D; Ros, Pablo R

2013-10-01

The Patient Protection and Affordable Care Act (ACA) generated significant media attention since its inception. When the law was approved in 2010, the U.S. health care system began facing multiple changes to adapt and to incorporate measures to meet the new requirements. These mandatory changes will be challenging for academic radiology departments (ARDs) since they will need to promote a shift from a volume-focused to a value-focused practice. This will affect all components of the mission of ARDs, including clinical practice, education, and research. A unique key element to success in this transition is to focus on both quality and safety, thus improving the value of radiology in the post-ACA era. Given the changes ARDs will face during the implementation of ACA, suggestions are provided on how to adapt ARDs to this new environment. Copyright © 2013. Published by Elsevier Inc.

Infant Reflux in the Primary Care Setting: A Brief Educational Intervention and Management Changes.

PubMed

Harris, Brendan Ryan; Bennett, William E

2018-07-01

There has been a significant increase in prescription of acid suppression therapy to infants despite limited support for efficacy and safety. Prior studies have shown that educational interventions can improve clinician practices. Our aim is to implement an educational module with high-yield evidence to decrease the rate of prescribing these medications. Chart review of infants seen by residents after completing module was performed. Twelve clinic sessions before and after intervention were examined. 28 residents completed the intervention and required clinics. Before implementation, 1.8% of infants seen were prescribed acid suppression with none receiving proton pump inhibitors (PPIs). After completion, 0.8% of infants were prescribed acid suppression and 1 patient received PPI. This was not a significant change. The study was unsuccessful in effecting changes in provider prescribing practices. Although, this is not the outcome expected, it is encouraging to have a low initial rate of PPI therapy prescribed patients.

Validation of a modified Bristol stool scale - inter-rater reliability amongst pediatric gastroenterologists

USDA-ARS?s Scientific Manuscript database

Stool form and changes in stool form are important criteria in both clinical practice and clinical research. However, descriptions of stool form from both patients and physicians alike may be subjective and objective measurements of stool form are not well developed. Although the Bristol stool scale...

Impact of clinical inertia on cardiovascular risk factors in patients with diabetes.

PubMed

Whitford, David L; Al-Anjawi, Hussam A; Al-Baharna, Marwa M

2014-07-01

To determine whether clinical inertia is associated with simpler interventions occurring more often than complex changes and the association between clinical inertia and outcomes. Prevalence of clinical inertia over a 30 month period for hyperglycaemia, hypertension and dyslipidaemia was calculated in a random sample (n=334) of patients attending a diabetes clinic. Comparisons between prevalence of clinical inertia and outcomes for each condition were examined using parametric tests of association. There was less clinical inertia in hyperglycaemia (29% of consultations) compared with LDL (80% of consultations) and systolic BP (68% of consultations). Consultations where therapy was intensified had a greater reduction in risk factor levels than when no change was made. No association was found between treatment intensity scores and changes in HbA1c, LDL or blood pressure over 30 months. Physicians are no more likely to intervene in conditions where simple therapeutic changes are necessary as opposed to complex changes. Greater clinical inertia leads to poorer outcomes. There continues to be substantial clinical inertia in routine clinical practice. Physicians should adopt a holistic approach to cardiovascular risk reduction in patients with diabetes, adhere more closely to established management guidelines and emphasize personal individualized target setting. Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Self-Reflection of Video-Recorded High-Fidelity Simulations and Development of Clinical Judgment.

PubMed

Bussard, Michelle E

2016-09-01

Nurse educators are increasingly using high-fidelity simulators to improve prelicensure nursing students' ability to develop clinical judgment. Traditionally, oral debriefing sessions have immediately followed the simulation scenarios as a method for students to connect theory to practice and therefore develop clinical judgment. Recently, video recording of the simulation scenarios is being incorporated. This qualitative, interpretive description study was conducted to identify whether self-reflection on video-recorded high-fidelity simulation (HFS) scenarios helped prelicensure nursing students to develop clinical judgment. Tanner's clinical judgment model was the framework for this study. Four themes emerged from this study: Confidence, Communication, Decision Making, and Change in Clinical Practice. This study indicated that self-reflection of video-recorded HFS scenarios is beneficial for prelicensure nursing students to develop clinical judgment. [J Nurs Educ. 2016;55(9):522-527.]. Copyright 2016, SLACK Incorporated.

A qualitative study of clinic and community member perspectives on intervention toolkits: "Unless the toolkit is used it won't help solve the problem".

PubMed

Davis, Melinda M; Howk, Sonya; Spurlock, Margaret; McGinnis, Paul B; Cohen, Deborah J; Fagnan, Lyle J

2017-07-18

Intervention toolkits are common products of grant-funded research in public health and primary care settings. Toolkits are designed to address the knowledge translation gap by speeding implementation and dissemination of research into practice. However, few studies describe characteristics of effective intervention toolkits and their implementation. Therefore, we conducted this study to explore what clinic and community-based users want in intervention toolkits and to identify the factors that support application in practice. In this qualitative descriptive study we conducted focus groups and interviews with a purposive sample of community health coalition members, public health experts, and primary care professionals between November 2010 and January 2012. The transdisciplinary research team used thematic analysis to identify themes and a cross-case comparative analysis to explore variation by participant role and toolkit experience. Ninety six participants representing primary care (n = 54, 56%) and community settings (n = 42, 44%) participated in 18 sessions (13 focus groups, five key informant interviews). Participants ranged from those naïve through expert in toolkit development; many reported limited application of toolkits in actual practice. Participants wanted toolkits targeted at the right audience and demonstrated to be effective. Well organized toolkits, often with a quick start guide, with tools that were easy to tailor and apply were desired. Irrespective of perceived quality, participants experienced with practice change emphasized that leadership, staff buy-in, and facilitative support was essential for intervention toolkits to be translated into changes in clinic or public -health practice. Given the emphasis on toolkits in supporting implementation and dissemination of research and clinical guidelines, studies are warranted to determine when and how toolkits are used. Funders, policy makers, researchers, and leaders in primary care and public health are encouraged to allocate resources to foster both toolkit development and implementation. Support, through practice facilitation and organizational leadership, are critical for translating knowledge from intervention toolkits into practice.

On implementation of an endodontic program.

PubMed

Koch, Margaretha

2013-01-01

It is widely accepted that the uptake of research findings by practitioners is unpredictable, yet until they are adopted, advances in technology and clinical research cannot improve health outcomes in patients. Despite extensive research there is limited knowledge of the processes by which changes occur and ways of measuring the effectiveness of change of practice. The overall aim of this thesis was to investigate aspects of an educational intervention in clinical endodontic routines and new instrumentation techniques in a Swedish County Public Dental Service. Special reference was made to the establishment of changed behaviour in practice, the process of change, and the clinical effects. Although a high level of competence in root canal treatment procedures is required in general dental practice, a number of Swedish studies have revealed inadequate root-fillings quality and associated periapical inflammation in general populations. It is suggested that the adoption of the nickel-titanium rotary instrumentation (NiTiR) technique would improve the cleaning and shaping of root canals and the quality of the root-filling. However, there is limited knowledge of the effectiveness of the technique when applied in general dental practice. In two of four consecutive studies, the subjects were employees of a county Public Dental Service. The aim was to investigate the rate of adoption of clinical routines and the NiTiR technique: the output, and the qualitative meaning of successful change in clinical practice. In the other two studies the aim was to investigate treatment effect and the cost-effectiveness of root canal treatment in a general population: the outcome. Four hundred employees (dentists, dental assistants, administrative assistants and clinical managers) of a Swedish County Public Dental Service were mandatorily enrolled in an educational and training program over two years. Change of practice was investigated in a post-education survey. The NiTiR technique was adopted by significantly more dentists in the intervention county compared to a control county (77% and 6% respectively). Dentists in the intervention county completed root canal instrumentation in significantly fewer sessions than the dentists in the control county. Eight in-depth interviews, two with each participant, (dentist, dental assistant, receptionist, clinical manager), were strategically selected for a phenomenological analysis. Four factors were identified as necessary for successful change: 1) disclosed motivation, 2) allowance for individual learning processes, 3) continuous professional collaboration, and 4) a facilitating educator. A random sample of 850 performed root canal treatments was used for a study of treatment outcome; 425 before and 425 after the education and adoption of the NiTiR technique. Root-filling quality, periapical status and tooth survival were assessed on radiographs taken at treatment and at follow-up, > or = 4 years later. Apical periodontitis was found in 34% of the teeth root-filled before the education compared to 33%, after. After the education, root-filling quality improved significantly, tooth survival was significantly higher, however, without a subsequent improvement in success rate post-education; 68% vs. 67%. A micro-costing model was used to calculate the costs of root canal instrumentation, pre- and post-education, in the same sample used in the study of treatment outcome. Costs were lower post-education: by SEK 264 for teeth with one canal and SEK 564 for teeth with three or more canals. A reason for lower costs was that the NiTiR technique dominated after the education and required significantly fewer instrumentation sessions. A cost-minimization analysis disclosed that root canal treatments undertaken post-education were more cost-effective. In conclusion, there was only a partial relationship between output and outcome. Although root-filling quality improved significantly, the study did not show any association between the more frequent use of NiTiR and an improvement in remaining teeth with normal periapical status or success rate. However, the use of NiTiR was more cost-effective. These results are in accordance with previous findings of the so called efficacy-effectiveness gap in clinical practice: a high output is not predictive of a high outcome. The overall conclusion to be drawn from these studies is that further research is warranted to identify factors associated with improvement of the quality of endodontic care. The general interpretation of the findings of these implementation studies is as important as the effects of the change in endodontic instrumentation: a clinically relevant and applicable intervention, introduced by experienced expertise under allowing learning and collaborating circumstances, disclosed clinicians' motivation and facilitated implementation. The finding of qualitative differences between the questionnaire responses and the in-depth interviews suggest that a critical approach is warranted when comparing surveys and qualitative methods aimed at investigating qualitative experiences of change, due to their different epistemological premises.

Clinical ethics and values: how do norms evolve from practice?

PubMed

Spranzi, Marta

2013-02-01

Bioethics laws in France have just undergone a revision process. The bioethics debate is often cast in terms of ethical principles and norms resisting emerging social and technological practices. This leads to the expression of confrontational attitudes based on widely differing interpretations of the same principles and values, and ultimately results in a deadlock. In this paper I would like to argue that focusing on values, as opposed to norms and principles, provides an interesting perspective on the evolution of norms. As Joseph Raz has convincingly argued, "life-building" values and practices are closely intertwined. Precisely because values have a more indeterminate meaning than norms, they can be cited as reasons for action by concerned stakeholders, and thus can help us understand how controversial practices, e.g. surrogate motherhood, can be justified. Finally, norms evolve when the interpretations of the relevant values shift and cause a change in the presumptions implicit in the norms. Thus, norms are not a prerequisite of the ethical solution of practical dilemmas, but rather the outcome of the decision-making process itself. Struggling to reach the right decision in controversial clinical ethics situations indirectly causes social and moral values to change and principles to be understood differently.

Data collection and information presentation for optimal decision making by clinical managers--the Autocontrol Project.

PubMed Central

Grant, A. M.; Richard, Y.; Deland, E.; Després, N.; de Lorenzi, F.; Dagenais, A.; Buteau, M.

1997-01-01

The Autocontrol methodology has been developed in order to support the optimisation of decision-making and the use of resources in the context of a clinical unit. The theoretical basis relates to quality assurance and information systems and is influenced by management and cognitive research in the health domain. The methodology uses population rather than individual decision making and because of its dynamic feedback design promises to have rapid and profound effect on practice. Most importantly the health care professional is the principle user of the Autocontrol system. In this methodology we distinguish three types of evidence necessary for practice change: practice based or internal evidence, best evidence derived from the literature or external evidence concerning the practice in question, and process based evidence on how to optimise the process of practice change. The software used by the system is of the executive decision support type which facilitates interrogation of large databases. The Autocontrol system is designed to interrogate the data of the patient medical record however the latter often lacks data on concomitant resource use and this must be supplemented. This paper reviews the Autocontrol methodology and gives examples from current studies. PMID:9357733

Data collection and information presentation for optimal decision making by clinical managers--the Autocontrol Project.

PubMed

Grant, A M; Richard, Y; Deland, E; Després, N; de Lorenzi, F; Dagenais, A; Buteau, M

1997-01-01

The Autocontrol methodology has been developed in order to support the optimisation of decision-making and the use of resources in the context of a clinical unit. The theoretical basis relates to quality assurance and information systems and is influenced by management and cognitive research in the health domain. The methodology uses population rather than individual decision making and because of its dynamic feedback design promises to have rapid and profound effect on practice. Most importantly the health care professional is the principle user of the Autocontrol system. In this methodology we distinguish three types of evidence necessary for practice change: practice based or internal evidence, best evidence derived from the literature or external evidence concerning the practice in question, and process based evidence on how to optimise the process of practice change. The software used by the system is of the executive decision support type which facilitates interrogation of large databases. The Autocontrol system is designed to interrogate the data of the patient medical record however the latter often lacks data on concomitant resource use and this must be supplemented. This paper reviews the Autocontrol methodology and gives examples from current studies.

How changes to the Medicare Benefits Schedule could improve the practice of cardiology and save taxpayer money.

PubMed

Harper, Richard W; Nasis, Arthur; Sundararajan, Vijaya

2015-09-21

Rising health care costs above inflation are placing serious strains on the sustainability of the Australian Medicare system in its current structure. The Medicare Benefits Schedule (MBS), which lists rebates payable to patients for private medical services provided on a fee-for-service basis, is the cornerstone of the Australian health care system. Introduced in the 1980s, the MBS has changed little despite major advances in the evidence base for the practice of cardiology. We outline how we believe sensible changes to the MBS listings for four cardiac services--invasive coronary angiography, computed tomography coronary angiography, stress testing and percutaneous coronary intervention--would improve the clinical practice of cardiology and save substantial amounts of taxpayer money.

Serum aminotransferase changes with significant weight loss: sex and age effects.

PubMed

Suzuki, Ayako; Binks, Martin; Sha, Ronald; Wachholtz, Amy; Eisenson, Howard; Diehl, Anna Mae

2010-02-01

In obese subjects, the liver may be differentially affected by significant weight loss depending on as yet unknown factors. We explored clinical factors associated with serum alanine aminotransferase (ALT) changes during significant weight loss in a residential weight loss program. Clinical data from 362 adults who received a comprehensive weight loss intervention (ie, diets, physical fitness, and behavioral modification) in the program were analyzed. Serum ALT was used as a surrogate marker of liver injury. The ALT changes during the program were calculated to create study outcome categories (improvement, no change, or deterioration of ALT during significant weight loss). Variables of demography, lifestyle, and comorbidities at baseline, and total/rate of weight change during the program were explored for associations with the ALT change categories using multiple logistic regression models. Variation by sex was apparent among predictors of ALT deterioration; men with rapid weight loss and women with higher initial body mass index were more likely to experience ALT deterioration, whereas men with prior alcohol consumption were less likely to experience ALT deterioration even after adjusting for baseline ALT (Ps < .03). Variation by age was apparent among predictors of ALT improvement; younger patients with current smoking and older patients with rapid weight loss, diabetes or impaired fasting glucose, or sleep apnea or who followed a reduced-carbohydrate diet were less likely to experience ALT improvement (Ps < .05). A number of clinical factors influence ALT changes during weight loss in sex- and age-specific manners. The patterns that we detected may have pathophysiologic significance beyond the practical implications of our findings in clinical practice related to underlying changes in fat metabolism. Copyright 2010 Elsevier Inc. All rights reserved.

Nursing Practice, Research and Education in the West: The Best Is Yet to Come.

PubMed

Young, Heather M; Bakewell-Sachs, Susan; Sarna, Linda

This paper celebrates the 60th anniversary of the Western Institute of Nursing, the nursing organization representing 13 states in the Western United States, and envisions a preferred future for nursing practice, research, and education. Three landmark calls to action contribute to transforming nursing and healthcare: the Patient Protection and Affordable Care Act of 2010; the Institute of Medicine report Future of Nursing: Leading Change, Advancing Health; and the report Advancing Healthcare Transformation: A New Era for Academic Nursing. Challenges abound: U.S. healthcare remains expensive, with poorer outcomes than other developed countries; costs of higher education are high; our profession does not reflect the diversity of the population; and health disparities persist. Pressing health issues, such as increases in chronic disease and mental health conditions and substance abuse, coupled with aging of the population, pose new priorities for nursing and healthcare. Changes are needed in practice, research, and education. In practice, innovative, cocreated, evidence-based models of care can open new roles for registered nurses and advanced practice registered nurses who have knowledge, leadership, and team skills to improve quality and address system change. In research, data can provide a foundation for clinical practice and expand our knowledge base in symptom science, wellness, self-management, and end-of-life/palliative care, as well as behavioral health, to demonstrate the value of nursing care and reduce health disparities. In education, personalized, integrative, and technology-enabled teaching and learning can lead to creative and critical thinking/decision-making, ethical and culturally inclusive foundations for practice, ensure team and communication skills, quality and system improvements, and lifelong learning. The role of the Western Institute of Nursing is more relevant than ever as we collectively advance nursing, health, and healthcare through education, clinical practice, and research.

Brief Mindfulness Practices for Healthcare Providers - A Systematic Literature Review.

PubMed

Gilmartin, Heather; Goyal, Anupama; Hamati, Mary C; Mann, Jason; Saint, Sanjay; Chopra, Vineet

2017-10-01

Mindfulness practice, where an individual maintains openness, patience, and acceptance while focusing attention on a situation in a nonjudgmental way, can improve symptoms of anxiety, burnout, and depression. The practice is relevant for health care providers; however, the time commitment is a barrier to practice. For this reason, brief mindfulness interventions (eg, ≤ 4 hours) are being introduced. We systematically reviewed the literature from inception to January 2017 about the effects of brief mindfulness interventions on provider well-being and behavior. Studies that tested a brief mindfulness intervention with hospital providers and measured change in well-being (eg, stress) or behavior (eg, tasks of attention or reduction of clinical or diagnostic errors) were selected for narrative synthesis. Fourteen studies met inclusion criteria; 7 were randomized controlled trials. Nine of 14 studies reported positive changes in levels of stress, anxiety, mindfulness, resiliency, and burnout symptoms. No studies found an effect on provider behavior. Brief mindfulness interventions may be effective in improving provider well-being; however, larger studies are needed to assess an impact on clinical care. Published by Elsevier Inc.

Enhancing Feedback On Case Reports To Third Year Medical Students On Clinical Attachment

PubMed Central

McKeown, Pascal

2017-01-01

Preparation of case reports during student attachments has the attraction of reflecting real life clinical practice, but lacks standardisation when used in summative assessment. This study examined the occurrence and nature of feedback after the introduction of a new system of formative case reports in Third Year clinical attachments. Quantitative and qualitative methods were used to compare the new system to previous practice. Comparison of questionnaire responses demonstrated more and earlier feedback in the New Third Year, which was likely to be delivered at a meeting rather than as written comment. In the New Third Year, the quality of feedback was better and several markers of high quality feedback were rated more highly. There was no difference, however, in students’ confidence in their ability to assess patients. The qualitative data from the New Third Year documented much excellent feedback but also examples of poor practice as well as inconsistency of advice. In conclusion, a relatively simple intervention effected radical changes to feedback practice and attitudes, although it is not known if the clinical skills of students improved. PMID:28298712

[Neural prostheses and neuromodulation : Research and clinical practice in therapy and rehabilitation].

PubMed

Stieglitz, T

2010-08-01

Stimulation of the nervous system with the aid of electrical active implants has changed the therapy of neurological diseases and rehabilitation of lost functions and has expanded clinical practice within the last few years. Alleviation of effects of neurodegenerative diseases, therapy of psychiatric diseases, the functional restoration of hearing as well as other applications have been transferred successfully into clinical practice. Other approaches are still under development in preclinical and clinical trials. The restoration of sight by implantable electronic systems that interface with the retina in the eye is an example how technological progress promotes novel medical devices. The idea of using the electrical signal of the brain to control technical devices and (neural) prostheses is driving current research in the field of brain-computer interfaces. The benefit for the patient always has to be balanced with the risks and side effects of those implants in comparison to medicinal and surgical treatments. How these and other developments become established in practice depends finally on their acceptance by the patients and the reimbursement of their costs.

Facilitators for practice change in Spanish community pharmacy.

PubMed

Gastelurrutia, Miguel A; Benrimoj, S I Charlie; Castrillon, Carla C; de Amezua, María J Casado; Fernandez-Llimos, Fernando; Faus, Maria J

2009-02-01

To identify and prioritise facilitators for practice change in Spanish community pharmacy. Spanish community pharmacies. Qualitative study. Thirty-three semi-structured interviews were conducted with community pharmacists (n = 15) and pharmacy strategists (n = 18), and the results were examined using the content analysis method. In addition, two nominal groups (seven community pharmacists and seven strategists) were formed to identify and prioritise facilitators. Results of both techniques were then triangulated. Facilitators for practice change. Twelve facilitators were identified and grouped into four domains (D1: Pharmacist; D2: Pharmacy as an organisation; D3: Pharmaceutical profession; D4: Miscellaneous). Facilitators identified in D1 include: the need for more clinical education at both pre- and post-graduate levels; the need for clearer and unequivocal messages from professional leaders about the future of the professional practice; and the need for a change in pharmacists' attitudes. Facilitators in D2 are: the need to change the reimbursement system to accommodate cognitive service delivery as well as dispensing; and the need to change the front office of pharmacies. Facilitators identified in D3 are: the need for the Spanish National Professional Association to take a leadership role in the implementation of cognitive services; the need to reduce administrative workload; and the need for universities to reduce the gap between education and research. Other facilitators identified in this study include: the need to increase patients' demand for cognitive services at pharmacies; the need to improve pharmacist-physician relationships; the need for support from health care authorities; and the need for improved marketing of cognitive services and their benefits to society, including physicians and health care authorities. Twelve facilitators were identified. Strategists considered clinical education and pharmacists' attitude as the most important, and remuneration of little importance. Community pharmacists, in contrast, considered remuneration as the most important facilitator for practice change.

The Invisible Army

PubMed Central

2017-01-01

ABSTRACT The “invisible army” of clinical microbiologists is facing major changes and challenges. The rate of change in both the science and technology is accelerating with no end in sight, putting pressure on our army to learn and adapt as never before. Health care funding in the United States is undergoing dramatic change which will require a new set of assumptions about how clinical microbiology is practiced here. A major challenge facing the discipline is the replacement of a generation of clinical microbiologists. In my opinion, it is incumbent on us in the invisible army to continue to work with the American Society for Microbiology (ASM) in meeting the future challenges faced by our discipline. In this commentary, I will first discuss some recent history of clinical microbiology within ASM and then some current challenges we face. PMID:28659316

Agents for Change: Nonphysician Medical Providers and Health Care Quality

PubMed Central

Boucher, Nathan A; McMillen, Marvin A; Gould, James S

2015-01-01

Quality medical care is a clinical and public health imperative, but defining quality and achieving improved, measureable outcomes are extremely complex challenges. Adherence to best practice invariably improves outcomes. Nonphysician medical providers (NPMPs), such as physician assistants and advanced practice nurses (eg, nurse practitioners, advanced practice registered nurses, certified registered nurse anesthetists, and certified nurse midwives), may be the first caregivers to encounter the patient and can act as agents for change for an organization’s quality-improvement mandate. NPMPs are well positioned to both initiate and ensure optimal adherence to best practices and care processes from the moment of initial contact because they have robust clinical training and are integral to trainee/staff education and the timely delivery of care. The health care quality aspects that the practicing NPMP can affect are objective, appreciative, and perceptive. As bedside practitioners and participants in the administrative and team process, NPMPs can fine-tune care delivery, avoiding the problem areas defined by the Institute of Medicine: misuse, overuse, and underuse of care. This commentary explores how NPMPs can affect quality by 1) supporting best practices through the promotion of guidelines and protocols, and 2) playing active, if not leadership, roles in patient engagement and organizational quality-improvement efforts. PMID:25663213

An interactive quality of work life model applied to organizational transition.

PubMed

Knox, S; Irving, J A

1997-01-01

Most healthcare organizations in the United States are in the process of some type of organizational change or transition. Professional nurses and other healthcare providers practicing in U.S. healthcare delivery organizations are very aware of the dramatic effects of restructuring processes. A phenomenal amount of change and concern is occurring with organizational redesign, generating many questions and uncertainties. These transitions challenge the basic assumptions and principles guiding the practice of clinical and management roles in healthcare.

A systems change: leading the way to meeting health needs.

PubMed

Deisher, Mirella

2013-01-01

Demonstrating the efficacy of our practice requires a paradigm shift. Becoming an effective leader and clinician can facilitate opportunities for program development and clinical research. The use of strategic planning strategies, such as needs assessment and SWOT analysis, can help lead the way to such change. The following illustrates the use of strategic planning to develop The Carpal and Cubital Tunnel Syndrome Program (CCTSP) within a growing orthopedic practice. Copyright © 2013 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.

How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution.

PubMed

Helfrich, Christian D; Rose, Adam J; Hartmann, Christine W; van Bodegom-Vos, Leti; Graham, Ian D; Wood, Suzanne J; Majerczyk, Barbara R; Good, Chester B; Pogach, Leonard M; Ball, Sherry L; Au, David H; Aron, David C

2018-02-01

One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition. We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as "the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines." We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience "reactance," ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together. By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence. © 2018 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.

Leg or foot amputation - dressing change

MedlinePlus

Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for management for rehabilitation of lower limb amputation. January 2008. www.healthquality.va.gov/guidelines/ ...

The art and science of chronic disease management come together in a lifestyle-focused approach to primary care.

PubMed

Egger, G; Katz, D; Sagner, M; Dixon, J; Stevens, J

2014-12-01

Changes in patterns of living result in changes in the nature and causes of disease. The industrial revolution of the late 18th century, and the technological revolution of the late 20th century are cases in point. The former was associated with a decline in infectious diseases; the latter with an increase in lifestyle and environmentally induced chronic diseases . Health practices are typically modified to deal with such changes, hence the recent rise in interest in lifestyle-oriented forms of clinical practice. © 2014 John Wiley & Sons Ltd.

Can training in advanced clinical skills in obstetrics, neonatal care and leadership, of non-physician clinicians in Malawi impact on clinical services improvements (the ETATMBA project): a process evaluation

PubMed Central

Ellard, David R; Chimwaza, Wanangwa; Davies, David; O'Hare, Joseph Paul; Kamwendo, Francis; Quenby, Siobhan; Griffiths, Frances

2014-01-01

Objectives The ‘enhancing human resources and the use of appropriate technologies for maternal and perinatal survival in sub-Saharan Africa’ (ETATMBA) project is training emergency obstetric and new-born care (EmONC) non-physician clinicians (NPCs) as advanced clinical leaders. Our objectives were to evaluate the implementation and changes to practice. Design A mixed methods process evaluation with the predominate methodology being qualitative. Setting Rural and urban hospitals in 8 of the 14 districts of northern and central Malawi. Participants 54 EmONC NPCs with 3 years’ plus experience. Intervention Training designed and delivered by clinicians from the UK and Malawi; it is a 2-year plus package of training (classroom, mentorship and assignments). Results We conducted 79 trainee interviews over three time points during the training, as well as a convenience sample of 10 colleagues, 7 district officers and 2 UK obstetricians. Trainees worked in a context of substantial variation in the rates of maternal and neonatal deaths between districts. Training reached trainees working across the target regions. For 46 trainees (8 dropped out of the course), dose delivered in terms of attendance was high and all 46 spent time working alongside an obstetrician. In early interviews trainees recalled course content unprompted indicating training had been received. Colleagues and district officers reported cascading of knowledge and initial changes in practice indicating early implementation. By asking trainees to describe actual cases we found they had implemented new knowledge and skills. These included life-saving interventions for postpartum haemorrhage and eclampsia. Trainees identified the leadership training as enabling them to confidently change their own practice and initiate change in their health facility. Conclusions This process evaluation suggests that trainees have made positive changes in their practice. Clear impacts on maternal and perinatal mortality are yet to be elucidated. PMID:25116455

Compliance with a pediatric clinical practice guideline for intravenous fluid and electrolyte administration.

PubMed

Hurdowar, Amanda; Urmson, Lynn; Bohn, Desmond; Geary, Denis; Laxer, Ronald; Stevens, Polly

2009-01-01

The occurrence of acute hyponatremia associated with cerebral edema in hospitalized children has been increasingly recognized, with over 50 cases of neurological morbidity and mortality reported in the past decade. This condition most commonly occurs in previously healthy children where maintenance intravenous (IV) fluids have been prescribed in the form of hypotonic saline (e.g., 0.2 or 0.3 NaCl). In response to similar problems at The Hospital for Sick Children (six identified through hospital morbidity and mortality reviews and safety reports prior to fall 2007), an interdisciplinary clinician group from our institution developed a clinical practice guideline (CPG) to guide fluid and electrolyte administration for pediatric patients. This article reviews the evaluation of one patient safety improvement to change the prescribing practice for IV fluids in an acute care pediatric hospital, including the removal of the ability to prescribe hypotonic IV solutions with a sodium concentration of < 75 mmol/L. The evaluation of key components of the CPG included measuring practice and process changes pre- and post-implementation. The evaluation showed that the use of restricted IV fluids was significantly reduced across the organization. Success factors of this safety initiative included the CPG development, forcing functions, reminders, team engagement and support from the hospital leadership. A key learning was that a project leader with considerable dedicated time is required during the implementation to develop change concepts, organize and liaise with stakeholders and measure changes in practice. This project highlights the importance of active implementation for policy and guideline documents.

Use of an Objective Structured Clinical Examination in Clinical Nurse Specialist Education.

PubMed

Cuevas, Heather E; Timmerman, Gayle M

2016-01-01

Helping patients maximize their potential using expert coaching to facilitate lifestyle change is an important practice area for clinical nurse specialists (CNSs). The purpose is to determine the usefulness of objective structured clinical examinations (OSCEs) for evaluating CNS students' coaching competencies in the context of facilitating lifestyle change. Despite the use of OSCEs to assess competencies in clinical skills (eg, performance of procedures, decision making), its potential for evaluating coaching competencies for lifestyle change has not been demonstrated. We developed 4 OSCEs dealing with coaching patients in exercise, weight loss, stress reduction, or nonpharmacologic management of hyperlipidemia. Evaluation criteria included (1) approach to the patient, (2) information gathering, (3) motivational interviewing, and (4) management (medical and behavioral strategies). Student performance ranged from highly organized with proficient coaching skills to disorganized and focused solely on clinical management and prescriptive communication. Student responses were positive. Objective structured clinical examinations were highly useful for evaluating CNS students' coaching competencies for lifestyle change. Using OSCEs early in the semester to provide students feedback on their performance and again at the end to determine improvement optimizes use of this teaching strategy.

Evaluation and applications of the clinically significant change method with the Violence Risk Scale-Sexual Offender version: implications for risk-change communication.

PubMed

Olver, Mark E; Beggs Christofferson, Sarah M; Wong, Stephen C P

2015-02-01

We examined the use of the clinically significant change (CSC) method with the Violence Risk Scale-Sexual Offender version (VRS-SO), and its implications for risk communication, in a combined sample of 945 treated sexual offenders from three international settings, followed up for a minimum 5 years post-release. The reliable change (RC) index was used to identify thresholds of clinically meaningful change and to create four CSC groups (already okay, recovered, improved, unchanged) based on VRS-SO dynamic scores and amount of change made. Outcome analyses demonstrated important CSC-group differences in 5-year rates of sexual and violent recidivism. However, when baseline risk was controlled via Cox regression survival analysis, the pattern and magnitude of CSC-group differences in sexual and violent recidivism changed to suggest that observed variation in recidivism base rates could be at least partly explained by pre-existing group differences in risk level. Implications for communication of risk-change information and applications to clinical practice are discussed. Copyright © 2015 John Wiley & Sons, Ltd.

Diffusion of innovation theory for clinical change.

PubMed

Sanson-Fisher, Robert W

2004-03-15

Maximising the adoption of evidence-based practice has been argued to be a major factor in determining healthcare outcomes. However, there are gaps between evidence-based recommendations and current care. Bridging the evidence gap will not be achieved simply by informing clinicians about the evidence. One theoretical approach to understanding how change may be achieved is Rogers' diffusion model. He argues that certain characteristics of the innovation itself may facilitate its adoption. Other factors influencing acceptance include promotion by influential role models, the degree of complexity of the change, compatibility with existing values and needs, and the ability to test and modify the new procedure before adopting it. The diffusion model may provide valuable insights into why some practices change and others do not, as well as guiding those who try to effect adoption of best-evidence practice.

Family physician practice visits arising from the Alberta Physician Achievement Review

PubMed Central

2013-01-01

Background Licensed physicians in Alberta are required to participate in the Physician Achievement Review (PAR) program every 5 years, comprising multi-source feedback questionnaires with confidential feedback, and practice visits for a minority of physicians. We wished to identify and classify issues requiring change or improvement from the family practice visits, and the responses to advice. Methods Retrospective analysis of narrative practice visit reports data using a mixed methods design to study records of visits to 51 family physicians and general practitioners who participated in PAR during the period 2010 to 2011, and whose ratings in one or more major assessment domains were significantly lower than their peer group. Results Reports from visits to the practices of family physicians and general practitioners confirmed opportunities for change and improvement, with two main groupings – practice environment and physician performance. For 40/51 physicians (78%) suggested actions were discussed with physicians and changes were confirmed. Areas of particular concern included problems arising from practice isolation and diagnostic conclusions being reached with incomplete clinical evidence. Conclusion This study provides additional evidence for the construct validity of a regulatory authority educational program in which multi-source performance feedback identifies areas for practice quality improvement, and change is encouraged by supplementary contact for selected physicians. PMID:24010980

Structured data quality reports to improve EHR data quality.

PubMed

Taggart, Jane; Liaw, Siaw-Teng; Yu, Hairong

2015-12-01

To examine whether a structured data quality report (SDQR) and feedback sessions with practice principals and managers improve the quality of routinely collected data in EHRs. The intervention was conducted in four general practices participating in the Fairfield neighborhood electronic Practice Based Research Network (ePBRN). Data were extracted from their clinical information systems and summarised as a SDQR to guide feedback to practice principals and managers at 0, 4, 8 and 12 months. Data quality (DQ) metrics included completeness, correctness, consistency and duplication of patient records. Information on data recording practices, data quality improvement, and utility of SDQRs was collected at the feedback sessions at the practices. The main outcome measure was change in the recording of clinical information and level of meeting Royal Australian College of General Practice (RACGP) targets. Birth date was 100% and gender 99% complete at baseline and maintained. DQ of all variables measured improved significantly (p<0.01) over 12 months, but was not sufficient to comply with RACGP standards. Improvement was greatest with allergies. There was no significant change in duplicate records. SDQRs and feedback sessions support general practitioners and practice managers to focus on improving the recording of patient information. However, improved practice DQ, was not sufficient to meet RACGP targets. Randomised controlled studies are required to evaluate strategies to improve data quality and any associated improved safety and quality of care. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Developing a Framework for Evaluating Ethical Outcomes of Good Participatory Practices in TB Clinical Drug Trials.

PubMed

MacQueen, Kathleen M; Eley, Natalie T; Frick, Mike; Mingote, Laia Ruiz; Chou, Alicia; Seidel, Stephanie S; Hannah, Stacey; Hamilton, Carol

2016-07-01

Good Participatory Practice Guidelines for TB Drug Trials (GPP-TB) were issued in 2012, based on similar guidelines for HIV prevention and reflecting growing acceptance of the importance of community engagement and participatory strategies in clinical research. Though the need for such strategies is clear, evaluation of the benefits and burdens are needed. Working with a diverse group of global TB stakeholders including advocates, scientists, and ethicists, we used a Theory of Change approach to develop an evaluation framework for GPP-TB that includes a clearly defined ethical goal, a set of powerful strategies derived from GPP-TB practices for achieving the goal, and outcomes connecting strategies to goal. The framework is a first step in systematically evaluating participatory research in clinical trials. © The Author(s) 2016.

Instituting parent education practices in the neonatal intensive care unit: an administrative case report of practice evaluation and statewide action.

PubMed

Dusing, Stacey C; Van Drew, Catherine M; Brown, Shaaron E

2012-07-01

Infants born preterm are at high risk of developmental disabilities and benefit from early developmental intervention programs. Physical therapists with neonatal expertise are ideally suited to educate parents about ways to support their infant's development in the first months of life. However, administrative policies are needed to support the therapist in providing adequate parent education in the neonatal intensive care unit (NICU). This administrative case report describes the process used by a team of neonatal therapists to evaluate clinical practice, determine the need for change, and develop and implement a new parent education program in the NICU. Physical therapy parent education practices were evaluated in an academic medical center with a 36-bed, level-3 NICU. Physical therapists with neonatal expertise covered multiple units within the hospital each day. A series of focus groups, a small descriptive study, and staff discussion were used to evaluate parent education practices in this academic medical center. A new parent education program was developed based on data collected and literature to improve clinical care. The new parent education model was implemented over the course of several months using overlapping initiatives. Administrative support for the change was developed through collaboration, open communication, and presentation of clinical data. In addition, this hospital-based program contributed to the development of a statewide initiative to educate parents of preterm infants about the importance of supporting development in the first months of life. A collaborative and data-driven approach to evaluating parent education practices supported the development of a new parent education practice while acknowledging the need to meet staff productivity standards and provide excellent care throughout the hospital.

Instituting Parent Education Practices in the Neonatal Intensive Care Unit: An Administrative Case Report of Practice Evaluation and Statewide Action

PubMed Central

Van Drew, Catherine M.; Brown, Shaaron E.

2012-01-01

Background and Purpose Infants born preterm are at high risk of developmental disabilities and benefit from early developmental intervention programs. Physical therapists with neonatal expertise are ideally suited to educate parents about ways to support their infant's development in the first months of life. However, administrative policies are needed to support the therapist in providing adequate parent education in the neonatal intensive care unit (NICU). This administrative case report describes the process used by a team of neonatal therapists to evaluate clinical practice, determine the need for change, and develop and implement a new parent education program in the NICU. Case Description Physical therapy parent education practices were evaluated in an academic medical center with a 36-bed, level-3 NICU. Physical therapists with neonatal expertise covered multiple units within the hospital each day. A series of focus groups, a small descriptive study, and staff discussion were used to evaluate parent education practices in this academic medical center. A new parent education program was developed based on data collected and literature to improve clinical care. Outcomes The new parent education model was implemented over the course of several months using overlapping initiatives. Administrative support for the change was developed through collaboration, open communication, and presentation of clinical data. In addition, this hospital-based program contributed to the development of a statewide initiative to educate parents of preterm infants about the importance of supporting development in the first months of life. Discussion A collaborative and data-driven approach to evaluating parent education practices supported the development of a new parent education practice while acknowledging the need to meet staff productivity standards and provide excellent care throughout the hospital. PMID:22466024

CHAracteristics of research studies that iNfluence practice: a GEneral survey of Canadian orthopaedic Surgeons (CHANGES): a pilot survey.

PubMed

de Sa, Darren; Thornley, Patrick; Evaniew, Nathan; Madden, Kim; Bhandari, Mohit; Ghert, Michelle

2015-01-01

Evidence Based Medicine (EBM) is increasingly being applied to inform clinical decision-making in orthopaedic surgery. Despite the promotion of EBM in Orthopaedic Surgery, the adoption of results from high quality clinical research seems highly unpredictable and does not appear to be driven strictly by randomized trial data. The objective of this study was to pilot a survey to determine if we could identify surgeon opinions on the characteristics of research studies that are perceived as being most likely to influence clinical decision-making among orthopaedic surgeons in Canada. A 28-question electronic survey was distributed to active members of the Canadian Orthopaedic Association (COA) over a period of 11 weeks. The questionnaire sought to analyze the influence of both extrinsic and intrinsic characteristics of research studies and their potential to influence practice patterns. Extrinsic factors included the perceived journal quality and investigator profiles, economic impact, peer/patient/industry influence and individual surgeon residency/fellowship training experiences. Intrinsic factors included study design, sample size, and outcomes reported. Descriptive statistics are provided. Of the 109 members of the COA who opened the survey, 95 (87%) completed the survey in its entirety. The overall response rate was 11% (95/841). Surgeons achieved consensus on the influence of three key designs on their practices: 1) randomized controlled trials 94 (99%), 2) meta-analysis 83 (87%), and 3) systematic reviews 81 (85%). Sixty-seven percent of surgeons agreed that studies with sample sizes of 101-500 or more were more likely to influence clinical practice than smaller studies (n = <100). Factors other than design influencing adoption included 1) reputation of the investigators (99%) and 2) perceived quality of the journal (75%). Although study design and sample size (i.e. minimum of 100 patients) have some influence on clinical decision making, surgeon respondents are equally influenced by investigator reputation and perceived journal quality. At present, continued emphasis on the generation of large, methodologically sound clinical trials remains paramount to translating research findings to clinical practice changes. Specific to this pilot survey, strategies to solicit more widespread responses will be pursued.

Functional connectivity change as shared signal dynamics

PubMed Central

Cole, Michael W.; Yang, Genevieve J.; Murray, John D.; Repovš, Grega; Anticevic, Alan

2015-01-01

Background An increasing number of neuroscientific studies gain insights by focusing on differences in functional connectivity – between groups, individuals, temporal windows, or task conditions. We found using simulations that additional insights into such differences can be gained by forgoing variance normalization, a procedure used by most functional connectivity measures. Simulations indicated that these functional connectivity measures are sensitive to increases in independent fluctuations (unshared signal) in time series, consistently reducing functional connectivity estimates (e.g., correlations) even though such changes are unrelated to corresponding fluctuations (shared signal) between those time series. This is inconsistent with the common notion of functional connectivity as the amount of inter-region interaction. New Method Simulations revealed that a version of correlation without variance normalization – covariance – was able to isolate differences in shared signal, increasing interpretability of observed functional connectivity change. Simulations also revealed cases problematic for non-normalized methods, leading to a “covariance conjunction” method combining the benefits of both normalized and non-normalized approaches. Results We found that covariance and covariance conjunction methods can detect functional connectivity changes across a variety of tasks and rest in both clinical and non-clinical functional MRI datasets. Comparison with Existing Method(s) We verified using a variety of tasks and rest in both clinical and non-clinical functional MRI datasets that it matters in practice whether correlation, covariance, or covariance conjunction methods are used. Conclusions These results demonstrate the practical and theoretical utility of isolating changes in shared signal, improving the ability to interpret observed functional connectivity change. PMID:26642966

Policy-into-practice for rheumatoid arthritis: randomized controlled trial and cohort study of e-learning targeting improved physiotherapy management.

PubMed

Fary, Robyn E; Slater, Helen; Chua, Jason; Ranelli, Sonia; Chan, Madelynn; Briggs, Andrew M

2015-07-01

To examine the effectiveness of a physiotherapy-specific, web-based e-learning platform, "RAP-el," in best-practice management of rheumatoid arthritis (RA) using a single-blind, randomized controlled trial (RCT) and prospective cohort study. Australian-registered physiotherapists were electronically randomized into intervention and control groups. The intervention group accessed RAP-eL over 4 weeks. Change in self-reported confidence in knowledge and skills was compared between groups at the end of the RCT using linear regression conditioned for baseline scores by a blinded assessor, using intent-to-treat analysis. Secondary outcomes included physiotherapists' satisfaction with RA management and responses to RA-relevant clinical statements and practice-relevant vignettes. Retention was evaluated in a cohort study 8 weeks after the RCT. Eighty physiotherapists were randomized into the intervention and 79 into the control groups. Fifty-six and 48, respectively, provided baseline data. Significant between-group differences were observed for change in confidence in knowledge (mean difference 8.51; 95% confidence interval [95% CI] 6.29, 10.73; effect size 1.62) and skills (mean difference 7.26; 95% CI 5.1, 9.4; effect size 1.54), with the intervention group performing better. Satisfaction in ability to manage RA, 4 of the 6 clinical statements, and responses to vignettes demonstrated significant improvement in the intervention group. Although 8-week scores showed declines in most outcomes, their clinical significance remains uncertain. RAP-eL can improve self-reported confidence, likely practice behaviors and satisfaction in physiotherapists' ability to manage people with RA, and improve their clinical knowledge in several areas of best-practice RA management in the short term. © 2015, American College of Rheumatology.

A nurse-facilitated depression screening program in an Army primary care clinic: an evidence-based project.

PubMed

Yackel, Edward E; McKennan, Madelyn S; Fox-Deise, Adrianna

2010-01-01

Depression, sometimes with suicidal manifestations, is a medical condition commonly seen in primary care clinics. Routine screening for depression and suicidal ideation is recommended of all adult patients in the primary care setting because it offers depressed patients a greater chance of recovery and response to treatment, yet such screening often is overlooked or omitted. The purpose of this study was to develop, to implement, and to test the efficacy of a systematic depression screening process to increase the identification of depression in family members of active duty soldiers older than 18 years at a military family practice clinic located on an Army infantry post in the Pacific. The Iowa Model of Evidence-Based Practice to Promote Quality Care was used to develop a practice guideline incorporating a decision algorithm for nurses to screen for depression. A pilot project to institute this change in practice was conducted, and outcomes were measured. Before implementation, approximately 100 patients were diagnosed with depression in each of the 3 months preceding the practice change. Approximately 130 patients a month were assigned a 311.0 Code 3 months after the practice change, and 140 patients per month received screenings and were assigned the correct International Classification of Diseases, Ninth Revision Code 311.0 at 1 year. The improved screening and coding for depression and suicidality added approximately 3 minutes to the patient screening process. The education of staff in the process of screening for depression and correct coding coupled with monitoring and staff feedback improved compliance with the identification and the documentation of patients with depression. Nurses were more likely than primary care providers to agree strongly that screening for depression enhances quality of care. Data gathered during this project support the integration of military and civilian nurse-facilitated screening for depression in the military primary care setting. The decision algorithm should be adapted and tested in other primary care environments.

Internal medicine board certification and career pathways in Japan.

PubMed

Koike, Soichi; Matsumoto, Masatoshi; Ide, Hiroo; Kawaguchi, Hideaki; Shimpo, Masahisa; Yasunaga, Hideo

2017-05-08

Establishing and managing a board certification system is a common concern for many countries. In Japan, the board certification system is under revision. The purpose of this study was to describe present status of internal medicine specialist board certification, to identify factors associated with maintenance of board certification and to investigate changes in area of practice when physicians move from hospital to clinic practice. We analyzed 2010 and 2012 data from the Survey of Physicians, Dentists and Pharmacists. We conducted logistic regression analysis to identify factors associated with the maintenance of board certification between 2010 and 2012. We also analyzed data on career transition from hospitals to clinics for hospital physicians with board certification. It was common for physicians seeking board certification to do so in their early career. The odds of maintaining board certification were lower in women and those working in locations other than academic hospitals, and higher in physicians with subspecialty practice areas. Among hospital physicians with board certification who moved to clinics between 2010 and 2012, 95.8% remained in internal medicine or its subspecialty areas and 87.7% maintained board certification but changed their practice from a subspecialty area to more general internal medicine. Revisions of the internal medicine board certification system must consider different physician career pathways including mid-career moves while maintaining certification quality. This will help to secure an adequate number and distribution of specialists. To meet the increasing demand for generalist physicians, it is important to design programs to train specialists in general practice.

Students Learn Systems-Based Care and Facilitate System Change as Stakeholders in a Free Clinic Experience

ERIC Educational Resources Information Center

Colbert, Colleen Y.; Ogden, Paul E.; Lowe, Darla; Moffitt, Michael J.

2010-01-01

Systems-based practice (SBP) is rarely taught or evaluated during medical school, yet is one of the required competencies once students enter residency. We believe Texas A&M College of Medicine students learn about systems issues informally, as they care for patients at a free clinic in Temple, TX. The mandatory free clinic rotation is part of…

Treatment Outcome and Metacognitive Change in CBT and GET for Chronic Fatigue Syndrome.

PubMed

Fernie, Bruce A; Murphy, Gabrielle; Wells, Adrian; Nikčević, Ana V; Spada, Marcantonio M

2016-07-01

Studies have reported that Cognitive Behavioural Therapy (CBT) and Graded Exercise Therapy (GET) are effective treatments for Chronic Fatigue Syndrome (CFS). One hundred and seventy-one patients undertook a course of either CBT (n = 116) or GET (n = 55) and were assessed on a variety of self-report measures at pre- and posttreatment and follow-up. In this paper we present analyses on treatment outcomes for CBT and GET in routine clinical practice and evaluate whether changes on subscales of the Metacognitions Questionnaire-30 (MCQ-30) predict fatigue severity independently of changes in other covariates, and across the two treatment modalities. Both CBT and GET were equally effective at decreasing fatigue, anxiety, and depression, and at increasing physical functioning. Changes on the subscales of the MCQ-30 were also found to have a significant effect on fatigue severity independently of changes in other covariates and across treatment modalities. The findings from the current study suggest that CFS treatment protocols for CBT and GET, based on those from the PACE trial, achieve similar to poorer outcomes in routine clinical practice as in a RCT.

OSHA regulations: how they relate to ophthalmic practice.

PubMed

Garber, N

1992-01-01

The OSHA regulations, which took effect March 6, 1992, require that all employees be trained in infection control practices when they are hired, their job description changes, or the standards for universal precautions are revised. An explanation, provided to inform employees where a copy of the OSHA standard can be reviewed should be available at each clinical and surgical site, and OSHA regulation definitions must also be posted. The OSHA regulation applies to any clinical, housekeeping, or administrative staff that has any potential risk of exposure to blood or other potentially infectious substances.

Translation of Nutritional Genomics into Nutrition Practice: The Next Step.

PubMed

Murgia, Chiara; Adamski, Melissa M

2017-04-06

Genetics is an important piece of every individual health puzzle. The completion of the Human Genome Project sequence has deeply changed the research of life sciences including nutrition. The analysis of the genome is already part of clinical care in oncology, pharmacology, infectious disease and, rare and undiagnosed diseases. The implications of genetic variations in shaping individual nutritional requirements have been recognised and conclusively proven, yet routine use of genetic information in nutrition and dietetics practice is still far from being implemented. This article sets out the path that needs to be taken to build a framework to translate gene-nutrient interaction studies into best-practice guidelines, providing tools that health professionals can use to understand whether genetic variation affects nutritional requirements in their daily clinical practice.

Physiotherapists in emergency departments: responsibilities, accountability and education.

PubMed

Crane, Jacqueline; Delany, Clare

2013-06-01

Emergency physiotherapy roles have evolved within the UK and are increasingly being adopted in Australia in response to a need for greater workforce flexibility and improved service provision to meet growing patient demand. This paper discusses the need for the physiotherapy profession to develop evidence-based regulatory, ethical and educative frameworks to keep pace with the changing clinical environment and service delivery in emergency departments. Definitions of Emergency Physiotherapy as either advanced practice or extended scope of practice are identified, and the implications for both regulation of practice and education are highlighted. Suggestions for education in areas of clinical skills, ethical understanding and legal and professional knowledge are highlighted as important areas to support physiotherapists moving into this area of practice. Copyright © 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Translation of Nutritional Genomics into Nutrition Practice: The Next Step

PubMed Central

Murgia, Chiara; Adamski, Melissa M.

2017-01-01

Genetics is an important piece of every individual health puzzle. The completion of the Human Genome Project sequence has deeply changed the research of life sciences including nutrition. The analysis of the genome is already part of clinical care in oncology, pharmacology, infectious disease and, rare and undiagnosed diseases. The implications of genetic variations in shaping individual nutritional requirements have been recognised and conclusively proven, yet routine use of genetic information in nutrition and dietetics practice is still far from being implemented. This article sets out the path that needs to be taken to build a framework to translate gene–nutrient interaction studies into best-practice guidelines, providing tools that health professionals can use to understand whether genetic variation affects nutritional requirements in their daily clinical practice. PMID:28383492

Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract.

PubMed

Checkland, Kath; Harrison, Stephen; McDonald, Ruth; Grant, Suzanne; Campbell, Stephen; Guthrie, Bruce

2008-07-01

In 2004 a new contract was introduced for General Practitioners in the UK, which introduced a significant element of 'pay-for-performance', including both clinical and organisational targets. The introduction of this contract has caused interest across the world, particularly amongst those responsible for commissioning primary care services. It can be argued that the clinical targets in the contract (known as the Quality and Outcomes Framework, QOF) represent a move towards a more biomedical model of health and illness, which is contrary to the ideal of providing holistic (or biopsychosocial) care that has been traditionally espoused by GPs. This paper reports results from two linked studies (in England and Scotland) investigating the early stages of the new contract. We describe the way in which four practices with different organisational approaches and espoused identities have all changed their practice structures, consultations and clinical care in response to QOF in ways which will result in patients receiving a more biomedical type of care. In spite of these observed changes, respondents continued to maintain discursive claims to holism. We discuss how this disconnection between rhetoric and reality can be maintained, and consider its implications for the future development of GPs' claims to a professional identity.

Crossing the gender boundaries: The gender experiences of male nursing students in initial nursing clinical practice in Taiwan.

PubMed

Liu, Hsing-Yuan; Li, Yun Ling

2017-11-01

The initial nursing clinical practice is the necessary practicum required for nursing students. Because of the changing learning style, many of them are under great pressure for environmental change and therefore their daily routine is severe affected. Interacting directly with patients in a female-dominated occupation, along with the general gender stereotypes, the impact is especially significant to male nursing students than to female nursing students. The purpose of this preliminary qualitative study is to explore the gendered experiences of male nursing students during their first initial nursing clinical practice. Both focus group interviews and individual interviews are conducted with twenty-two sophomore nursing students from a university of technology in northern Taiwan, with ten male students and twelve female students. Two main themes emerge from the gendered experiences shared by the nursing students: Gender consciousness awakening and thus maintaining masculinity, and male advantage in the learning environments. The results identify the specific gendered experiences of nursing students, providing implications for future nursing education and counseling service. Further, this study may serve to promote an active yet gender-sensitive nursing education for training nursing professionals. Published by Elsevier Ltd.

Implementing autonomous clinical nurse specialist prescriptive authority: a competency-based transition model.

PubMed

Klein, Tracy Ann

2012-01-01

The purpose of this study was to identify and implement a competency-based regulatory model that transitions clinical nurse specialists (CNSs) to autonomous prescriptive authority pursuant to change in state law. Prescriptive authority for CNSs may be optional or restricted under current state law. Implementation of the APRN Consensus Model includes full prescriptive authority for all advanced practice registered nurses. Clinical nurse specialists face barriers to establishing their prescribing authority when laws or practice change. Identification of transition models will assist CNSs who need to add prescriptive authority to their scope of practice. Identification and implementation of a competency-based transition model for expansion of CNS prescriptive authority. By January 1, 2012, 9 CNSs in the state exemplar have completed a practicum and been granted full prescriptive authority including scheduled drug prescribing. No complaints or board actions resulted from the transition to autonomous prescribing. Transition to prescribing may be facilitated through competency-based outcomes including practicum hours as appropriate to the individual CNS nursing specialty. Outcomes from this model can be used to develop and further validate educational and credentialing policies to reduce barriers for CNSs requiring prescriptive authority in other states.

Translational behavioral medicine for population and individual health: gaps, opportunities, and vision for practice-based translational behavior change research.

PubMed

Ma, Jun; Lewis, Megan A; Smyth, Joshua M

2018-04-12

In this commentary, we propose a vision for "practice-based translational behavior change research," which we define as clinical and public health practice-embedded research on the implementation, optimization, and fundamental mechanisms of behavioral interventions. This vision intends to be inclusive of important research elements for behavioral intervention development, testing, and implementation. We discuss important research gaps and conceptual and methodological advances in three key areas along the discovery (development) to delivery (implementation) continuum of evidence-based interventions to improve behavior and health that could help achieve our vision of practice-based translational behavior change research. We expect our proposed vision to be refined and evolve over time. Through highlighting critical gaps that can be addressed by integrating modern theoretical and methodological approaches across disciplines in behavioral medicine, we hope to inspire the development and funding of innovative research on more potent and implementable behavior change interventions for optimal population and individual health.

An international survey to identify the intrinsic and extrinsic factors of research studies most likely to change orthopaedic practice.

PubMed

Thornley, P; de Sa, D; Evaniew, N; Farrokhyar, F; Bhandari, M; Ghert, M

2016-04-01

Evidence -based medicine (EBM) is designed to inform clinical decision-making within all medical specialties, including orthopaedic surgery. We recently published a pilot survey of the Canadian Orthopaedic Association (COA) membership and demonstrated that the adoption of EBM principles is variable among Canadian orthopaedic surgeons. The objective of this study was to conduct a broader international survey of orthopaedic surgeons to identify characteristics of research studies perceived as being most influential in informing clinical decision-making. A 29-question electronic survey was distributed to the readership of an established orthopaedic journal with international readership. The survey aimed to analyse the influence of both extrinsic (journal quality, investigator profiles, etc.) and intrinsic characteristics (study design, sample size, etc.) of research studies in relation to their influence on practice patterns. A total of 353 surgeons completed the survey. Surgeons achieved consensus on the 'importance' of three key designs on their practices: randomised controlled trials (94%), meta-analyses (75%) and systematic reviews (66%). The vast majority of respondents support the use of current evidence over historical clinical training; however subjective factors such as journal reputation (72%) and investigator profile (68%) continue to influence clinical decision-making strongly. Although intrinsic factors such as study design and sample size have some influence on clinical decision-making, surgeon respondents are equally influenced by extrinsic factors such as investigator reputation and perceived journal quality.Cite this article: Dr M. Ghert. An international survey to identify the intrinsic and extrinsic factors of research studies most likely to change orthopaedic practice. Bone Joint Res 2016;5:130-136. DOI: 10.1302/2046-3758.54.2000578. © 2016 Ghert et al.

Care delivery and compensation system changes: a case study of organizational readiness within a large dental care practice organization in the United States.

PubMed

Cunha-Cruz, Joana; Milgrom, Peter; Huebner, Colleen E; Scott, JoAnna; Ludwig, Sharity; Dysert, Jeanne; Mitchell, Melissa; Allen, Gary; Shirtcliff, R Mike

2017-12-20

Dental care delivery systems in the United States are consolidating and large practice organizations are becoming more common. At the same time, greater accountability for addressing disparities in access to care is being demanded when public funds are used to pay for care. As change occurs within these new practice structures, attempts to implement change in the delivery system may be hampered by failure to understand the organizational climate or fail to prepare employees to accommodate new goals or processes. Studies of organizational behavior within oral health care are sparse and have not addressed consolidation of current delivery systems. The objective of this case study was to assess organizational readiness for implementing change in a large dental care organization consisting of staff model clinics and affiliated dental practices and test associations of readiness with workforce characteristics and work environment. A dental care organization implemented a multifaceted quality improvement program, called PREDICT, in which community-based mobile and clinic-based dental services were integrated and the team compensated based in part on meeting performance targets. Dental care providers and supporting staff members (N = 181) were surveyed before program implementation and organizational readiness for implementing change (ORIC) was assessed by two 5-point scales: change commitment and efficacy. Providers and staff demonstrated high organizational readiness for change. Median change commitment was 3.8 (Interquartile range [IQR]: 3.3-4.3) and change efficacy was 3.8 (IQR: 3.0-4.2). In the adjusted regression model, change commitment was associated with organizational climate, support for methods to arrest tooth decay and was inversely related to office chaos. Change efficacy was associated with organizational climate, support for the company's mission and was inversely related to burnout. Each unit increase in the organizational climate scale predicted 0.45 and 0.8-unit increases in change commitment and change efficacy. The survey identified positive readiness for change and highlighted weaknesses that are important cautions for this organization and others initiating change. Future studies will examine how organizational readiness to change, workforce characteristics and work environment influenced successful implementation within this organization.

[Quantitative Prediction of Drug-Drug Interaction Caused by CYP Inhibition and Induction from In Vivo Data and Its Application in Daily Clinical Practices-Proposal for the Pharmacokinetic Interaction Significance Classification System (PISCS)].

PubMed

Ohno, Yoshiyuki

2018-01-01

　Drug-drug interactions (DDIs) can affect the clearance of various drugs from the body; however, these effects are difficult to sufficiently evaluate in clinical studies. This article outlines our approach to improving methods for evaluating and providing drug information relative to the effects of DDIs. In a previous study, total exposure changes to many substrate drugs of CYP caused by the co-administration of inhibitor or inducer drugs were successfully predicted using in vivo data. There are two parameters for the prediction: the contribution ratio of the enzyme to oral clearance for substrates (CR), and either the inhibition ratio for inhibitors (IR) or the increase in clearance of substrates produced by induction (IC). To apply these predictions in daily pharmacotherapy, the clinical significance of any pharmacokinetic changes must be carefully evaluated. We constructed a pharmacokinetic interaction significance classification system (PISCS) in which the clinical significance of DDIs was considered in a systematic manner, according to pharmacokinetic changes. The PISCS suggests that many current 'alert' classifications are potentially inappropriate, especially for drug combinations in which pharmacokinetics have not yet been evaluated. It is expected that PISCS would contribute to constructing a reliable system to alert pharmacists, physicians and consumers of a broad range of pharmacokinetic DDIs in order to more safely manage daily clinical practices.

How did general practitioners protect themselves, their family, and staff during the SARS epidemic in Hong Kong?

PubMed Central

Wong, W; Lee, A; Tsang, K; Wong, S

2004-01-01

Context: Severe acute respiratory syndrome (SARS) is a newly emerging infectious disease and how the frontline community doctors respond to it is not known. Objectives: To explore the impact of SARS on general practitioners (GPs) in Hong Kong. Design: A cross sectional survey. Setting: Community based primary care clinics. Participants: 183 family medicine tutors affiliated with a local university. Postal survey sent to all tutors with a 74.8% response rate. Main outcome measures: Change of clinical behaviour and practices during the epidemic; anxiety level of primary care doctors. Results: All agreed SARS had changed their clinical practices. Significant anxiety was found in family doctors. Three quarters of respondents recalled requesting more investigations while a quarter believed they had over-prescribed antibiotics. GPs who were exposed to SARS or who had worked in high infection districts were less likely to quarantine themselves (10.8% versus 33.3%; p<0.01; 6.5% versus 27.5%; p<0.01 respectively). Exposure to SARS, the infection rates in their working district, and anxiety levels had significant impact on the level of protection or prescribing behaviour. Conclusion: The clinical practice of GPs changed significantly as a result of SARS. Yet, those did not quarantine themselves suggesting other factors may have some part to play. As failure to apply isolation precautions to suspected cases of SARS was one major reason for its spread, a contingency plan from the government to support family doctors is of utmost importance. Interface between private and public sectors are needed in Hong Kong to prepare for any future epidemics. PMID:14966227

How did general practitioners protect themselves, their family, and staff during the SARS epidemic in Hong Kong?

PubMed

Wong, W C W; Lee, A; Tsang, K K; Wong, S Y S

2004-03-01

Severe acute respiratory syndrome (SARS) is a newly emerging infectious disease and how the frontline community doctors respond to it is not known. To explore the impact of SARS on general practitioners (GPs) in Hong Kong. A cross sectional survey. Community based primary care clinics. 183 family medicine tutors affiliated with a local university. Postal survey sent to all tutors with a 74.8% response rate. Change of clinical behaviour and practices during the epidemic; anxiety level of primary care doctors. All agreed SARS had changed their clinical practices. Significant anxiety was found in family doctors. Three quarters of respondents recalled requesting more investigations while a quarter believed they had over-prescribed antibiotics. GPs who were exposed to SARS or who had worked in high infection districts were less likely to quarantine themselves (10.8% versus 33.3%; p<0.01; 6.5% versus 27.5%; p<0.01 respectively). Exposure to SARS, the infection rates in their working district, and anxiety levels had significant impact on the level of protection or prescribing behaviour. The clinical practice of GPs changed significantly as a result of SARS. Yet, those did not quarantine themselves suggesting other factors may have some part to play. As failure to apply isolation precautions to suspected cases of SARS was one major reason for its spread, a contingency plan from the government to support family doctors is of utmost importance. Interface between private and public sectors are needed in Hong Kong to prepare for any future epidemics.

Green shoots of recovery: a realist evaluation of a team to support change in general practice.

PubMed

Bartlett, Maggie; Basten, Ruth; McKinley, Robert K

2017-02-08

A multidisciplinary support team for general practice was established in April 2014 by a local National Health Service (NHS) England management team. This work evaluates the team's effectiveness in supporting and promoting change in its first 2 years, using realist methodology. Primary care in one area of England. Semistructured interviews were conducted with staff from 14 practices, 3 key senior NHS England personnel and 5 members of the support team. Sampling of practice staff was purposive to include representatives from relevant professional groups. The team worked with practices to identify areas for change, construct action plans and implement them. While there was no specified timescale for the team's work with practices, it was tailored to each. In realist evaluations, outcomes are contingent on mechanisms acting in contexts, and both an understanding of how an intervention leads to change in a socially constructed system and the resultant changes are outcomes. The principal positive mechanisms leading to change were the support team's expertise and its relationships with practice staff. The 'external view' provided by the team via its corroborative and normalising effects was an important mechanism for increasing morale in some practice contexts. A powerful negative mechanism was related to perceptions of 'being seen as a failing practice' which included expressions of 'shame'. Outcomes for practices as perceived by their staff were better communication, improvements in patients' access to appointments resulting from better clinical and managerial skill mix, and improvements in workload management. The support team promoted change within practices leading to signs of the 'green shoots of recovery' within the time frame of the evaluation. Such interventions need to be tailored and responsive to practices' needs. The team's expertise and relationships between team members and practice staff are central to success. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

An evaluative case study of online learning for healthcare professionals.

PubMed

Pullen, Darren L

2006-01-01

This evaluation study assessed the pedagogical and instructional design (e-pedagogy) effectiveness of online continuing professional education (CPE) courses offered by a large Australian CPE provider. A naturalistic theory approach and a multilevel evaluation were used to examine the impact of web-based learning on more than 300 healthcare professionals. Participant satisfaction, learning achievement, self-reported practice performance change, and e-pedagogical courseware characteristics were assessed by various qualitative and quantitative data collection methods. Findings revealed that learning online was an effective means for increasing CPE knowledge (p < .05) and improving self-reported practice performance change (p < .05). Courses containing a clinical tool resulted in an increased self-reported practice performance change over courses that did not (Zobs = 3.757). Online CPE offers a convenient format for healthcare professionals from educationally and geographically diverse populations to update their knowledge and view best practice.

Situational Analysis of Physical Therapist Clinical Instructors' Facilitation of Students' Emerging Embodiment of Movement in Practice.

PubMed

Covington, Kyle; Barcinas, Susan J

2017-06-01

Physical therapists improve the functional ability of patients after injury and disease. A unique component of their practice is the ability to use the movement of their own bodies to effect change in their patients. This ability has been recognized as a distinctive attribute of expert physical therapists. The purpose of this qualitative situational analysis study was to examine how physical therapist clinical instructors perceive and facilitate their students' emerging integration of movement in practice. Data collection and analysis were guided by a theoretical framework for understanding "professional ways of being." Data were analyzed using coding and mapping strategies consistent with situational analysis techniques. The study included 5 physical therapist clinical instructors and their respective 5 physical therapist students. Data were collected during beginning, midterm, and final weeks of the students' clinical internships using participant interviews, observation, and document analysis. Coded data were summarized using situational analysis mapping strategies, resulting in 11 maps. These maps were further analyzed and reduced to 5 thematic behaviors enacted by a clinical instructor as he or she helps facilitate students' use of movement in practice. These behaviors are adapt, prepare, enhance, connect , and develop . The limited number of participants and the relative homogeneity of the student sample may have limited the diversity of data collected. The 5 behaviors are useful when considered as a trajectory of development. To our knowledge, this study marks the first description of how physical therapist clinical instructors develop students' use of movement in practice and how to enact behaviors important in students' continued professional development. The findings are important for clinical instructors and academic programs considering how best to prepare students to use movement and develop their skills early in practice. © 2017 American Physical Therapy Association

What does it take to change practice? Perspectives of pharmacists in Ontario.

PubMed

Gregory, Paul A M; Teixeira, Beatriz; Austin, Zubin

2018-01-01

This is a time of rapid change in the profession of pharmacy. Anecdotally, there are concerns that the pace, extent and rate of practice evolution are lagging. There is little evidence documenting the influencers and mechanisms that drive practice changes forward in pharmacy in Canada. An exploratory qualitative method was selected, using both one-on-one interviews with self-categorized typical pharmacists and larger focus groups to provide context and confirmation of themes generated through interviews. Data were analyzed and coded using a constant-comparative iterative method, in order to generate themes related to the factors influencing pharmacists to actually change their practice. A total of 46 pharmacists meeting inclusion criteria participated in this study in focus groups, interviews or both. Nine themes were identified: 1) permission, 2) process pointers, 3) practice/rehearsal, 4) positive reinforcement, 5) personalized attention, 6) peer referencing, 7) physician acceptance, 8) patients' expectations and 9) professional identity supportive of a truly clinical role. One theme that did not emerge was payment, or remuneration, as a specific or isolated motivational factor for change. The complexity of practice change in pharmacy and the multiple factors highlighted in this study point to a more deliberate and concerted effort being needed by diverse pharmacy organizations (educators, regulators, employers, professional associations, etc.) to support pharmacists through the change management process. The "9 Ps of practice change" identified through this study can provide pharmacists with guidance in terms of how to better support evolution of the profession in a more time-efficient and effective manner.

Added Value of Patient-Reported Outcome Measures in Stroke Clinical Practice.

PubMed

Katzan, Irene L; Thompson, Nicolas R; Lapin, Brittany; Uchino, Ken

2017-07-21

There is uncertainty regarding the clinical utility of the data obtained from patient-reported outcome measures (PROMs) for patient care. We evaluated the incremental information obtained by PROMs compared to the clinician-reported modified Rankin Scale (mRS). This was an observational study of 3283 ischemic stroke patients seen in a cerebrovascular clinic from September 14, 2012 to June 16, 2015 who completed the routinely collected PROMs: Stroke Impact Scale-16 (SIS-16), EQ-5D, Patient Health Questionnaire-9, PROMIS Physical Function, and PROMIS fatigue. The amount of variation in the PROMs explained by mRS was determined using r 2 after adjustment for age and level of stroke impairment. The proportion with meaningful change was calculated for patients with ≥2 visits. Concordance with change in the other scales and the ability to discriminate changes in health state as measured by c-statistic was evaluated for mRS versus SIS-16. Correlation between PROMs and mRS was highest for SIS-16 ( r =-0.64, P <0.01). The r 2 ranged from 0.11 (PROMIS fatigue) to 0.56 (SIS-16). Change in scores occurred in 51% with mRS and 35% with SIS-16. There was lower agreement and less ability to discriminate change in mRS than in SIS-16 with change in the other measures. PROMs provide additional valuable information compared to the mRS alone in stroke patients seen in the ambulatory setting. SIS-16 may have a better ability to identify change than mRS in health status of relevance to the patient. PROMs may be a useful addition to mRS in the assessment of health status in clinical practice. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Training in neurology.

PubMed

Aminoff, Michael J

2008-05-13

The training of clinical neurologists is undergoing profound change. Increasing subspecialization within neurology, the widening separation of clinical neurology from other branches of internal medicine, limitations of exposure to training in internal medicine, mandated restrictions in working hours, and attempts to shorten the training period are likely to have adverse effects on the next generation of clinical neurologists. Despite the need for a broad base in general medicine, discussed here, the exposure of neurology trainees to general medical disorders is diminishing. An emphasis on an algorithmic approach to patient management rather than on educating residents to use their reasoning faculties when applying new techniques and knowledge to clinical practice may adversely affect patient care. Neurologists require broad-based training in neurology, internal medicine, and psychiatry, to ensure excellence in clinical practice. It is time to question again whether they are receiving the training that they need.

Research and Clinical Center for Child Development Annual Report, 1997-1998, No. 21.

ERIC Educational Resources Information Center

Chen, Shing-Jen, Ed.; Furutsuka, Takashi, Ed.; Shirotani, Yukari, Ed.

This annual report discusses several topics related to the work of the Clinical Center for Child Development at Hokkaido University in Sapporo, Japan. The articles are: (1) "The Study of Mothers' Parenting Practices with Child's Withdrawn Behaviors and Temperament" (Sueko Toda); (2) "Structure, Developmental Change, and Sex…

Supporting chronic disease self-management: translating policies and principles into clinical practice.

PubMed

Higgins, Rosemary; Murphy, Barbara; Worcester, Marian; Daffey, Angela

2012-01-01

To support self-management, health professionals need to adopt a client-centred approach and learn to deliver evidence-based behaviour change interventions. This paper reports on the evaluation of 1- and 2-day training programs developed to improve health professionals' capacity to support chronic disease self-management (CDSM). The 321 participants attended one of eighteen supporting CDSM courses held in urban and rural settings. Participants included nurses, allied health professionals, Aboriginal health workers and general practitioners. Data were collected at three time points: before participation; immediately after the training; and, for a sub-sample of 37 participants, 2 months after the training. Results revealed a significant and sustained increase in CDSM self-efficacy following training regardless of participants' gender, age or qualifications. A thematic analysis of the responses concerning intended practice revealed four main areas of intended practice change, namely: use behavioural strategies; improve communication with clients; adopt a client-centred approach; and improve goal setting. The number of practice changes at 2 months reported by a sub-sample of participants ranged from 1 to 20 with a mean of 14 (s.d.=4). The three most common areas of practice change point to the adoption by health professionals of a collaborative approach with chronic disease patients. Lack of staff trained in CDSM was seen as a major barrier to practice change, with lack of support and finance also named as barriers to practice change. Participants identified that increased training, support and awareness of the principles of supporting CDSM would help to overcome barriers to practice change. These results indicate a readiness among health professionals to adopt a more collaborative approach given the skills and the tools to put this approach into practice.

Proportion of adults fasting for lipid testing relative to guideline changes in Alberta.

PubMed

Ma, Irene; Viczko, Jeannine; Naugler, Christopher

2017-04-01

Guidelines have historically recommended measuring lipid profile tests in a fasting state. However, in April 2011 and 2014, the Canadian city of Calgary and its province of Alberta, respectively, have changed their lipid guidelines to allow testing for individuals in any fasting state; several years prior to the release of the 2016 Canadian Cardiovascular Society and Hypertension Canada guidelines. The purpose of this study was to document the proportion of individuals in Calgary who fasted for a lipid encounter in relation to the change in various guidelines and policies. Counts were collected each month per gender from January 1, 2010 to June 30, 2016 for community-based adults ≥18years old who fasted (≥8h) or did not fast (<8h) for a lipid encounter. During the study period, 793,719 community-based lipid profiles were performed, 590,174 in a fasting state. The proportion of adults who fasted declined from 98.59%±0.379% (mean±SD) in 2010 to 41.65%±1.295% (mean±SD) in 2016. However, a marked decline in the proportion of adults fasting for a lipid encounter was not observed until February 2015, which coincided with the release of Alberta's Toward Optimized Practice Clinical Practice Guidelines. This documentation of individuals fasting for a lipid encounter may assist other jurisdictions in Canada with the new nonfasting lipid guideline changes. We recommend releasing provincial clinical practice guidelines, in addition to laboratory bulletins and continuing medical education presentations, regarding the new nonfasting lipid recommendations in other jurisdictions to ensure community patients are aware of this change. Copyright © 2016 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

The impact of the care equity project with community/public health nursing students.

PubMed

Kamau-Small, Sylvia; Joyce, Barbara; Bermingham, Neysa; Roberts, Jada; Robbins, Curtis

2015-01-01

The purpose of this article is to report on the evaluation process of a multi-disciplinary interactive teaching-learning workshop implemented in a college of nursing baccalaureate program. A 6-hr workshop on cultural humility and care equity was implemented using educational theater to bring clinical situations involved in community/public health practice into the classroom. One hundred and forty-nine students participated in the workshop. Stages of Change (Prochaska and DiClemente [2005] Handbook of psychotherapy integration. New York: Oxford University Press) and the Learning Transfer Barriers Framework (Price, Miller, Rahm, Brace, & Larson [2010] Journal of Continuing Education in the Health Professions, 30, 237-245.) provided conceptual underpinnings for project evaluation. Nursing students completed a quiz, post-workshop online surveys at 2 and 8 weeks, and a clinical application report (CAR). Survey data provided information on barriers to the transfer of knowledge from theory class to the clinical setting. Qualitative methods were used to audit the CARs. Each CAR was independently reviewed to determine the Stage of Change reflected in the narrative. Workshop evaluation outcomes provide evidence that cultural humility skill building has created behavior change in clinical practice for new health care community/public health nursing providers. © 2014 Wiley Periodicals, Inc.

[How to write, how to implement and how to evaluate a practice guideline in order to improve quality of care?].

PubMed

Moret, L; Lefort, C; Terrien, N

2012-11-01

Initiatives of clinical practices improvement have been gradually developing in France for 20 years. Nevertheless, effective implementation of change is still difficult for numerous reasons. The use of clinical practices guidelines is one of the different ways of improvement. It is however necessary to adapt these national guidelines to the specificities of the hospital and the team, to ensure implementation and appropriation by the professionals. These recommendations are thus translated into applicable and concrete standard operating procedures. These documents have to be built by and for the concerned professionals. They are also communication and training tools, precise, directive, uniform in terms of presentation and attractive visually. Once drafted, they have to be distributed widely to the professionals to facilitate implementation. The simple distribution of the recommendations is insufficient to modify the clinical practices and require association of several methods of promotion for an optimal appropriation. How then to make sure of their effective use? Practices evaluation is one of the steps of continuous professional development, including continuous training and analysis of clinical practices by using methods promoted by the "Haute Autorité de santé". One of them is the clinical audit; use of method assessing non-pertinent treatment is interesting too. Analysis of the non-conformities and gaps between theory and practice allows identifying various possible causes (professional, institutional, organizational or personal) in order to implement corrective action plans, in a logic of continuous improvement. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Bringing the best of medical librarianship to the patient team.

PubMed

Shearer, Barbara S; Seymour, Anne; Capitani, Cheryl

2002-01-01

This article introduces a series of articles examining the state of the medical library profession as practiced in the clinical context. It is widely understood that many changes across the spectrum of medical librarianship practice have been brought about by both technological advances and economic realities. These changes have created strains felt by many in the profession. Discussions of evolving roles for medical librarians that have gone on for years have taken on a new sense of urgency, not just because support of library services is at stake, but also because new opportunities, which many are eager to explore, await librarians. In June 2000, an editorial appearing in a mainstream medical journal proposed a reinvention of clinical librarianship that, if designed as presented in the editorial, would have a dramatic effect on current hospital-based library practice. This series of articles was developed in an effort to provide thoughtful consideration of the "informationist" model and to present new ways to look at the core competencies that define the profession.

Bringing the best of medical librarianship to the patient team

PubMed Central

Shearer, Barbara S.; Seymour, Anne; Capitani, Cheryl

2002-01-01

This article introduces a series of articles examining the state of the medical library profession as practiced in the clinical context. It is widely understood that many changes across the spectrum of medical librarianship practice have been brought about by both technological advances and economic realities. These changes have created strains felt by many in the profession. Discussions of evolving roles for medical librarians that have gone on for years have taken on a new sense of urgency, not just because support of library services is at stake, but also because new opportunities, which many are eager to explore, await librarians. In June 2000, an editorial appearing in a mainstream medical journal proposed a reinvention of clinical librarianship that, if designed as presented in the editorial, would have a dramatic effect on current hospital-based library practice. This series of articles was developed in an effort to provide thoughtful consideration of the “informationist” model and to present new ways to look at the core competencies that define the profession. PMID:11838456

Psychiatry chief resident opinions toward basic and clinical neuroscience training and practice.

PubMed

Bennett, Jeffrey I; Handa, Kamna; Mahajan, Aman; Deotale, Pravesh

2014-04-01

The authors queried attendees to a chief resident conference on whether program education and training in neuroscience or in translating neuroscience research into practice is sufficient and what changes are needed. The authors developed and administered a 26-item voluntary questionnaire to each attendee at the Chief Residents' Leadership Conference at the American Psychiatric Association 2013 annual meeting in San Francisco, CA. Out of 94 attendees, 55 completed and returned questionnaires (58.5%). A majority of respondents stated that their program provided adequate training in neuroscience (61.8%); opportunities for neuroscience research existed for them (78.2%), but that their program did not prepare them for translating future neuroscience research findings into clinical practice (78.9%) or educate them on the NIMH Research Domain Criteria (83.3%). A majority of respondents stated that the ACGME should require a specific neuroscience curriculum (79.6%). Chief residents believe that curricular and cultural change is needed in psychiatry residency neuroscience education.

Integration of Treatment Innovation Planning and Implementation: Strategic Process Models and Organizational Challenges

PubMed Central

Lehman, Wayne E. K.; Simpson, D. Dwayne; Knight, Danica K.; Flynn, Patrick M.

2015-01-01

Sustained and effective use of evidence-based practices in substance abuse treatment services faces both clinical and contextual challenges. Implementation approaches are reviewed that rely on variations of plan-do-study-act (PDSA) cycles, but most emphasize conceptual identification of core components for system change strategies. A 2-phase procedural approach is therefore presented based on the integration of TCU models and related resources for improving treatment process and program change. Phase 1 focuses on the dynamics of clinical services, including stages of client recovery (cross-linked with targeted assessments and interventions), as the foundations for identifying and planning appropriate innovations to improve efficiency and effectiveness. Phase 2 shifts to the operational and organizational dynamics involved in implementing and sustaining innovations (including the stages of training, adoption, implementation, and practice). A comprehensive system of TCU assessments and interventions for client and program-level needs and functioning are summarized as well, with descriptions and guidelines for applications in practical settings. PMID:21443294

Behavior change interventions and policies influencing primary healthcare professionals' practice-an overview of reviews.

PubMed

Chauhan, Bhupendrasinh F; Jeyaraman, Maya M; Mann, Amrinder Singh; Lys, Justin; Skidmore, Becky; Sibley, Kathryn M; Abou-Setta, Ahmed M; Zarychanski, Ryan

2017-01-05

There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers. Study design: overview of reviews. MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015). two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language. two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors' conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.). Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change. Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change.

DSM-5 and ADHD - an interview with Eric Taylor.

PubMed

Taylor, Eric

2013-09-12

In this podcast we talk to Prof Eric Taylor about the changes to the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) in DSM-5 and how these changes will affect clinical practice. The podcast for this interview is available at: http://www.biomedcentral.com/sites/2999/download/Taylor.mp3.

Redefining Practice: Challenging Academic and Institutional Traditions with Clinical Distance Learning

ERIC Educational Resources Information Center

Delgaty, Laura E.

2017-01-01

With the uptake of distance learning (DL), which has actually been marginal for most academics, teaching contexts, traditional power structures and relationships have been transformed, leaving lecturers potentially disenfranchised. Institutional and cultural change is vital, particularly changes concerning academic roles. The advent of DL has…

The future of anesthesiology: implications of the changing healthcare environment.

PubMed

Prielipp, Richard C; Cohen, Neal H

2016-04-01

Anesthesiology is at a crossroad, particularly in the USA. We explore the changing and future roles for anesthesiologists, including the implication of new models of care such as the perioperative surgical home, changes in payment methodology, and the impact other refinements in healthcare delivery will have on practice opportunities and training requirements for anesthesiologists. The advances in the practice of anesthesiology are having a significant impact on patient care, allowing a more diverse and complex patient population to benefit from the knowledge, skills and expertise of anesthesiologists. Expanded clinical opportunities, increased utilization of technology and expansion in telemedicine will provide the foundation to care for more patients in diverse settings and to better monitor patients remotely while ensuring immediate intervention as needed. Although the roles of anesthesiologists have been diverse, the scope of practice varies from one country to another. The changing healthcare needs in the USA in particular are creating new opportunities for American anesthesiologists to define expanded roles in healthcare delivery. To fulfill these evolving needs of patients and health systems, resident training, ongoing education and methods to ensure continued competency must incorporate new approaches of education and continued certification to ensure that each anesthesiologist has the full breadth and depth of clinical skills needed to support patient and health system needs. The scope of anesthesia practice has expanded globally, providing anesthesiologists, particularly those in the USA, with unique new opportunities to assume a broader role in perioperative care of surgical patients.

Narrative Approaches to Organizational Development: A Case Study of Implementation of Collaborative Helping.

PubMed

Madsen, William C

2016-06-01

Across North America, community agencies and state/provincial jurisdictions are embracing family-centered approaches to service delivery that are grounded in strength-based, culturally responsive, accountable partnerships with families. This article details a collaborative consultation process to initiate and sustain organizational change toward this effort. It draws on innovative ideas from narrative theory, organizational development, and implementation science to highlight a three component approach. This approach includes the use of appreciative inquiry focus groups to elicit existing best practices, the provision of clinical training, and ongoing coaching with practice leaders to build on those better moments and develop concrete practice frameworks, and leadership coaching and organizational consultation to develop organizational structures that institutionalize family-centered practice. While the article uses a principle-based practice framework, Collaborative Helping, to illustrate this process, the approach is applicable with a variety of clinical frameworks grounded in family-centered values and principles. © 2016 Family Process Institute.

Capturing the Integration of Practice-Based Learning with Beliefs, Values, and Attitudes using Modified Concept Mapping.

PubMed

Mcnaughton, Susan; Barrow, Mark; Bagg, Warwick; Frielick, Stanley

2016-01-01

Practice-based learning integrates the cognitive, psychomotor, and affective domains and is influenced by students' beliefs, values, and attitudes. Concept mapping has been shown to effectively demonstrate students' changing concepts and knowledge structures. This article discusses how concept mapping was modified to capture students' perceptions of the connections between the domains of thinking and knowing, emotions, behavior, attitudes, values, and beliefs and the specific experiences related to these, over a period of eight months of practice-based clinical learning. The findings demonstrate that while some limitations exist, modified concept mapping is a manageable way to gather rich data about students' perceptions of their clinical practice experiences. These findings also highlight the strong integrating influence of beliefs and values on other areas of practice, suggesting that these need to be attended to as part of a student's educational program.

Capturing the Integration of Practice-Based Learning with Beliefs, Values, and Attitudes using Modified Concept Mapping

PubMed Central

Mcnaughton, Susan; Barrow, Mark; Bagg, Warwick; Frielick, Stanley

2016-01-01

Practice-based learning integrates the cognitive, psychomotor, and affective domains and is influenced by students’ beliefs, values, and attitudes. Concept mapping has been shown to effectively demonstrate students’ changing concepts and knowledge structures. This article discusses how concept mapping was modified to capture students’ perceptions of the connections between the domains of thinking and knowing, emotions, behavior, attitudes, values, and beliefs and the specific experiences related to these, over a period of eight months of practice-based clinical learning. The findings demonstrate that while some limitations exist, modified concept mapping is a manageable way to gather rich data about students’ perceptions of their clinical practice experiences. These findings also highlight the strong integrating influence of beliefs and values on other areas of practice, suggesting that these need to be attended to as part of a student's educational program. PMID:29349311

The computer in office medical practice.

PubMed

Dowdle, John

2002-04-01

There will continue to be change and evolution in the medical office environment. As voice recognition systems continue to improve, instant creation of office notes with the absence of dictation may be commonplace. As medical and computer technology evolves, we must continue to evaluate the many new computer systems that can assist us in our clinical office practice.

Didactic CME and Practice Change: Don't Throw that Baby out Quite yet

ERIC Educational Resources Information Center

Olson, Curtis A.; Tooman, Tricia R.

2012-01-01

Skepticism exists regarding the role of continuing medical education (CME) in improving physician performance. The harshest criticism has been reserved for didactic CME. Reviews of the scientific literature on the effectiveness of CME conclude that formal or didactic modes of education have little or no impact on clinical practice. This has led…

Virtual Reality-Based Technologies in Dental Medicine: Knowledge, Attitudes and Practice among Students and Practitioners

ERIC Educational Resources Information Center

Sabalic, Maja; Schoener, Jason D.

2017-01-01

Virtual reality-based technologies have been used in dentistry for almost two decades. Dental simulators, planning software and CAD/CAM (computer-aided design/computer-aided manufacturing) systems have significantly developed over the years and changed both dental education and clinical practice. This study aimed to assess the knowledge, attitudes…

Simulating Real Life: Enhancing Social Work Education on Alcohol Screening and Brief Intervention

ERIC Educational Resources Information Center

Osborne, Victoria A.; Benner, Kalea; Sprague, Debra J.; Cleveland, Ivy N.

2016-01-01

Social work students typically use role play with student colleagues to practice clinical intervention skills. Practice with simulated clients (SCs) rather than classmates changes the dynamics of the role play and may improve learning. This is the first known study to employ the SC model in substance use assessment in social work education. Social…

Interventions for sustained healthcare professional behaviour change: a protocol for an overview of reviews.

PubMed

Dombrowski, Stephan U; Campbell, Pauline; Frost, Helen; Pollock, Alex; McLellan, Julie; MacGillivray, Steve; Gavine, Anna; Maxwell, Margaret; O'Carroll, Ronan; Cheyne, Helen; Presseau, Justin; Williams, Brian

2016-10-13

Failure to successfully implement and sustain change over the long term continues to be a major problem in health and social care. Translating evidence into routine clinical practice is notoriously complex, and it is recognised that to implement new evidence-based interventions and sustain them over time, professional behaviour needs to change accordingly. A number of theories and frameworks have been developed to support behaviour change among health and social care professionals, and models of sustainability are emerging, but few have translated into valid and reliable interventions. The long-term success of healthcare professional behavioural change interventions is variable, and the characteristics of successful interventions unclear. Previous reviews have synthesised the evidence for behaviour change, but none have focused on sustainability. In addition, multiple overlapping reviews have reported inconsistent results, which do not aid translation of evidence into practice. Overviews of reviews can provide accessible succinct summaries of evidence and address barriers to evidence-based practice. We aim to compile an overview of reviews, identifying, appraising and synthesising evidence relating to sustained social and healthcare professional behaviour change. We will conduct a systematic review of Cochrane reviews (an Overview). We plan to systematically search the Cochrane Database of Systematic Reviews. We will include all systematic reviews of randomised controlled trials comparing a healthcare professional targeted behaviour change intervention to a standard care or no intervention control group. Two reviewers will independently assess the eligibility of the reviews and the methodological quality of included reviews using the ROBIS tool. The quality of evidence within each comparison in each review will be judged based on the GRADE criteria. Disagreements will be resolved through discussion. Effects of interventions will be systematically tabulated and the quality of evidence used to determine implications for clinical practice and make recommendations for future research. This overview will bring together the best available evidence relating to the sustainability of health professional behaviour change, thus supporting policy makers with decision-making in this field.

Microbiology specimens obtained at the time of surgical lung biopsy for interstitial lung disease: clinical yield and cost analysis.

PubMed

Fibla, Juan J; Brunelli, Alessandro; Allen, Mark S; Wigle, Dennis; Shen, Robert; Nichols, Francis; Deschamps, Claude; Cassivi, Stephen D

2012-01-01

In efforts to obtain complete results, current practice in surgical lung biopsy (LB) for interstitial lung disease (ILD) recommends sending lung tissue samples for bacterial, mycobacterial, fungal, and viral cultures. This study assesses the value of this practice by evaluating the microbiology findings obtained from LB for ILD and their associated costs. A total of 296 consecutive patients (140 women, 156 men, median age=61 years) underwent LB for ILD from 2002 to 2009. All had lung tissue sent for microbiology examination. Microbiology results and resultant changes in patient management were analyzed retrospectively. A cost analysis was performed based upon nominal hospital charges adjusted on current inflation rates. Cost data included cultures, stains, smears, direct fluorescent antibody studies, and microbiologist consulting fees. As many as 25 patients (8.4%) underwent open LB and 271 (91.6%) underwent thoracoscopic LB. A total of 592 specimens were assessed (range 1-4 per patient). The most common pathologic diagnoses were idiopathic pulmonary fibrosis in 122 (41.2%), cryptogenic organizing pneumonia in 31 (10.5%), and respiratory bronchiolitis ILD in 16 (5.4%). Microbiology testing was negative in 174 patients (58.8%). A total of 118 of 122 (96.7%) positive results were clinically considered to be contaminants and resulted in no change in clinical management. The most common contaminants were Propionibacterium acnes (38 patients; 31%) and Penicillium fungus (16 patients; 13%). In only four patients (1.4%), the organism cultured (Nocardia one, Histoplasma one, and Aspergillus fumigatus two) resulted in a change in clinical management. The cost of microbiology studies per specimen was $984 (€709), with a total cost for the study cohort being $582,000 (€420,000). The yield and impact on clinical management of microbiology specimens from LB for ILD is very low. Its routine use in LB is questionable. We suggest it should be limited to those cases of ILD with a high suspicion of infection. Substantial cost savings are possible with this change in clinical practice.

Review of Virtual Reality Treatment in Psychiatry: Evidence Versus Current Diffusion and Use.

PubMed

Mishkind, Matthew C; Norr, Aaron M; Katz, Andrea C; Reger, Greg M

2017-09-18

This review provides an overview of the current evidence base for and clinical applications of the use of virtual reality (VR) in psychiatric practice, in context of recent technological developments. The use of VR in psychiatric practice shows promise with much of the research demonstrating clinical effectiveness for conditions including post-traumatic stress disorder, anxiety and phobias, chronic pain, rehabilitation, and addictions. However, more research is needed before the use of VR is considered a clinical standard of practice in some areas. The recent release of first generation consumer VR products signals a change in the viability of further developing VR systems and applications. As applications increase so will the need for good quality research to best understand what makes VR effective, and when VR is not appropriate for clinical services. As the field progresses, it is hopeful that the flexibility afforded by this technology will yield superior outcomes and a better understanding of the underlying mechanisms impacting those outcomes.

Primary Care Practices’ Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement

PubMed Central

Cohen, Deborah J.; Dorr, David A.; Knierim, Kyle; DuBard, C. Annette; Hemler, Jennifer R.; Hall, Jennifer D.; Marino, Miguel; Solberg, Leif I.; McConnell, K. John; Nichols, Len M.; Nease, Donald E.; Edwards, Samuel T.; Wu, Winfred Y.; Pham-Singer, Hang; Kho, Abel N.; Phillips, Robert L.; Rasmussen, Luke V.; Duffy, F. Daniel; Balasubramanian, Bijal A.

2018-01-01

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports—but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures. PMID:29608365

Knowledge management strategies: Enhancing knowledge transfer to clinicians and patients.

PubMed

Roemer, Lorrie K; Rocha, Roberto A; Del Fiol, Guilherme; Bradshaw, Richard L; Hanna, Timothy P; Hulse, Nathan C

2006-01-01

At Intermountain Healthcare (Intermountain), executive clinical content experts are responsible for disseminating consistent evidence-based clinical content throughout the enterprise at the point-of-care. With a paper-based system it was difficult to ensure that current information was received and was being used in practice. With electronic information systems multiple applications were supplying similar, but different, vendor-licensed and locally-developed content. These issues influenced the consistency of clinical practice within the enterprise, jeopardized patient and clinician safety, and exposed the enterprise and its employees to potential financial penalties. In response to these issues Intermountain is developing a knowledge management infrastructure providing tools and services to support clinical content development, deployment, maintenance, and communication. The Intermountain knowledge management philosophy includes strategies guiding clinicians and consumers of health information to relevant best practice information with the intention of changing behaviors. This paper presents three case studies describing different information management problems identified within Intermountain, methods used to solve the problems, implementation challenges, and the current status of each project.

Marketing the interventional clinical practice to the referring community and to patients.

PubMed

Murphy, Timothy P; Soares, Gregory M

2005-03-01

If interventionalists are able to set up clinical practices and promote themselves along service lines, especially peripheral arterial disease, it is likely that they will have some market share and that market share will grow as new devices and technologies become available. The key to success will be changing the impression of the referring community that interventional radiologists are technical specialists and don't see patients. Marketing experts tell us that several impressions are required for a concept to stick with the target audience. One of the most important points that an interventionalist can make to establish themselves as a clinical specialty is high-quality work and effective communications.

Technology-based strategies for promoting clinical reasoning skills in nursing education.

PubMed

Shellenbarger, Teresa; Robb, Meigan

2015-01-01

Faculty face the demand of preparing nursing students for the constantly changing health care environment. Effective use of online, classroom, and clinical conferencing opportunities helps to enhance nursing students' clinical reasoning capabilities needed for practice. The growth of technology creates an avenue for faculty to develop engaging learning opportunities. This article presents technology-based strategies such as electronic concept mapping, electronic case histories, and digital storytelling that can be used to facilitate clinical reasoning skills.

Urination - painful

MedlinePlus

... the urine ? Are there any changes in the volume or frequency of urination? Do you feel the ... Walls RM, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 8th ed. Philadelphia, PA: Elsevier ...

Medical biochemistry in Macedonia: a profession for physicians and natural scientists.

PubMed

Traikovska, S; Dzhekova-Stojkova, S

2001-06-01

Medical biochemistry or clinical chemistry in its roots is an interdisciplinary science between natural sciences and medicine. The largest part of medical biochemistry is natural science (chemistry, biochemistry, biology, physics, mathematics), which is very well integrated in deduction of medical problems. Medical biochemistry throughout the world, including Macedonia, should be a professional field open to both physicians and natural scientists, according to its historical development, theoretical characteristics and applied practice. Physicians and natural scientists follow the same route in clinical chemistry during the postgraduate training of specialization in medical biochemistry/clinical chemistry. However, in Macedonia the specialization in medical biochemistry/clinical chemistry is today regulated by law only for physicians and pharmacists. The study of clinical chemistry in Europe has shown its interdisciplinary character. In most European countries different professions, such as physicians, chemists/biochemists, pharmacists, biologists and others could specialize in clinical chemistry. The question for the next generation of specialists in Macedonia is whether to accept the present conditions or to attempt to change the law to include chemists/biochemists and biologists as well. The latter used to be a practice in Macedonia 20 years ago, and still is in many European countries. Such change in law would also result in changes in the postgraduate educational program in medical biochemistry in Macedonia. The new postgraduate program has to follow the European Syllabus, recommended by EC4. To obtain sufficient knowledge in clinical chemistry, the duration of vocational training (undergraduate and postgraduate) for all trainees (physicians, pharmaceutics, chemists/biochemists and biologists) should be 8 years.

Retrospective analysis of pharmacist interventions in an ambulatory palliative care practice.

PubMed

Ma, Joseph D; Tran, Victor; Chan, Carissa; Mitchell, William M; Atayee, Rabia S

2016-12-01

We have previously reported the development of an outpatient palliative care practice under pharmacist-physician collaboration. The Doris A. Howell Service at the University of California, San Diego Moores Cancer Center includes two pharmacists who participate in a transdisciplinary clinic and provide follow-up care to patients. This study evaluated pharmacist interventions and patient outcomes of a pharmacist-led outpatient palliative care practice. This was a retrospective data analysis conducted at a single, academic, comprehensive cancer center. New (first visit) patient consultations were referred by an oncologist or hematologist to an outpatient palliative care practice. A pharmacist evaluated the patient at the first visit and at follow-up (second, third, and fourth visits). Medication problems identified, medication changes made, and changes in pain scores were assessed. Eighty-four new and 135 follow-up patient visits with the pharmacist occurred from March 2011 to March 2012. All new patients (n = 80) were mostly women (n = 44), had localized disease (n = 42), a gastrointestinal cancer type (n = 21), and were on a long-acting (n = 61) and short-acting (n = 70) opioid. A lack of medication efficacy was the most common problem for symptoms of pain, constipation, and nausea/vomiting that was identified by the pharmacist at all visits. A change in pain medication dose and initiation of a new medication for constipation and nausea/vomiting were the most common interventions by the pharmacist. A statistically significant change in pain score was observed for the third visit, but not for the second and fourth visits. A pharmacist-led outpatient palliative care practice identified medication problems for management of pain, constipation, and nausea/vomiting. Medication changes involved a change in dose and/or initiating a new medication. Trends were observed in improvement and stabilization of pain over subsequent clinic visits. © The Author(s) 2015.

An inexpensive modification of the laboratory computer display changes emergency physicians' work habits and perceptions.

PubMed

Marinakis, Harry A; Zwemer, Frank L

2003-02-01

Little is known about how the availability of laboratory data affects emergency physicians' practice habits and satisfaction. We modified our clinical information system to display laboratory test status with continuous updates, similar to an airport arrival display. The objective of this study was to determine whether the laboratory test status display altered emergency physicians' work habits and increased satisfaction compared with the time period before implementation of laboratory test status. A retrospective analysis was performed of emergency physicians' actual use of the clinical information system before and after implementation of the laboratory test status display. Emergency physicians were retrospectively surveyed regarding the effect of laboratory test status display on their practice habits and clinical information system use. Survey responses were matched with actual use of the clinical information system. Data were analyzed by using dependent t tests and Pearson correlation coefficients. The study was conducted at a university hospital. Clinical information system use by 46 emergency physicians was analyzed. Twenty-five surveys were returned (71.4% of available emergency physicians). All emergency physicians perceived fewer clinical information system log ons per day after laboratory test status display. The actual average decrease was 19%. Emergency physicians who reported the greatest decrease in log ons per day tended to have the greatest actual decrease (r =-0.36). There was no significant correlation between actual and perceived total time logged on (r =0.08). In regard to effect on emergency physicians' practice habits, 95% reported increased efficiency, 80% reported improved satisfaction with data access, and 65% reported improved communication with patients. An inexpensive computer modification, laboratory test status display, significantly increased subjective efficiency, changed work habits, and improved satisfaction regarding data access and patient communication among emergency physicians. Knowledge of the test queue changed emergency physician behavior and improved satisfaction.

A case report using the mental state examination scale (MSES): a tool for measuring change in mental state.

PubMed

Fernando, Irosh; Carter, Gregory

2016-02-01

There is a need for a simple and brief tool that can be used in routine clinical practice for the quantitative measurement of mental state across all diagnostic groups. The main utilities of such a tool would be to provide a global metric for the mental state examination, and to monitor the progression over time using this metric. We developed the mental state examination scale (MSES), and used it in an acute inpatient setting in routine clinical work to test its initial feasibility. Using a clinical case, the utility of MSES is demonstrated in this paper. When managing the patient described, the MSES assisted the clinician to assess the initial mental state, track the progress of the recovery, and make timely treatment decisions by quantifying the components of the mental state examination. MSES may enhance the quality of clinical practice for clinicians, and potentially serve as an index of universal mental healthcare outcome that can be used in clinical practice, service evaluation, and healthcare economics. © The Royal Australian and New Zealand College of Psychiatrists 2015.

Clinical-academic partnerships research: converting the rhetoric into reality.

PubMed

Happell, Brenda

2005-09-01

An increasing recognition of the importance of research-based practice to the nursing profession has led to a number of strategies designed to increase the utilization and conduct of nursing research. The transfer of nursing education from hospitals to universities occurred partly in response to the identified theory-practice gap. Subsequently, a significant investment in joint clinical-academic positions and clinical professorial positions has been made with the intention of bridging the gap between the tertiary sector and the clinical field. Anecdotal evidence suggests that neither strategy has achieved the desired degree of success. The available literature suggests that nurses do not tend to become involved in the conduct of research, nor do they readily utilise research findings in their practice. It is hypothesized in this paper that this reflects the strong cultural differences between the clinical and academic worlds in nursing. The aim of this paper is to discuss the impact of these cultural differences and describe specific principals that could contribute to significant cultural change and the bridging of the academic-clinician divide.

How do clinicians actually use the Diagnostic and Statistical Manual of Mental Disorders in clinical practice and why we need to know more.

PubMed

First, Michael B; Bhat, Venkat; Adler, David; Dixon, Lisa; Goldman, Beth; Koh, Steve; Levine, Bruce; Oslin, David; Siris, Sam

2014-12-01

The clinical use of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is explicitly stated as a goal for both the DSM Fourth Edition and DSM Fifth Edition (DSM-5) revisions. Many uses assume a relatively faithful application of the DSM diagnostic definitions. However, studies demonstrate significant discrepancies between clinical psychiatric diagnoses with those made using structured interviews suggesting that clinicians do not systematically apply the diagnostic criteria. The limited information regarding how clinicians actually use the DSM raises important questions: a) How can the clinical use be improved without first having a baseline assessment? b) How can potentially significant shifts in practice patterns based on wording changes be assessed without knowing the extent to which the criteria are used as written? Given the American Psychiatric Association's plans for interim revisions to the DSM-5, the value of a detailed exploration of its actual use in clinical practice remains a significant ongoing concern and deserves further study including a number of survey and in vivo studies.

Motivational interviewing and the clinical science of Carl Rogers.

PubMed

Miller, William R; Moyers, Theresa B

2017-08-01

The clinical method of motivational interviewing (MI) evolved from the person-centered approach of Carl Rogers, maintaining his pioneering commitment to the scientific study of therapeutic processes and outcomes. The development of MI pertains to all 3 of the 125th anniversary themes explored in this special issue. Applications of MI have spread far beyond clinical psychology into fields including health care, rehabilitation, public health, social work, dentistry, corrections, coaching, and education, directly impacting the lives of many people. The public relevance and impact of clinical psychology are illustrated in the similarity of MI processes and outcomes across such diverse fields and the inseparability of human services from the person who provides them, in that both relational and technical elements of MI predict client outcomes. Within the history of clinical psychology MI is a clear product of clinical science, arising from the seminal work of Carl Rogers whose own research grounded clinical practice in empirical science. As with Rogers' work 70 years ago, MI began as an inductive empirical approach, observing clinical practice to develop and test hypotheses about what actually promotes change. Research on MI bridges the current divide between evidence-based practice and the well-established importance of therapeutic relationship. Research on training and learning of MI further questions the current model of continuing professional education through self-study and workshops as a way of improving practice behavior and client outcomes. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Ambulatory Assessment of Depression in Primary Care

DTIC Science & Technology

2016-06-29

activities (anhedonia) for over 2 weeks, plus at least four of the following symptoms: changes in sleep, changes in appetite or weight, fatigue, change...such as pain are the initial presenting symptoms of patients who are subsequently diagnosed with depression in a family practice clinic. Somatic...authors concluded that general practitioners should carefully evaluate medically unexplained physical symptoms. These symptoms included back pain

Clinical application of plasma thermograms. Utility, practical approaches and considerations.

PubMed

Garbett, Nichola C; Mekmaysy, Chongkham S; DeLeeuw, Lynn; Chaires, Jonathan B

2015-04-01

Differential scanning calorimetry (DSC) studies of blood plasma are part of an emerging area of the clinical application of DSC to biofluid analysis. DSC analysis of plasma from healthy individuals and patients with various diseases has revealed changes in the thermal profiles of the major plasma proteins associated with the clinical status of the patient. The sensitivity of DSC to the concentration of proteins, their interactions with other proteins or ligands, or their covalent modification underlies the potential utility of DSC analysis. A growing body of literature has demonstrated the versatility and performance of clinical DSC analysis across a range of biofluids and in a number of disease settings. The principles, practice and challenges of DSC analysis of plasma are described in this article. Copyright © 2014 Elsevier Inc. All rights reserved.

Clinical application of plasma thermograms. Utility, practical approaches and considerations

PubMed Central

Garbett, Nichola C.; Mekmaysy, Chongkham S.; DeLeeuw, Lynn; Chaires, Jonathan B.

2014-01-01

Differential scanning calorimetry (DSC) studies of blood plasma are part of an emerging area of the clinical application of DSC to biofluid analysis. DSC analysis of plasma from healthy individuals and patients with various diseases has revealed changes in the thermal profiles of the major plasma proteins associated with the clinical status of the patient. The sensitivity of DSC to the concentration of proteins, their interactions with other proteins or ligands, or their covalent modifications underlies the potential utility of DSC analysis. A growing body of literature has demonstrated the versatility and performance of clinical DSC analysis across a range of biofluids and in a number of disease settings. The principles, practice and challenges of DSC analysis of plasma are described in this article. PMID:25448297

Primary care renewal: regional faculty development and organizational change.

PubMed

Quirk, Mark E; Haley, Heather-Lyn; Hatem, David; Starr, Susan; Philbin, Mary

2005-03-01

Many reports, including the Future of Family Medicine, have called for change in primary care, but few have defined, implemented, and evaluated mechanisms to address such change. The regional, interdisciplinary Primary Care Renewal Project was designed to address problems in primary care practice and teaching related to practice management, compensation, increasing responsibility for teaching, and faculty development. Twelve northeastern US medical schools assembled a conference attended by teams of key stakeholders representing both clinical and educational missions. Teams developed and implemented an institutional plan to address identified needs. Outcome data was collected during, and for 1 year after, the conference. Findings demonstrate novel ways of improving learning experiences, coordinating and centralizing planning efforts, and addressing faculty needs. The magnitude of organizational change ranged from establishing new administrative units with significant institutional authority (eg, restructuring dean's office) to enhancing the strategic planning process and refining mission statements to reflect emphasis on primary care. A well-planned, regional interdisciplinary effort that fosters the development of concrete plans can be associated with significant change in medical education. A central theme emerged--that primary care medicine will survive only if institutions align their educational and clinical missions and foster system-wide change.

Rotigotine transdermal patch in combination therapy for Parkinson's disease--observations in routine clinical practice.

PubMed

Ceballos-Baumann, Andres; Häck, Hermann-Josef

2011-10-01

The dopamine agonist rotigotine has shown efficacy and safety for the treatment of early and advanced Parkinson's disease (PD) in controlled clinical trials. This observational study evaluated rotigotine administration in combination with other antiparkinsonian medication in routine clinical practice. Data were collected by 688 German practice-based neurologists, initiating rotigotine treatment in patients with idiopathic Parkinson's disease. Assessments included rotigotine maintenance dose, changes in concomitant PD medication, changes in sleep quality, and rotigotine tolerability over an observation period of 12-16 weeks. The median rotigotine maintenance dose was 6 mg/24 h (n = 969, full analysis set). The proportion of all other prescribed PD medications declined over the observation period; combination therapy decreased by 18.7%. Daily levodopa intake was markedly reduced by 87 mg (18.9%) in 47.6% of the patients with levodopa documentation; 7% no longer required levodopa after 12-16 weeks. Mean overall sleep quality (PD Sleep Scale item 1) improved by 21.4 points, the occurrence of nocturias (PDSS item 8) by 13.4 points, and 'turning in bed' (Unified Parkinson's Disease Rating Scale part II) by 0.6 points. Drug-related adverse events were reported for 7.9% of all patients (n = 1152, safety population). Application site reactions were the most common adverse events (2.2%) resulting in early discontinuation in 1.4% of patients. In routine clinical practice, treatment initiation with rotigotine transdermal patch was associated with a reduction of other prescribed PD medications and with an improvement of self-reported sleep quality.

Dentists United to Extinguish Tobacco (DUET): a study protocol for a cluster randomized, controlled trial for enhancing implementation of clinical practice guidelines for treating tobacco dependence in dental care settings.

PubMed

Ostroff, Jamie S; Li, Yuelin; Shelley, Donna R

2014-02-21

Although dental care settings provide an exceptional opportunity to reach smokers and provide brief cessation advice and treatment to reduce oral and other tobacco-related health conditions, dental care providers demonstrate limited adherence to evidence-based guidelines for treatment of tobacco use and dependence. Guided by a multi-level, conceptual framework that emphasizes changes in provider beliefs and organizational characteristics as drivers of improvement in tobacco treatment delivery, the current protocol will use a cluster, randomized design and multiple data sources (patient exit interviews, provider surveys, site observations, chart audits, and semi-structured provider interviews) to study the process of implementing clinical practice guidelines for treating tobacco dependence in 18 public dental care clinics in New York City. The specific aims of this comparative-effectiveness research trial are to: compare the effectiveness of three promising strategies for implementation of tobacco use treatment guidelines-staff training and current best practices (CBP), CBP + provider performance feedback (PF), and CBP + PF + provider reimbursement for delivery of tobacco cessation treatment (pay-for-performance, or P4P); examine potential theory-driven mechanisms hypothesized to explain the comparative effectiveness of three strategies for implementation; and identify baseline organizational factors that influence the implementation of evidence-based tobacco use treatment practices in dental clinics. The primary outcome is change in providers' tobacco treatment practices and the secondary outcomes are cost per quit, use of tobacco cessation treatments, quit attempts, and smoking abstinence. We hypothesize that the value of these promising implementation strategies is additive and that incorporating all three strategies (CBP, PF, and P4P) will be superior to CBP alone and CBP + PF in improving delivery of cessation assistance to smokers. The findings will improve knowledge pertinent to the implementation, dissemination, and sustained utilization of evidence-based tobacco use treatment in dental practices. NCT01615237.

How to manage organisational change and create practice teams: experiences of a South African primary care health centre.

PubMed

Mash, B J; Mayers, P; Conradie, H; Orayn, A; Kuiper, M; Marais, J

2008-07-01

In South Africa, first-contact primary care is delivered by nurses in small clinics and larger community health centres (CHC). CHCs also employ doctors, who often work in isolation from the nurses, with poor differentiation of roles and little effective teamwork or communication. Worcester CHC, a typical public sector CHC in rural South Africa, decided to explore how to create more successful practice teams of doctors and nurses. This paper is based on their experience of both unsuccessful and successful attempts to introduce practice teams and reports on their learning regarding organisational change. An emergent action research study design utilised a co-operative inquiry group. The first nine months of inquiry focused on understanding the initial unsuccessful attempt to create practice teams. This paper reports primarily on the subsequent nine months (four cycles of planning, action, observation and reflection) during which practice teams were re-introduced. The central question was how more effective practice teams of doctors and nurses could be created. The group utilised outcome mapping to assist with planning, monitoring and evaluation. Outcome mapping defined a vision, mission, boundary partners, outcome challenges, progress markers and strategies for the desired changes and supported quantitative monitoring of the process. Qualitative data were derived from the co-operative inquiry group (CIG) meetings and interviews with doctors, nurses, practice teams and patients. The CIG engaged effectively with 68% of the planned strategies, and more than 60% of the progress markers were achieved for clinical nurse practitioners, doctors, support staff and managers, but not for patients. Key themes that emerged from the inquiry group's reflection on their experience of the change process dealt with the amount of interaction, type of communication, team resilience, staff satisfaction, leadership style, reflective capacity, experimentation and evolution of new structures. The group's learning supported a view of change that sees the organisation as a living system in which information flow, participation and the development of resilience are key aspects. These themes fit well into an understanding of change based on complexity theory. If managers of the health system wish to enhance organisational change, then their goal may need to shift from optimising health care delivery in a mechanistic model to optimising health care workers in a living system.

Reliable Change Indices and Standardized Regression-Based Change Score Norms for Evaluating Neuropsychological Change in Children with Epilepsy

PubMed Central

Busch, Robyn M.; Lineweaver, Tara T.; Ferguson, Lisa; Haut, Jennifer S.

2015-01-01

Reliable change index scores (RCIs) and standardized regression-based change score norms (SRBs) permit evaluation of meaningful changes in test scores following treatment interventions, like epilepsy surgery, while accounting for test-retest reliability, practice effects, score fluctuations due to error, and relevant clinical and demographic factors. Although these methods are frequently used to assess cognitive change after epilepsy surgery in adults, they have not been widely applied to examine cognitive change in children with epilepsy. The goal of the current study was to develop RCIs and SRBs for use in children with epilepsy. Sixty-three children with epilepsy (age range 6–16; M=10.19, SD=2.58) underwent comprehensive neuropsychological evaluations at two time points an average of 12 months apart. Practice adjusted RCIs and SRBs were calculated for all cognitive measures in the battery. Practice effects were quite variable across the neuropsychological measures, with the greatest differences observed among older children, particularly on the Children’s Memory Scale and Wisconsin Card Sorting Test. There was also notable variability in test-retest reliabilities across measures in the battery, with coefficients ranging from 0.14 to 0.92. RCIs and SRBs for use in assessing meaningful cognitive change in children following epilepsy surgery are provided for measures with reliability coefficients above 0.50. This is the first study to provide RCIs and SRBs for a comprehensive neuropsychological battery based on a large sample of children with epilepsy. Tables to aid in evaluating cognitive changes in children who have undergone epilepsy surgery are provided for clinical use. An excel sheet to perform all relevant calculations is also available to interested clinicians or researchers. PMID:26043163

Clinical evaluation of cardiovascular devices: principles, problems, and proposals for European regulatory reform. Report of a policy conference of the European Society of Cardiology.

PubMed

Fraser, Alan G; Daubert, Jean-Claude; Van de Werf, Frans; Estes, N A Mark; Smith, Sidney C; Krucoff, Mitchell W; Vardas, Panos E; Komajda, Michel

2011-07-01

The European Commission announced in 2008 that a fundamental revision of the medical device directives is being considered in order to clarify and strengthen the current legal framework. The system for testing and approving devices in Europe was established >20 years ago as a 'New Approach' to a previously little-regulated industry. It is recognized by many that the regulatory system has not kept pace with technological advances and changing patterns of medical practice. New legislation will be drafted during 2011, but medical experts have been little involved in this important process. This context makes it an opportune time for a professional association to advise from both clinical and academic perspectives about changes which should be made to improve the safety and efficacy of devices used in clinical practice and to develop more appropriate systems for their clinical evaluation and post-marketing surveillance. This report summarizes how medical devices are regulated and it reviews some serious clinical problems that have occurred with cardiovascular devices. Finally, it presents the main recommendations from a Policy Conference on the Clinical Evaluation of Cardiovascular Devices that was held at the European Heart House in January 2011.

[Clinical guidelines for the prevention of infective endocarditis].

PubMed

Pérez-Lescure Picarzo, J; Crespo Marcos, D; Centeno Malfaz, F

2014-03-01

This article sets out the recommendations for the prevention of infective endocarditis (IE), contained in the guidelines developed by the American Heart Association (AHA) and the European Society of Cardiology (ESC), from which the recommendations of the Spanish Society of Paediatric Cardiology and Congenital Heart Disease have been agreed. In recent years, there has been a considerable change in the recommendations for the prevention of IE, mainly due to the lack of evidence on the effectiveness of antibiotic prophylaxis in prevention, and the risk of the development of antibiotic resistance. The main change is a reduction of the indications for antibiotic prophylaxis, both in terms of patients and procedures considered at risk. Clinical practice guidelines and recommendations should assist health professionals in making clinical decisions in their daily practice. However, the ultimate judgment regarding the care of a particular patient must be taken by the physician responsible. Copyright © 2013 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.

Placebo Response and Practice Effects in Schizophrenia Cognition Trials.

PubMed

Keefe, Richard S E; Davis, Vicki G; Harvey, Philip D; Atkins, Alexandra S; Haig, George M; Hagino, Owen; Marder, Stephen; Hilt, Dana C; Umbricht, Daniel

2017-08-01

Patients' previous experience with performance-based cognitive tests in clinical trials for cognitive impairment associated with schizophrenia can create practice-related improvements. Placebo-controlled trials for cognitive impairment associated with schizophrenia are at risk for these practice effects, which can be difficult to distinguish from placebo effects. To conduct a systematic evaluation of the magnitude of practice effects on the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery (MCCB) in cognitive impairment associated with schizophrenia and to examine which demographic, clinical, and cognitive characteristics were associated with improvement in placebo conditions. A blinded review was conducted of data from 813 patients with schizophrenia who were treated with placebo in 12 randomized placebo-controlled clinical trials conducted mostly in outpatient clinics in North America, Europe, Asia, and Latin America from February 22, 2007, to March 1, 2014. A total of 779 patients provided data for the primary outcome measure at baseline and at least 1 follow-up. Seven trials had prebaseline assessments wherein the patients knew that they were not receiving treatment, allowing a comparison of practice and placebo effects in the same patients. Placebo compared with various experimental drug treatments. Composite score on the MCCB. Of the 813 patients in the study (260 women and 553 men; mean [SD] age, 41.2 [11.5] years), the mean MCCB composite score at baseline was 22.8 points below the normative mean, and the mean (SEM) total change in the MCCB during receipt of placebo was 1.8 (0.2) T-score points (95% CI, 1.40-2.18), equivalent to a change of 0.18 SD. Practice effects in the 7 studies in which there was a prebaseline assessment were essentially identical to the postbaseline placebo changes. Baseline factors associated with greater improvements in the MCCB during receipt of placebo included more depression/anxiety (F1,438 = 5.41; P = .02), more motivation (F1,272 = 4.63; P = .03), and less improvement from screening to baseline (F1,421 = 59.32; P < .001). Placebo effects were minimal and associated with the number of postbaseline assessments and several patient characteristics. Given that the patients performed 2.28 SDs below normative standards on average at baseline, a mean placebo-associated improvement of less than 0.2 SD provides evidence that ceiling effects do not occur in these trials. These minimal changes in the MCCB could not be responsible for effective active treatments failing to separate from placebo.

Evolving healthcare delivery paradigms and the optimization of 'value' in anesthesiology.

PubMed

Alem, Navid; Kain, Zeev

2017-04-01

Healthcare worldwide is evolving to yield enhanced care provided at a lowered cost. Patient-centric paradigms that hasten surgical recovery and strengthen collaboration amongst medical professionals are gaining impetus. This review will discuss the changing healthcare landscape and outline its implications on anesthesiology practice. Anesthesiologists must be nimble and versatile as they adapt to healthcare redesign. An increased responsibility for patient outcomes should be embraced by extending the breadth and depth of clinical practice throughout the surgical care continuum. The perioperative surgical home and enhanced recovery after surgery provide paradigms to further integrate expanding clinical opportunities and improved patient outcomes. Investment is needed in perioperative medical education and research efforts to best position anesthesiologists for success both now and in the future. Exemplifying opportunities to demonstrate value-added care, the scope of anesthesiology education and clinical practice should diversify to further integrate perioperative care of surgical patients.

Lessons learned from the reimbursement profile of a mature private medical toxicology practice: office-based practice pays.

PubMed

Thompson, Trevonne M; Leikin, Jerrold B

2015-03-01

We previously reported the financial data for the first 5 years of one of the author's medical toxicology practice. The practice has matured; changes have been made. The practice is increasing its focus on office-based encounters and reducing hospital-based acute care encounters. We report the reimbursement rates and other financial metrics of the current practice. Financial records from October 2009 through September 2013 were reviewed. This is a period of 4 fiscal years and represents the currently available financial data. Charges, payments, and reimbursement rates were recorded according to the type and setting of the medical toxicology encounter: forensic consultations, outpatient clinic encounters, nonpsychiatric inpatient consultations, emergency department (ED) consultations, and inpatient psychiatric consultations. All patients were seen regardless of ability to pay or insurance status. The number of billed Current Procedural Terminology (CPT) codes for office-based encounters increased over the study period; the number of billed CPT codes for inpatient and ED consultations reduced. Office-based encounters demonstrate a higher reimbursement rate and higher payments. In the fiscal year (FY) of 2012, office-based revenue exceeded hospital-based acute care revenue by over $140,000 despite a higher number of billed CPT encounters in acute care settings, and outpatient payments were 2.39 times higher than inpatient, inpatient psychiatry, observation unit, and ED payments combined. The average payment per CPT code was higher for outpatient clinic encounters than inpatient encounters for each fiscal year studied. There was an overall reduction in CPT billing volume between FY 2010 and FY 2013. Despite this, there was an increase in total practice revenue. There was no change in payor mix, practice logistics, or billing/collection service company. In this medical toxicology practice, office-based encounters demonstrate higher reimbursement rates and overall payments compared to inpatient and ED consultations. While consistent with our previous studies, these differences have been accentuated. This study demonstrates the results of changes to the practice--reduced inpatient/ED consultations and increased outpatient encounters. These practice changes resulted in higher overall revenue despite a lower patient volume. In this analysis, the office-based practice of medical toxicology has higher reimbursement rates, nearly 2.5 times higher, when compared to hospital-based acute care consultations.

Effect of a dengue clinical case management course on physician practices in Puerto Rico

PubMed Central

Han, George S.; Gregory, Christopher J.; Biggerstaff, Brad J.; Horiuchi, Kalanthe; Perez, Carmen; Soto-Gomez, Eunice; Matos, Desiree; Margolis, Harold S.; Tomashek, Kay M.

2015-01-01

Background Prior to 2010, the clinical management of dengue in Puerto Rico was shown to be inconsistent with World Health Organization guidelines. A four-hour classroom-style course on dengue clinical management was developed in 2009 and mandated in 2010 for Puerto Rico medical licensure. Fifty physicians were trained as ‘master trainers’ and gave this course to 7,638 physicians. This study evaluated the effect of the course on the clinical management of hospitalized dengue patients. Methods Pre- and post-course test responses from participants were analyzed. Changes in physician practices were assessed by reviewing the medical records of 430 adult and 1075 pediatric dengue patients at the 12 hospitals in Puerto Rico that reported the most cases during 2008–2009 (pre-intervention) and 2011(post-intervention). Mixed-effects logistic regression was used to compare key indicators of dengue management. Key informant interviews of hospital medical directors and department chiefs were conducted to understand reasons for, or barriers to, changes in practice. Findings Physician test scores increased from 48% correct to 72% after taking the course. Medical record review showed that the percentage of adult patients who did not receive corticosteroids increased from 30% to 68% (OR 5.9, 95% CI 3.7–9.5) and from 91% to 96% in pediatric patients (OR 2.7, 95% CI 1.5–4.9). Usage of isotonic intravenous saline solutions during the critical period increased from 57% to 90% in adult patients (OR 6.2, 95% CI 1.9–20.4) and from 25% to 44% in pediatric patients (OR 3.4, 95% CI 2.2–5.3). Key informant interviewees attributed improvements in practice to the course and identified additional barriers to further change. Interpretation The management of hospitalized dengue patients improved significantly following implementation of a classroom-style physician training course taught by master trainers. An online version of the course was launched in 2014 to expand its reach and sustainability. PMID:27506689

Return on Investment in Electronic Health Records in Primary Care Practices: A Mixed-Methods Study

PubMed Central

Sanche, Steven

2014-01-01

Background The use of electronic health records (EHR) in clinical settings is considered pivotal to a patient-centered health care delivery system. However, uncertainty in cost recovery from EHR investments remains a significant concern in primary care practices. Objective Guided by the question of “When implemented in primary care practices, what will be the return on investment (ROI) from an EHR implementation?”, the objectives of this study are two-fold: (1) to assess ROI from EHR in primary care practices and (2) to identify principal factors affecting the realization of positive ROI from EHR. We used a break-even point, that is, the time required to achieve cost recovery from an EHR investment, as an ROI indicator of an EHR investment. Methods Given the complexity exhibited by most EHR implementation projects, this study adopted a retrospective mixed-method research approach, particularly a multiphase study design approach. For this study, data were collected from community-based primary care clinics using EHR systems. Results We collected data from 17 primary care clinics using EHR systems. Our data show that the sampled primary care clinics recovered their EHR investments within an average period of 10 months (95% CI 6.2-17.4 months), seeing more patients with an average increase of 27% in the active-patients-to-clinician-FTE (full time equivalent) ratio and an average increase of 10% in the active-patients-to-clinical-support-staff-FTE ratio after an EHR implementation. Our analysis suggests, with a 95% confidence level, that the increase in the number of active patients (P=.006), the increase in the active-patients-to-clinician-FTE ratio (P<.001), and the increase in the clinic net revenue (P<.001) are positively associated with the EHR implementation, likely contributing substantially to an average break-even point of 10 months. Conclusions We found that primary care clinics can realize a positive ROI with EHR. Our analysis of the variances in the time required to achieve cost recovery from EHR investments suggests that a positive ROI does not appear automatically upon implementing an EHR and that a clinic’s ability to leverage EHR for process changes seems to play a role. Policies that provide support to help primary care practices successfully make EHR-enabled changes, such as support of clinic workflow optimization with an EHR system, could facilitate the realization of positive ROI from EHR in primary care practices. PMID:25600508

How Effective Are Clinical Pathways With and Without Online Peer-Review? An Analysis of Bone Metastases Pathway in a Large, Integrated National Cancer Institute-Designated Comprehensive Cancer Center Network

DOE Office of Scientific and Technical Information (OSTI.GOV)

Beriwal, Sushil, E-mail: beriwals@upmc.edu; Rajagopalan, Malolan S.; Flickinger, John C.

2012-07-15

Purpose: Clinical pathways are an important tool used to manage the quality in health care by standardizing processes. This study evaluated the impact of the implementation of a peer-reviewed clinical pathway in a large, integrated National Cancer Institute-Designated Comprehensive Cancer Center Network. Methods: In 2003, we implemented a clinical pathway for the management of bone metastases with palliative radiation therapy. In 2009, we required the entry of management decisions into an online tool that records pathway choices. The pathway specified 1 or 5 fractions for symptomatic bone metastases with the option of 10-14 fractions for certain clinical situations. The datamore » were obtained from 13 integrated sites (3 central academic, 10 community locations) from 2003 through 2010. Results: In this study, 7905 sites were treated with 64% of courses delivered in community practice and 36% in academic locations. Academic practices were more likely than community practices to treat with 1-5 fractions (63% vs. 23%; p < 0.0001). The number of delivered fractions decreased gradually from 2003 to 2010 for both academic and community practices (p < 0.0001); however, greater numbers of fractions were selected more often in community practices (p < 0.0001). Using multivariate logistic regression, we found that a significantly greater selection of 1-5 fractions developed after implementation online pathway monitoring (2009) with an odds ratio of 1.2 (confidence interval, 1.1-1.4) for community and 1.3 (confidence interval, 1.1-1.6) for academic practices. The mean number of fractions also decreased after online peer review from 6.3 to 6.0 for academic (p = 0.07) and 9.4 to 9.0 for community practices (p < 0.0001). Conclusion: This is one of the first studies to examine the efficacy of a clinical pathway for radiation oncology in an integrated cancer network. Clinical pathway implementation appears to be effective in changing patterns of care, particularly with online clinical peer review as a valuable aid to encourage adherence to evidence-based practice.« less

Best practice wound care.

PubMed

O'Brien, Melissa L; Lawton, Joanna E; Conn, Chris R; Ganley, Helen E

2011-04-01

This article describes the barriers, changes and achievements related to implementing one element of a wound care programme being best practice care. With the absence of a coordinated approach to wound care, clinical practice within our Area Health Service (AHS) was diverse, inconsistent and sometimes outdated. This was costly and harmful, leading to overuse of unhelpful care, underuse of effective care and errors in execution. The major aim was to improve the outcomes and quality of life for patients with wound care problems within our community. A collaborative across ten sites/services developed, implemented and evaluated policies and guidelines based on evidence-based bundles of care. Key barriers were local resistance and lack of experience in implementing structural and cultural changes. This was addressed by appointing a wound care programme manager, commissioning of a strategic oversight committee and local wound care committees. The techniques of spread and adoption were used, with early adopters making changes observable and allowing local adaption of guidelines, where appropriate. Deployment and improvement results varied across the sites, ranging from activity but no changes in practice to modest improvement in practice. Evaluating implementation of the leg ulcer guideline as an exemplar, it was demonstrated that there was a statistically significant improvement in overall compliance from 26% to 84%. However, only 7·7% of patients received all interventions to which they were entitled. Compliance with the eight individual interventions of the bundle ranged from 26% to 84%. Generic performance was evaluated against the wound assessment, treatment and evaluation plan with an average compliance of 70%. Early results identified that 20% of wounds were healed within the target of 10 days. As more standardised process are implemented, clinical outcomes should continue to improve and costs decrease. © 2011 The Authors. © 2011 Blackwell Publishing Ltd and Medicalhelplines.com Inc.

Tobacco use disorder treatment in primary care

PubMed Central

Kunyk, Diane; Els, Charl; Papadakis, Sophia; Selby, Peter

2014-01-01

Abstract Objective To test a team-based, site-specific, multicomponent clinical system pathway designed for enhancing tobacco use disorder treatment by primary care physicians. Design A prospective cohort study. Setting Sixty primary care sites in Alberta. Participants A convenience sample of 198 primary care physicians from the population of 2857. Main outcome measures Data collection occurred between September 2010 and February 2012 on 3 distinct measures. Twenty-four weeks after the intervention, audits of the primary care practices assessed the adoption and sustainability of 10 tobacco clinical system pathway components, a survey measured changes in physicians’ treatment intentions, and patient chart reviews examined changes in physicians’ consistency with the treatment algorithm. Results The completion rate by physicians was 89.4%. An intention-to-treat approach was undertaken for statistical analysis. Intervention uptake was demonstrated by positive changes at 4 weeks in how many of the 10 clinical system measures were performed (mean [SD] = 4.22 [1.60] vs 8.57 [1.46]; P < .001). Physicians demonstrated significant favourable changes in 9 of the 12 measures of treatment intention (P < .05). The 18 282 chart reviews documented significant increases in 6 of the 8 algorithm components. Conclusion Our findings suggest that the provision of a tobacco clinical system pathway that incorporates other members of the health care team and builds on existing office infrastructures will support positive and sustainable changes in tobacco use disorder treatment by physicians in primary care. This study reaffirms the substantive and important role of supporting how treatment is delivered in physicians’ practices. PMID:25022640

[Roles and competences of nurses with postgraduate master degree in nursing science in everyday practice. Multicentre descriptive survey].

PubMed

Dante, Angelo; Occoffer, Elisa Maria; Miniussi, Claudia; Margetic, Helga; Palese, Alvisa; Saiani, Luisa

2014-01-01

Roles and competences of nurses with postgraduate master degree in nursing science in everyday practice. Multicentre descriptive survey. Few information are available on the role and activities of Italian nurses with Laurea Magistrale (postgraduate master degree in nursing science). To describe the implementation of the advanced competences acquired after Laurea Magistrale by nurses, as well as changes in their professional career. A multicenter descriptive study on 7 consecutive cohorts (from 2004/2005 to 2011/2012) of nurses of 3 universities of northern Italy was conducted. Data on managerial, teaching, research and clinical competences and changes in the professional role were collected with semi-structured questionnaires. 232/285 graduates completed the questionnaire; 216 (88.8%) used their managerial competences, 178 (76.7%) educational competences, 122 (52.6%) clinical competences and 115 (49.5%) research competences. Eigthy graduates (34.4%) changed their professional roles, occupying managerial positions (from 89 to 212, +123, 14.5%) and in the education field (from 33 to 44 +11, 4.8%) while the number of nurses with a clinical role decreased (from 110 to 65, -45, -19.4%). The role changes occured mainly after three years from graduation (p = 0.006) with significant differences across areas (p = 0.018). Until recently the main field of occupation of Laureati magistrali was in management but the changing needs of the organizations require a major focus on the clinical competences. The characteristics of contexts that favour or prevent the implementation of the new compentences and the upgrade of the roles should be studied.

Clinical Evidence: a useful tool for promoting evidence-based practice?

PubMed

Formoso, Giulio; Moja, Lorenzo; Nonino, Francesco; Dri, Pietro; Addis, Antonio; Martini, Nello; Liberati, Alessandro

2003-12-23

Research has shown that many healthcare professionals have problems with guidelines as they would prefer to be given all relevant information relevant to decision-making rather than being told what they should do. This study assesses doctors' judgement of the validity, relevance, clarity and usability of the Italian translation of Clinical Evidence (CE) after its free distribution launched by the Italian Ministry of Health. Opinions elicited using a standardised questionnaire delivered either by mail or during educational or professional meetings. Twenty percent (n = 1350) doctors participated the study. Most of them found CE's content valid, useful and relevant for their clinical practice, and said CE can foster communications among clinicians, particularly among GPs and specialists. Hospital doctors (63%) more often than GPs (48%) read the detailed presentation of individual chapters. Twenty-nine percent said CE brought changes in their clinical practice. Doctors appreciated CE's nature of an evidence-based information compendium and would have not preferred a collection of practice guidelines. Overall, the pilot initiative launched by the Italian Ministry of Health seems to have been well received and to support the subsequent decision to make the Italian edition of Clinical Evidence concise available to all doctors practising in the country. Local implementation initiatives should be warranted to favour doctor's use of CE.

Evidence based mental healthcare and service innovation: review of concepts and challenges.

PubMed

Kouimtsidis, Ch; John-Smith, St; Kemp, P; Ikkos, G

2013-01-01

Health provision systems in the developed western nations are currently facing major financial challenges. In order to meet these challenges, a number of new approaches used to assist the provision of health have been introduced, including the practice of health professionals. These approaches utilize specific methods of data capture and summarization such as: evidence based medicine (EBM) and practice guidelines. Evidence is generated from systematic clinical research as well as reported clinical experience and individually case based empirical evidence. All types of research though (quantitative or qualitative) have limitations. Similarly all types of evidence have advantages and disadvantages and can be complimentary to each other. Evidencebased individual decision (EBID) making is the commonest evidence-based medicine as practiced by the individual clinician in making decisions about the care of the individual patient. It involves integrating individual clinical expertise with the best available external clinical evidence from systematic research. However this sort of evidence-based medicine, focuses excessively on the individual (potentially at the expense of others) in a system with limited budgets. Evidence-based guidelines (EBG) also support the practice of evidence-based medicine but at the organizational or institutional level. The main aim is to identify which interventions, over a range of patients, work best and which is cost-effective in order to guide service development and provision at a strategic level. Doing this effectively is a scientific and statistical skill in itself and the quality of guidelines is based primarily on the quality research evidence. It is important to note that lack of systematic evidence to support an intervention does not automatically mean that an intervention must instantly be abandoned. It is also important that guidelines are understood for what they are, i.e. not rules, or complete statements of knowledge. EBM will never have enough suitable evidence for all and every aspects of health provision in every locality. Innovation signifies a substantial positive change compared to gradual or incremental changes. Innovation using inductive reasoning has to play a major role within health care system and it is applicable to all three level of service provision: clinical practice, policy and organisation structure. The aim of this paper is to examine critically the above concepts and their complimentary role in supporting provision of health care systems which are suitable for the requirements of the population, affordable, deliverable, flexible and adaptable to social changes.

Clinical nurse specialist practice domains and evidence-based practice competencies: a matrix of influence.

PubMed

Kring, Daria L

2008-01-01

The purpose of this article is to describe master's-level evidence-based practice (EBP) competencies as determined by a national consensus panel and present an EBP matrix that illustrates the influence that the clinical nurse specialist (CNS) practice can have on driving EBP change. Evidence-based practice is a growing and necessary paradigm for nursing care. The ACE Star Model conceptualizes the knowledge transformation that must occur in an EBP environment as 5 distinct points: discovery, summary, translation, integration, and evaluation. Master's-level EBP competencies based on these 5 steps were established by a national consensus panel. The CNS's practice can be organized around 5 domains: expert practitioner, researcher, consultant, educator, and leader. The master's-level EBP competencies can be transposed on a crosswalk of the ACE Star Model and the 5 CNS practice domains to form a matrix representing the influence that CNSs can have over the EBP process. Each competency falls well within the practice domains of the CNS, making the CNS an ideal person to lead the EBP movement forward, providing tangible outcomes to further demonstrate the need for the CNS role.

Clinical dimensions of a 'biological concept': transsexualism and the interplay between etiological theory and clinical therapy.

PubMed

Lea, Andrew S

2016-09-01

In 1966, the Johns Hopkins University School of Medicine became the first American medical institution to perform sex reassignment surgeries. This article interrogates the relationship between the emergence of this clinical therapy in the United States and the changing medical understandings of the contemporaneous condition it was intended to address - 'transsexualism.' I argue that, during the mid-to-late twentieth century, therapeutic practices and theories about the etiology of transsexualism were mutually constitutive. On one hand, the clinical development of sex reassignment surgery precipitated a newfound interest in the possible biological, as opposed to psychopathological, underpinnings of transsexualism. At the same time, different theories about etiology were marshaled by both advocates and critics of sex reassignment in their efforts to secure or undercut the medical legitimacy and clinical presence of competing therapeutic practices. Debates surrounding transsexualism's etiology were therefore about much more than the causes of this condition: these etiological conversations also intervened in fundamental debates about the ethics of medical care and the therapeutic identity of different clinical practices (that is, whether sex reassignment and psychotherapy were to be considered primarily symptomatic or curative). Copyright © 2016 Elsevier Ltd. All rights reserved.

Integration of systematic clinical interprofessional training in a student-faculty collaborative primary care practice.

PubMed

Weinstein, Amy R; Dolce, Maria C; Koster, Megan; Parikh, Ravi; Hamlyn, Emily; A McNamara, Elizabeth; Carlson, Alexa; DiVall, Margarita V

2018-01-01

The changing healthcare environment and movement toward team-based care are contemporary challenges confronting health professional education. The primary care workforce must be prepared with recent national interprofessional competencies to practice and lead in this changing environment. From 2012 to 2014, the weekly Beth Israel Deaconess Crimson Care Collaborative Student-Faculty Practice collaborated with Northeastern University to develop, implement and evaluate an innovative model that incorporated interprofessional education into primary care practice with the goal of improving student understanding of, and ability to deliver quality, team-based care. In the monthly interprofessional clinic, an educational curriculum empowered students with evidence-based, team-based care principles. Integration of nursing, pharmacy, medicine, and masters of public health students and faculty into direct patient care, provided the opportunity to practice skills. The TeamSTEPPS® Teamwork Attitudes Questionnaire was administered pre- and post-intervention to assess its perceived impact. Seventeen students completed the post-intervention survey. Survey data indicated very positive attitudes towards team-based care at baseline. Significant improvements were reported in attitudes towards situation monitoring, limiting personal conflict, administration support and communication. However, small, but statistically significant declines were seen on one team structure and two communication items. Our program provides further evidence for the use of interprofessional training in primary care.

Top 20 Research Studies of 2014 for Primary Care Physicians.

PubMed

Ebell, Mark H; Grad, Roland

2015-09-01

A team of primary care clinicians with expertise in evidence-based medicine performed monthly surveillance of more than 110 English-language clinical research journals during 2014, and identified 255 studies that had the potential to change how family physicians practice. Each study was critically appraised and summarized, focusing on its relevance to primary care practice, validity, and likelihood that it could change practice. A validated tool was used to obtain feedback from members of the Canadian Medical Association about the clinical relevance of each POEM (patient-oriented evidence that matters) and the benefits they expect for their practice. This article, the fourth installment in this annual series, summarizes the 20 POEMs based on original research studies judged to have the greatest impact on practice for family physicians. Key studies for this year include advice on symptomatic management and prognosis for acute respiratory infections; a novel and effective strengthening treatment for plantar fasciitis; a study showing that varenicline plus nicotine replacement is more effective than varenicline alone; a network meta-analysis concluding that angiotensin-converting enzyme inhibitors are preferred over angiotensin II receptor blockers; the clear benefits of initial therapy with metformin over other agents in patients with diabetes mellitus; and important guidance on the use of anticoagulants.

Perceptions of general practitioners towards the use of a new system for treating back pain: a qualitative interview study.

PubMed

Sanders, Tom; Foster, Nadine E; Ong, Bie Nio

2011-05-09

Changing clinicians' behaviour is recognised as a major challenge. It is clear that behaviour change not only depends on demonstrating the proven effectiveness of clinical interventions; contextual and occupational factors, such as 'change readiness', may be central to their implementation. This paper highlights the context of behaviour change in relation to a healthcare innovation introduced within primary care, highlighting the importance of organisational and interpersonal factors that may help explain the dynamics of implementation. Qualitative interviews were conducted with general practitioners (GPs) before (n = 32) and after (n = 9) the introduction of a subgrouping for targeted treatment system. GPs were offered an electronic six-item subgrouping tool, to identify patients according to their risk of poor outcome ('high', 'low') in order to help inform their decision making about treatment approaches. Recruitment was based on a 'maximum diversification sample', to obtain a wide representation of views across all five practices. A coding scheme was developed based on the emergent findings, and the data were analysed using 'constant comparison', drawing upon insights and developing connections between themes. We adopted the normalisation process theory (NPT) to explain the uptake of the new system and to examine the relevance of coherence for the implementation of innovations in organisations. GPs perceived back pain as a low clinical priority, and highlighted the importance of 'practical' and 'relational' coherence in decisions to adopt and engage with the new subgrouping for targeted treatment system. Health professionals often engage in 'sense making' about new innovations to 'road test' their applicability or relevance to daily clinical routines. Low back pain was generally perceived as an 'uninteresting' and clinically unchallenging health problem by GPs, which may partly explain their lack of engagement with the new subgrouping for targeted treatment system. The adoption of this new way of working by GPs was determined by the meaning that they ascribed to it in the context of their daily clinical routines. We conclude that the key obstacle to implementation of the new subgrouping for targeted treatment system for low back pain in primary care was an initial failure to achieve 'coherence' of the desired practice change with GPs. Despite this, GPs used the tool to different degrees, though this signified a general commitment to participating in the study rather than a deeper attitude change towards the new system.

Clinical Issues-November 2017.

PubMed

Johnstone, Esther M

2017-11-01

Heating, ventilation, and air-conditioning (HVAC) systems in the OR Key words: airborne contaminants, HVAC system, air pressure, air quality, temperature and humidity. Air changes and positive pressure Key words: air changes, positive pressure airflow, unidirectional airflow, outdoor air, recirculated air. Product selection Key word: product evaluation, product selection, selection committee. Entry into practice Key words: associate degree in nursing, bachelor of science in nursing, entry-level position, advanced education, BSN-prepared RNs. Mentoring in perioperative nursing Key words: mentor, novice, practice improvement, nursing workforce. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Change in Cardiopulmonary Arrest Response in an Anesthesiology Residency: A practice-based learning initiative.

PubMed

Takla, Amgad; Dorotta, Ihab; Staszak, John; Tetzlaff, John E

2007-01-01

Because of increases in the acuity in our patient population, increasing complexity of the care provided and the structure of our residency, we decided to systematically alter our participation in the hospital-wide cardiac arrest system. The need to provide optimum service in an increasingly complex clinical care system was the motivation for change. With substantive input from trainees and practitioners, we created a multi-tier-system of response along with predefined criteria for the anesthesiology response. We report the result of our practice based learning initiative.

Patients with cancer and change of general practice: a Danish population-based cohort study

PubMed Central

Grooss, Kasper; Hjertholm, Peter; Carlsen, Anders H; Vedsted, Peter

2016-01-01

Background General practice plays an important role in the cancer care pathway. Patient dissatisfaction with the diagnostic process may be expressed by changing to another general practice. Aim To compare the frequency of change of practice (COP) in patients with cancer (n = 150 216) with a matched cancer-free control cohort (n = 1 502 114) and to analyse associations with cancer type and patient characteristics. Design and setting A population-based matched cohort study using historical and prospectively collected data from Danish nationwide registers. Method COP was defined as a change of practice list, unrelated to change of address or reorganisation of the practice. Data were analysed monthly in the year before and after a cancer diagnosis. Results More patients with cancer than controls changed general practice (4.1% versus 2.6%) from 7 months before and until 12 months after diagnosis. The COP rate varied by cancer type (rectal cancer served as reference). Before the diagnosis, COP was most often seen among patients with ovarian cancer (risk ratio [RR] 1.51, 95% confidence interval [CI] = 1.10 to 2.08) and multiple myeloma (RR 1.89, 95% CI = 1.34 to 2.67). After the diagnosis, COP was most frequent among patients with brain cancer (RR 1.38, 95% CI = 1.05 to 1.82) and ovarian cancer (RR 1.51, 95% CI = 1.21 to 1.88). Conclusion Patients with cancer changed general practice more frequently than the cancer-free controls. COP variations between cancer types may be attributed to lack of diagnostic timeliness due to clinical complexity of the diagnosis and the role of the GP in the diagnostic process. PMID:27215570

Time to talk, time to see: changing microeconomies of professional practice among nurses and doctors in Australian general practice.

PubMed

Phillips, Christine; Dwan, Kathryn; Pearce, Christopher; Hall, Sally; Porritt, Julie; Yates, Rachel; Sibbald, Bonnie

2007-08-01

In Australia, more nurses are entering general practice, and nurses' work is being funded in increasingly complex ways through Medicare. Little research has explored the ways doctors and nurses realign their priorities and activities when working together in general practice. We undertook rapid, intensive multimethod studies of 25 general practices to explore the ways in which the labour of nurses and doctors was structured, and the implicit decisions made by both professions about the values placed on different ways of working and on their time. Data collected included photographs, floor-plans, interviews with 37 nurses, 24 doctors and 22 practice managers, and 50 hours of structured observation. Nursing time was constructed by both nurses and doctors as being fluid and non-contingent; they were regarded as being 'available' to patients in a way that doctors were not. Compared to medical time, nursing time could be disposed more flexibly, underpinning a valorized attribute of nursing: deep clinical and personal contact with patients. The location of practice nurses' desks in areas of traffic, such as administrative stations, or in the treatment room, underpinned this valuable unstructured contact with patients. Changes to the practice nurse role through direct fee-for-service items for nurses may lead to greater congruence between the microeconomies of nursing and medicine in general practice. In a time of pressure upon a primary care workforce, this is likely to lead to more independent clinical work by nurses, but may also lead to a decrease in flexible contact with patients.

Connecting to success: practice management on the Net.

PubMed

Freydberg, B K

2001-08-15

Profound changes in the way dental practices manage data, patient records, and communication are beginning to unfold. Sooner than most of us can imagine, secured patient medical and dental records will reside on the Internet. Additionally, communication between health care providers and patients will become virtually 100% electronic. As the Application Service Provider (ASP) dental models mature, practices will transition from paper to "paperless" to "web-based" management and clinical systems. This article examines and explains these future frontiers.

Technological innovations in digital data management and changing roles of imaging specialists in Japan.

PubMed

Ehara, Shigeru

2010-11-28

Technical innovations in digital data management pose a threat to radiologists in that can we remain in the process of clinical decision making or be assigned to a secondary role in future clinical practice. The value added to the imaging studies by diagnostic radiologists, or imaging specialists, has never been questioned more seriously.

Using Standardized Patients to Evaluate Screening, Brief Intervention, and Referral to Treatment (SBIRT) Knowledge and Skill Acquisition for Internal Medicine Residents

ERIC Educational Resources Information Center

Satterfield, Jason M.; O'Sullivan, Patricia; Satre, Derek D.; Tsoh, Janice Y.; Batki, Steven L.; Julian, Kathy; McCance-Katz, Elinore F.; Wamsley, Maria

2012-01-01

Comprehensive clinical competency curricula for hazardous drinking and substance use disorders (SUDs) exists for medical students, residents, and practicing health care providers. Evaluations of these curricula typically focus on learner attitudes and knowledge, although changes in clinical skills are of greater interest and utility. The authors…

Clinical practice guidelines for the diagnosis and management of melanoma: melanomas that lack classical clinical features.

PubMed

Mar, Victoria J; Chamberlain, Alex J; Kelly, John W; Murray, William K; Thompson, John F

2017-10-16

A Cancer Council Australia multidisciplinary working group is currently revising and updating the 2008 evidence-based clinical practice guidelines for the management of cutaneous melanoma. While there have been many recent improvements in treatment options for metastatic melanoma, early diagnosis remains critical to reducing mortality from the disease. Improved awareness of the atypical presentations of this common malignancy is required to achieve this. A chapter of the new guidelines was therefore developed to aid recognition of atypical melanomas. Main recommendations: Because thick, life-threatening melanomas may lack the more classical ABCD (asymmetry, border irregularity, colour variegation, diameter > 6 mm) features of melanoma, a thorough history of the lesion with regard to change in morphology and growth over time is essential. Any lesion that is changing in morphology or growing over a period of more than one month should be excised or referred for prompt expert opinion. Changes in management as a result of the guidelines: These guidelines provide greater emphasis on improved recognition of the atypical presentations of melanoma, in particular nodular, desmoplastic and acral lentiginous subtypes, with particular awareness of hypomelanotic and amelanotic lesions.

Feasibility of energy medicine in a community teaching hospital: an exploratory case series.

PubMed

Dufresne, Francois; Simmons, Bonnie; Vlachostergios, Panagiotis J; Fleischner, Zachary; Joudeh, Ramsey; Blakeway, Jill; Julliard, Kell

2015-06-01

Energy medicine (EM) derives from the theory that a subtle biologic energy can be influenced for therapeutic effect. EM practitioners may be trained within a specific tradition or work solo. Few studies have investigated the feasibility of solo-practitioner EM in hospitals. This study investigated the feasibility of EM as provided by a solo practitioner in inpatient and emergent settings. Feasibility study, including a prospective case series. Inpatient units and emergency department. To investigate the feasibility of EM, acceptability, demand, implementation, and practicality were assessed. Short-term clinical changes were documented by treating physicians. Patients, employees, and family members were enrolled in the study only if study physicians expected no or slow improvement in specific symptoms. Those with secondary gains or who could not communicate perception of symptom change were excluded. EM was found to have acceptability and demand, and implementation was smooth because study procedures dovetailed with conventional clinical practice. Practicality was acceptable within the study but was low upon further application of EM because of cost of program administration. Twenty-four of 32 patients requested relief from pain. Of 50 reports of pain, 5 (10%) showed no improvement; 4 (8%), slight improvement; 3 (6%), moderate improvement; and 38 (76%), marked improvement. Twenty-one patients had issues other than pain. Of 29 non-pain-related problems, 3 (10%) showed no, 2 (7%) showed slight, 1 (4%) showed moderate, and 23 (79%) showed marked improvement. Changes during EM sessions were usually immediate. This study successfully implemented EM provided by a solo practitioner in inpatient and emergent hospital settings and found that acceptability and demand justified its presence. Most patients experienced marked, immediate improvement of symptoms associated with their chief complaint. Substantial practicality issues must be addressed to implement EM clinically in a hospital, however.

Screening and assessment of chronic pain among children with cerebral palsy: a process evaluation of a pain toolbox.

PubMed

Orava, Taryn; Provvidenza, Christine; Townley, Ashleigh; Kingsnorth, Shauna

2018-06-08

Though high numbers of children with cerebral palsy experience chronic pain, it remains under-recognized. This paper describes an evaluation of implementation supports and adoption of the Chronic Pain Assessment Toolbox for Children with Disabilities (the Toolbox) to enhance pain screening and assessment practices within a pediatric rehabilitation and complex continuing care hospital. A multicomponent knowledge translation strategy facilitated Toolbox adoption, inclusive of a clinical practice guideline, cerebral palsy practice points and assessment tools. Across the hospital, seven ambulatory care clinics with cerebral palsy caseloads participated in a staggered roll-out (Group 1: exclusive CP caseloads, March-December; Group 2: mixed diagnostic caseloads, August-December). Evaluation measures included client electronic medical record audit, document review and healthcare provider survey and interviews. A significant change in documentation of pain screening and assessment practice from pre-Toolbox (<2%) to post-Toolbox adoption (53%) was found. Uptake in Group 2 clinics lagged behind Group 1. Opportunities to use the Toolbox consistently (based on diagnostic caseload) and frequently (based on client appointments) were noted among contextual factors identified. Overall, the Toolbox was positively received and clinically useful. Findings affirm that the Toolbox, in conjunction with the application of integrated knowledge translation principles and an established knowledge translation framework, has potential to be a useful resource to enrich and standardize chronic pain screening and assessment practices among children with cerebral palsy. Implications for Rehabilitation It is important to engage healthcare providers in the conceptualization, development, implementation and evaluation of a knowledge-to-action best practice product. The Chronic Pain Toolbox for Children with Disabilities provides rehabilitation staff with guidance on pain screening and assessment best practice and offers a range of validated tools that can be incorporated in ambulatory clinic settings to meet varied client needs. Considering unique clinical contexts (i.e., opportunities for use, provider engagement, staffing absences/turnover) is required to optimize and sustain chronic pain screening and assessment practices in rehabilitation outpatient settings.

Responses to clinical uncertainty in Australian general practice trainees: a cross-sectional analysis.

PubMed

Cooke, Georga; Tapley, Amanda; Holliday, Elizabeth; Morgan, Simon; Henderson, Kim; Ball, Jean; van Driel, Mieke; Spike, Neil; Kerr, Rohan; Magin, Parker

2017-12-01

Tolerance for ambiguity is essential for optimal learning and professional competence. General practice trainees must be, or must learn to be, adept at managing clinical uncertainty. However, few studies have examined associations of intolerance of uncertainty in this group. The aim of this study was to establish levels of tolerance of uncertainty in Australian general practice trainees and associations of uncertainty with demographic, educational and training practice factors. A cross-sectional analysis was performed on the Registrar Clinical Encounters in Training (ReCEnT) project, an ongoing multi-site cohort study. Scores on three of the four independent subscales of the Physicians' Reaction to Uncertainty (PRU) instrument were analysed as outcome variables in linear regression models with trainee and practice factors as independent variables. A total of 594 trainees contributed data on a total of 1209 occasions. Trainees in earlier training terms had higher scores for 'Anxiety due to uncertainty', 'Concern about bad outcomes' and 'Reluctance to disclose diagnosis/treatment uncertainty to patients'. Beyond this, findings suggest two distinct sets of associations regarding reaction to uncertainty. Firstly, affective aspects of uncertainty (the 'Anxiety' and 'Concern' subscales) were associated with female gender, less experience in hospital prior to commencing general practice training, and graduation overseas. Secondly, a maladaptive response to uncertainty (the 'Reluctance to disclose' subscale) was associated with urban practice, health qualifications prior to studying medicine, practice in an area of higher socio-economic status, and being Australian-trained. This study has established levels of three measures of trainees' responses to uncertainty and associations with these responses. The current findings suggest differing 'phenotypes' of trainees with high 'affective' responses to uncertainty and those reluctant to disclose uncertainty to patients. More research is needed to examine the relationship between clinical uncertainty and clinical outcomes, temporal changes in tolerance for uncertainty, and strategies that might assist physicians in developing adaptive responses to clinical uncertainty. © 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

Application of self-efficacy theory in dental clinical practice.

PubMed

Kakudate, N; Morita, M; Fukuhara, S; Sugai, M; Nagayama, M; Kawanami, M; Chiba, I

2010-11-01

In clinical practice, self-efficacy refers to how certain a patient feels about his or her ability to take the necessary action to improve the indicators and maintenance of health. It is assumed that the prognosis for patient behaviour can be improved by assessing the proficiency of their self-efficacy through providing psychoeducational instructions adapted for individual patients, and promoting behavioural change for self-care. Therefore, accurate assessment of self-efficacy is an important key in daily clinical preventive care. The previous research showed that the self-efficacy scale scores predicted patient behaviour in periodontal patients and mother's behaviour in paediatric dental practice. Self-efficacy belief is constructed from four principal sources of information: enactive mastery experience, vicarious experience, verbal persuasion, and physiological and affective states. Thus, self-efficacy can be enhanced by the intervention exploiting these sources. The previous studies revealed that behavioural interventions to enhance self-efficacy improved oral-care behaviour of patients. Therefore, assessment and enhancement of oral-care specific self-efficacy is important to promote behaviour modification in clinical dental practice. However, more researches are needed to evaluate the suitability of the intervention method. © 2010 John Wiley & Sons A/S.