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A clinical evaluation tool for nursing students based on the nursing process.

An integrated curriculum was implemented in an upper division baccalaureate nursing program which required letter grades for clinical courses. The second semester clinical course involved student evaluation in four different settings. The original evaluation tool lacked both the discrimination needed for letter grades and the competencies common to all the settings. A computerized evaluation tool was developed to identify behaviors which could be evaluated and assigned a letter grade in all four clinical settings, and to provide formative and summative evaluation of performance for students throughout the semester. The tool focuses on the four areas of the nursing process, each of which is weighted according to the conceptual framework of the curriculum and the ability of a student at this level. In each of these four areas, entry level behaviors were identified and then built upon by progression from fundamental skills to more complex and independent behaviors. Students are rated on a criterion-referenced rating scale. A statistician verified that the tool was mathematically sound. Once developed, the tool was placed on computer where both students and faculty evaluate student clinical performance every two to four weeks. Because the tool was placed on computer, students receive immediate feedback, which facilitates formative evaluations. Trends in student performance can be identified easily, and faculty paperwork is decreased. The tool also promotes objectivity in evaluation and student awareness of expected behaviors. Finally, faculty and students have become more familiar and more comfortable with computers.

Clinical Competence↗

How valid are utilization review tools in assessing appropriate use of acute care beds?

BACKGROUND: Despite their widespread acceptance, utilization review tools, which were designed to assess the appropriateness of care in acute care hospitals, have not been well validated in Canada. The aim of this study was to assess the validity of 3 such tools--ISD (Intensity of service, Severity of illness, Discharge screens), AEP (Appropriateness Evaluation Protocol) and MCAP (Managed Care Appropriateness Protocol)--as determined by their agreement with the clinical judgement of a panel of experts. METHODS: The cases of 75 patients admitted to an acute cardiology service were reviewed retrospectively. The criteria of each utilization review tool were applied by trained reviewers to each day the patients spent in hospital. An abstract of each case prepared in a day-by-day format was evaluated independently by 3 cardiologists, using clinical judgement to decide the appropriateness of each day spent in hospital. RESULTS: The panel considered 92% of the admissions and 67% of the subsequent hospital days to be appropriate. The ISD underestimated the appropriateness rates of admission and subsequent days; the AEP and MCAP overestimated the appropriateness rate of subsequent days in hospital. The kappa statistic of overall agreement between tool and panel was 0.45 for ISD, 0.24 for MCAP and 0.25 for AEP, indicating poor to fair validity of the tools. INTERPRETATION: Published validation studies had average kappa values of 0.32-0.44 (i.e., poor to fair) for admission days and for subsequent days in hospital for the 3 tools. The tools have only a low level of validity when compared with a panel of experts, which raises serious doubts about their usefulness for utilization review.

Angina, Unstable↗

Developing leadership in healthcare administration: a competency assessment tool.

Despite the many graduate programs that specialize in health administration, healthcare leaders and practitioners have expressed concern about the quality of preparation of health administration graduates. The purpose of this study was to facilitate one part of an integrated approach to leadership development that spans academic and practitioner settings. The approach was to design a competency assessment tool for early careerists who have two to five years of postgraduate experience and who aspire to fill senior leadership positions in complex, provider-based healthcare organizations. Open-ended interviews with key informants and a comprehensive review of relevant literature were done to identify and categorize a set of competencies relevant to early careerists. Based on data from key informants, specific work experiences and academic courses were mapped to each competency, indicating where and how such competencies might be developed. A simple rating system was then added to assess each competency, which resulted in the completion of the tool. Finally, the tool was piloted in a practitioner setting at the Massachusetts General Hospital Administrative Fellowship Program and in an academic setting at the Yale University Health Management Program. The resulting tool includes 52 competencies categorized into four domains: (1) technical skills (operations, finance; information resources, human resources, and strategic planning/external affairs); (2) industry knowledge (clinical process and healthcare institutions); (3) analytic and conceptual reasoning; and (4) interpersonal and emotional intelligence. Early experience with the tool suggests that it can facilitate career planning among graduate students, early careerists, and their mentors. Further, the tool can help directors of both academic and practitioner programs identify strengths and gaps in their existing curricula or training programs. By offering specific competencies linked to work experiences and graduate courses, the tool is an initial step toward promoting collaborative efforts between academic and practitioner programs.

Administrative Personnel↗

Terminology tools: state of the art and practical lessons.

OBJECTIVES: As controlled medical terminologies evolve from simple code-name-hierarchy arrangements, into rich, knowledge-based ontologies of medical concepts, increased demands are placed on both the developers and users of the terminologies. In response, researchers have begun developing tools to address their needs. The aims of this article are to review previous work done to develop these tools and then to describe work done at Columbia University and New York Presbyterian Hospital (NYPH). METHODS: Researchers working with the Systematized Nomenclature of Medicine (SNOMED), the Unified Medical Language System (UMLS), and NYPH's Medical Entities Dictionary (MED) have created a wide variety of terminology browsers, editors and servers to facilitate creation, maintenance and use of these terminologies. RESULTS: Although much work has been done, no generally available tools have yet emerged. Consensus on requirement for tool functions, especially terminology servers is emerging. Tools at NYPH have been used successfully to support the integration of clinical applications and the merger of health care institutions. CONCLUSIONS: Significant advancement has occurred over the past fifteen years in the development of sophisticated controlled terminologies and the tools to support them. The tool set at NYPH provides a case study to demonstrate one feasible architecture.

Computer Systems↗

From immunome to vaccine: epitope mapping and vaccine design tools.

Since the publication of the complete genome of a pathogenic bacterium in 1995, more than 50 bacterial pathogens have been sequenced and at least 120 additional projects are currently underway. Faced with the expanding volume of information now available from genome databases, vaccinologists are turning to epitope mapping tools to screen vaccine candidates. Bioinformatics tools such as EpiMatrix and Conservatrix, which search for unique or multi-HLA-restricted (promiscuous) T cell epitopes and can find epitopes that are conserved across variant strains of the same pathogen, have accelerated the process of epitope mapping. Additional tools for screening epitopes for similarity to 'self' (BlastiMer) and for assembling putative epitopes into strings if they overlap (EpiAssembler) have been developed at EpiVax. Tools that map proteasome cleavage sires are available on the Internet. When used together, these bioinformatics tools offer a significant advantage over traditional methods of vaccine design since high throughput screening and design is performed in silico, followed by confirmatory studies in vitro. These new tools are being used to develop novel vaccines and therapeutics for the prevention and treatment of infectious diseases such as HIV, hepatitis C, tuberculosis, and some cancers. More recent applications of the tools involve deriving novel vaccine candidates directly from whole genomes, an approach that has been named 'genome to vaccine'.

Allergy and Immunology↗

The stadium diagram, a web-based tool for visualizing the expected outcomes of alternative clinical management strategies.

OBJECTIVE: To explore the use of graphical animation for helping clinicians to understand the evidence about expected risks and benefits associated with multi-step clinical management strategies. METHODS: We used Flash and XML to create a tool capable of displaying the sequence of health state changes that may result from a specific management strategy, as applied to a simulated population. We evaluated this tool in 6 focus groups involving a total of 44 community internists and family physicians. We successively revised the tool based on grounded theory analysis of the focus group transcripts. RESULTS: The process of responding to design issues raised in focus groups resulted in a final tool that presents a group of person icons arranged in rows to give the illusion of people in a stadium or theater. Each action in the management strategy causes persons to change color and move among rows to reflect changes in health state. The tool can play audio narration to explain each step and links are provided to the supporting evidence. Most physicians found these visualizations to be attractive and clear. Some were interested in using the tool with patients. Others rejected the specific decision model used to demonstrate the tool and a few rejected the notion of applying quantitative risks to individual patients. CONCLUSIONS: A visual approach to demonstrating the possible benefits and harms of a given management strategy holds interest for many clinicians. However, visualizations may fail to influence clinicians who do not believe the available evidence.

Computer Graphics↗

Validation of the critical-care pain observation tool in adult patients.

BACKGROUND: Little research has been conducted to validate pain assessment tools in critical care, especially for patients who cannot communicate verbally. OBJECTIVE: To validate the Critical-Care Pain Observation Tool. METHODS: A total of 105 cardiac surgery patients in the intensive care unit, recruited in a cardiology health center in Quebec, Canada, participated in the study. Following surgery, 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated; all 105 were evaluated after extubation. For each of the 3 testing periods, patients were evaluated by using the Critical-Care Pain Observation Tool at rest, during a nociceptive procedure (positioning), and 20 minutes after the procedure, for a total of 9 assessments. Each patient's self-report of pain was obtained while the patient was conscious and intubated and after extubation. RESULTS: The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. Interrater reliability was supported by moderate to high weighted kappa coefficients. For criterion validity, significant associations were found between the patients' self-reports of pain and the scores on the Critical-Care Pain Observation Tool. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest. CONCLUSIONS: The Critical-Care Pain Observation Tool showed that no matter their level of consciousness, critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain. Therefore, the tool could be used to assess the effect of various measures for the management of pain.

Cardiac Surgical Procedures↗

Knowledge-engineering software. A demonstration of a high-end tool.

Many investigators wanting to apply knowledge-based systems (KBSs) as consultants for cancer diagnosis have turned to tools running on personal computers. While some of these tools serve well for small tasks, they lack the power available with such high-end KBS tools as KEE (Knowledge Engineering Environment) and ART (Automated Reasoning Tool). These tools were originally developed on Lisp machines and have the full functionality of the Lisp language as well as many additional features. They provide a rich and highly productive environment for the software developer. This paper illustrates the capability of one of these high-end tools. First, a table showing the classification of benign soft tissue tumors was converted into a KEE knowledge base. The tools available in KEE were then used to identify the tumor type for a hypothetical patient.

Age Factors↗

Physicians' usefulness ratings of family-oriented clinical tools.

BACKGROUND: Family-oriented patient care is a cornerstone of family practice. Family practice educators have proposed various methods to help the physician to better assess and treat families. Little is known, however, of the usefulness of family-oriented clinical tools to practicing physicians. METHODS: On a mailed survey questionnaire, 595 members of the Wisconsin Academy of Family Physicians were asked to rate the usefulness of 10 family-oriented tools and indicate the frequency of use and level of training received for each item. In addition, physicians rated their current and desired level of competency for involving families in patient care. RESULTS: Two hundred ninety-nine (50%) physicians responded. Most of the tools were rated as useful but used infrequently. Identifying the effects of chemical dependency on the health of families and conducting family conferences were rated as highly useful and frequently used skills. Clinical tools rated as least useful were record keeping by family charts and folders and family function assessment by the Family APGAR: Physicians who had received training in the use of a tool rated it as more useful, except for the Family APGAR and family charts or folders. Physicians with busier practices rated some of the tools as less useful than did other physicians. Respondents indicated a desire to develop their family counseling skills. CONCLUSIONS: Most family-oriented tools were reported to be useful but used infrequently by practicing physicians. Residency programs should continue to provide training for assessing and treating families, particularly in the areas of family systems theory, self-awareness of the physician's own family background, and the effect of chemical dependency on families. Future research should target larger and more varied groups of family physicians.

Attitude of Health Personnel↗

Use of a tool-set by Pan troglodytes troglodytes to obtain termites (Macrotermes) in the periphery of the Dja Biosphere Reserve, southeast Cameroon.

At the northern periphery of the Dja Biosphere Reserve (southeastern Cameroon) we recorded a new use of a tool-set by Pan troglodytes troglodytes to prey on Macrotermes muelleri, M. renouxi, M. lilljeborgi, and M. nobilis. We recovered 79 puncturing sticks and 47 fishing probes at 17 termite nests between 2002 and 2005. The mean length of the puncturing sticks (n = 77) and fishing probes (n = 45) was 52 cm and 56 cm, respectively, and the mean diameter was 9 mm and 4.5 mm, respectively. Sixty-eight percent of 138 chimpanzee fecal samples contained major soldiers of four Macrotermes species. The chimpanzees in southeastern Cameroon appeared to be selective in their choice of plant material to make their tools. The tools found at our study site resemble those from other sites in this region. However, in southeastern Cameroon only one tool-set type was found, whereas two tool-set types have been reported in Congo. Our study suggests that, along with the different vegetation types and the availability of plant material around termite nests, the nest and gallery structure and foraging behavior of the different Macrotermes spp. at all Central African sites must be investigated before we can attribute differences in tool-use behavior to culture.

Animals↗

The evolutionary neuroscience of tool making.

The appearance of the first intentionally modified stone tools over 2.5 million years ago marked a watershed in human evolutionary history, expanding the human adaptive niche and initiating a trend of technological elaboration that continues to the present day. However, the cognitive foundations of this behavioral revolution remain controversial, as do its implications for the nature and evolution of modern human technological abilities. Here we shed new light on the neural and evolutionary foundations of human tool making skill by presenting functional brain imaging data from six inexperienced subjects learning to make stone tools of the kind found in the earliest archaeological record. Functional imaging of this complex, naturalistic task was accomplished through positron emission tomography with the slowly decaying radiological tracer (18)flouro-2-deoxyglucose. Results show that simple stone tool making is supported by a mosaic of primitive and derived parietofrontal perceptual-motor systems, including recently identified human specializations for representation of the central visual field and perception of three-dimensional form from motion. In the naïve tool makers reported here, no activation was observed in prefrontal executive cortices associated with strategic action planning or in inferior parietal cortex thought to play a role in the representation of everyday tool use skills. We conclude that uniquely human capacities for sensorimotor adaptation and affordance perception, rather than abstract conceptualization and planning, were central factors in the initial stages of human technological evolution.

Adaptation, Psychological↗

Failure of a Web-based educational tool to improve residents' scores on the American Board of Surgery In-Training Examination.

HYPOTHESIS: Usage of a Web-based educational tool will improve residents' scores on the American Board of Surgery In-Training Examination (ABSITE). DESIGN: Before and after trial. SETTING: Academic surgical residency in a tertiary care university hospital. PARTICIPANTS: Nineteen postgraduate year 1 (PGY1) and PGY2 residents. INTERVENTION: All PGY1 and PGY2 residents were given unlimited access to a Web-based educational tool aimed at early-level residents in surgery. The educational tool covers the basic science of surgery and basic concepts of clinical surgery and uses a variety of educational techniques (readings, problem-based learning, case-based learning, and practice tests). Although residents were encouraged to complete the learning package, they were not required to do so. MAIN OUTCOME MEASURES: The ABSITE scores and changes in ABSITE scores were compared with the amount of time residents spent using the program and the number of tutorials completed. RESULTS: There was no significant difference in ABSITE scores before or after the use of the Web-based educational tool. There was no significant relationship between use of the tool (either in total time or total tutorials) and ABSITE score. For PGY2 residents, there was a negative relationship between total time spent on the program and ABSITE score (linear regression analysis best-fit slope, -0.20 +/- 0.1; r2 = 0.33) and total tutorials completed and ABSITE score (linear regression analysis best-fit slope, -0.34 +/- 0.22; r2 = 0.25). CONCLUSION: There was no demonstrable beneficial effect of a Web-based educational tool on cognitive knowledge of residents as measured by ABSITE scores.

Computer-Assisted Instruction↗

Transfer of tools and food between groups of tufted capuchins (Cebus apella).

This research examined tool and food transfer between two groups of tufted capcuhin monkeys (Cebus apella). Subjects in one group transferred stones to subjects in a second group who in turn used the stones as cutting tools and then transferred food to subjects in the first group. Aspects of the capuchins' behavior are similar to those described for food-sharing in Cebus, cooperative tool use in Papio, and tool and food exchange in Pan. We propose that tool use and food-sharing facilitate tool and food transfer between captive groups of Cebus apella.

Animals↗

Geographic variation in tool use on Neesia fruits in orangutans.

Geographic variation in the presence of skilled behavior may reflect geographic variation in genetic predispositions or ecological conditions (accompanied by reliable expression during development), or it may reflect the vagaries of invention and the appropriate social conditions for persistence. In this study, we compare the feeding techniques and tool-using skills used by orangutans to extract the nutritious seeds from Neesia fruits between Suaq Balimbing on Sumatra and Gunung Palung on Borneo, and map the distribution of Neesia tool use in Sumatran swamps. We show that neither genetics nor ecology is sufficient to explain the distribution of this tool use, confirming earlier findings on chimpanzees. We conclude that the ability to learn to use tools determines the geographic distribution. It is impossible to distinguish between the history of invention and the conditions for social transmission as the causal factors, but the high density and the social tolerance at Suaq Balimbing create propitious conditions for the maintenance of the skill as a tradition once it has been invented. High orangutan densities in the other Sumatran coastal swamps with Neesia tool use support the conclusion that suitable transmission conditions are the critical factor to explain the geographic distribution of skills such as feeding tool use.

Animals↗

Development of a validated quality of life tool specific to children with bladder dysfunction.

AIMS: To date there have not been any generic or continence-specific measurement tools that allow clinicians to investigate quality of life in children with bladder dysfunction. The aim of this research was to create a cross-cultural tool to assess and measure the wider psychosocial impact of current and new interventions for bladder dysfunction in children. MATERIALS AND METHODS: The study was conducted in three parts: expert consultation with continence clinicians; design and administration of a child-completed international questionnaire; item analysis, validity and reliability testing, and design of a new tool. RESULTS: The need for a pediatric incontinence QoL measure evaluation was strongly endorsed by clinicians. Data from 156 child-completed questionnaires collected in 10 countries was analyzed for item characteristics and found to be free of item correlation and ceiling and floor effects. Factor analysis revealed 2 factors, which were labeled intrinsic and extrinsic. Rasch analyses showed the internal validity of both subscales was reasonable good. Cronbach's alpha for each factor was 0.91 and 0.72. After analysis, items were selected for the new tool, PinQ, and evaluated for ambiguity, clarity, comprehension level required, choice of words and phrases, and age-appropriate concepts. Twenty-one items were finally selected and randomly positioned within the tool. CONCLUSIONS: A cross-cultural tool that quantifies the holistic effect of bladder dysfunction in children has been designed and tested for validity.

Adolescent↗

Backed tools in Middle Pleistocene central Africa and their evolutionary significance.

The fashioning of stone inserts for composite tools by blunting flakes and blades is a technique usually associated with Late Pleistocene modern humans. Recent reports from two sites in south central Africa (Twin Rivers and Kalambo Falls) suggest that this backed tool technology originated in the later Middle Pleistocene with early or "archaic" Homo sapiens. This paper investigates these claims critically from the perspective of the potential mixing of Middle and Later Stone Age deposits at the two sites and the possible creation of misleading assemblages. The review shows that backed tools form a statistically minor, but technologically significant feature of the early Middle Stone Age of south central Africa. They first appear in the Lupemban industry at approximately 300 ka and remain an element of the Middle Stone Age technological repertoire of the region. Comparisons are made with early backed tool assemblages of east Africa and with the much younger Howiesons Poort industry of southern Africa. The paper concludes that Lupemban tools lack the standardization of the Howiesons Poort backed pieces, but form part of a regionally distinctive and diverse assemblage of heavy and light duty tools. Some modern-like behaviours appear to have emerged by the later Middle Pleistocene in south central Africa.

Africa↗

Non-tool-using rooks, Corvus frugilegus, solve the trap-tube problem.

The trap-tube problem is used to assess whether an individual is able to foresee the outcome of its actions. To solve the task, an animal must use a tool to push a piece of food out of a tube, which has a trap along its length. An animal may learn to avoid the trap through a rule based on associative processes, e.g. using the distance of trap or food as a cue, or by understanding relations between cause and effect. This task has been used to test physical cognition in a number of tool-using species, but never a non-tool-user. We developed an experimental design that enabled us to test non-tool-using rooks, Corvus frugilegus. Our modification of the task removed the cognitive requirements of active tool use but still allowed us to test whether rooks can solve the trap-tube problem, and if so how. Additionally, we developed two new control tasks to determine whether rooks were able to transfer knowledge to similar, but novel problems, thus revealing more about the mechanisms involved in solving the task. We found that three out of seven rooks solved the modified trap-tube problem task, showing that the ability to solve the trap-tube problem is not restricted to tool-using animals. We found no evidence that the birds solved the task using an understanding of its causal properties, given that none of the birds passed the novel transfer tasks.

Animals↗

GIS-EpiLink: a spatial search tool for linking environmental and health data.

One inherent characteristic of both environmental data and health data is that they have a location component. This characteristic makes Geographic Information Systems (GIS) an ideal and sometimes indispensable tool for analyzing environmental and health data. Indeed, the past decade witnessed significant efforts in developing GIS tools for supporting epidemiologic research. Despite these efforts, the availability of accessible GIS tools that can be easily used by epidemiologists to link environmental and health data has remained a problem. We present a simple spatial search tool--GIS-EpiLink--that can be used to link environmental and health data when distance between an environmental site and the location of the maternal address of a case or control is used as a proxy for exposure. The tool was used in a research project and it successfully provided the necessary data for epidemiological analyses. This tool should be very useful to epidemiologists in environmental health research.

Environmental Exposure↗