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PubMed2002

Prevalence of community-oriented primary care knowledge, training, and practice.

BACKGROUND AND OBJECTIVES: Recent recommendations requiring resident training in community-oriented primary care (COPC) indicate a continued interest among family medicine educators. This study examines COPC-related aspects of training and practice and whether or not respondents report COPC knowledge. The study also compares residency program and physician responses. METHODS: A total of 400 randomly selected practicing physicians and 470 residency directors were asked about COPC curricular and practice experiences. Physicians were asked if they practice COPC. Programs were asked if they taught COPC. Both were asked if they were knowledgeable about COPC. RESULTS: Response rates for practicing physicians and programs were 58.4% and 71.8%, respectively; 38.8% of programs teach COPC, and 6.7% of physicians reported that they practice COPC. Sixty-seven percent of programs and 19% of physicians reported COPC knowledge. Programs with knowledge of COPC conducted more COPC-related activities than those without such knowledge. This relationship was not seen among practicing physicians. CONCLUSIONS: Aspects of COPC exist in training and in practice environments. Knowledge about COPC is associated with differences in programs' COPC activities but not in the COPC activities of practicing physicians. Programs and physicians differ in COPC implementation in training and practice.

Clinical Competence↗

PubMed1999

Beyond the biopsychosocial model: new approaches to doctor-patient interactions.

BACKGROUND: The biopsychosocial model has been a cornerstone for the training of family physicians; however, little is known about the use of this model in community practice. This study, conducted in an urban Native American health center, examined the application of the biopsychosocial model by an experienced family physician (Dr M). METHODS: Interactions between Dr M and 9 Native Americans with type 2 diabetes were audio-recorded following preliminary interviews. Interpretations of the interactions were elicited from Dr M through interpersonal process recall and interpretive dialogue sessions. The author analyzed this data using techniques from interpretive anthropology and narrative discourse analysis. RESULTS: In a preliminary interview, Dr M described a sophisticated biopsychosocial approach to practice. However, she viewed her actual interactions with these patients as imbued with misunderstanding, mistrust, and disconnection. This occurred in spite of her experience and commitment to providing culturally sensitive primary care. CONCLUSIONS: Biopsychosocial models of disease may conflict with patient-centered approaches to communication. To overcome difficulties in her practice environment, Dr M adopted a strategy that combined an instrumental biopsychosocial approach with a utilitarian mode of knowing and interacting with patients. The misunderstandings, mistrust, and constrained interactions point to deeper problems with the way knowledge is formed in clinical practice. We need further understanding of the interrelationships between physicians' clinical environments, knowledge of patients, and theories of disease. These elements are interwoven in the physicians' patient-specific narratives that influence their interactions in primary care settings.

Adult↗

PubMed1997

Is good clinical research practice for clinical trials good clinical practice?

This article presents results of monitoring of the recruitment process for a phase III study of a new antidepressant drug in elderly patients with depressive disorders, focusing on the peculiarities of recruitment posed by the presence of comorbidity and coadministration of medications. Data are derived from screening of 188 patients, the majority of whom lived at home, referred for trial inclusion. One hundred and seventy-one (91%) had Hamilton Rating Scale score in excess of 18 and met inclusion criteria. Only eight (4.2%) elderly depressed subjects could be recruited, after application of exclusion criteria. The trial data so obtained may be scientifically credible, but the conclusions reached by trials with very stringent exclusion criteria do not reflect the practice environment in which the product will be prescribed by clinicians. This raises questions of the relevance of good clinical research practice and good clinical practice guidelines to the reality of good clinical practice beyond the trial situation.

Aged↗

PubMed2002

Challenges in home care practice: a decision-making perspective.

A qualitative approach using an ethnographic design was used to investigate the nature of clinical decision making in home care practice from home care nurses' perspective. In-depth interviews were conducted with experienced home care nurses (N = 16) in addition to observations of nurses during meetings and client visits. The findings indicate that the decision-making challenges involved in home care practice consisted of the following 4 major categories: (a) challenges that arise in the development of client-centered care plans, (b) challenges that arise from the home care practice environment, (c) challenges related to developing confidence in clinical decision making, and (d) challenges in ethical decision making. Education and practice recommendations for enhancing clinical decision making are also discussed.

Communication↗

PubMed1991

Primary care in New York State: report and recommendations of the associated medical schools of New York.

Medical education in New York is unique in the country in its scope and its diversity. It is important, as we go forward, that these strengths be neither eroded nor compromised. The AMS member institutions are making a collective commitment to work together to promote changes that will improve medical education for all students by providing them with enriched experience in primary care. Our major resource is faculty. To whatever degree medical schools can influence career choice, it is essential to this aim that the best possible people are placed in the settings in which primary care is taught. The schools will intensify their efforts to recruit and retain such faculty and, in whatever way is appropriate to each institution, provide them with the stature needed to emphasize the value which the school places on primary care. The schools will also work to provide exposure to primary care early in a student's academic career given anecdotal evidence, at least, that such early experience can influence subsequent specialty choice. Finally, the medical schools will assume greater responsibility for graduate medical education. If, with state support, ambulatory teaching sites are developed, the schools will make every effort to assure that they are staffed with high-quality faculty. Residents and students must see primary care practiced with total commitment to quality. It is hoped that, with state-initiated improvements in the practice environment, the ultimate outcome will be an increase in the number of our graduates selecting primary care disciplines for their practices and locating in areas in need of physicians.2+ Corporation, and the Greater New York Hospital Association. We are ready to work with others toward our common objectives, and we call on all of those who share these concerns to participate with us.

Career Choice↗

PubMed2005

Illuminating continuing professional education: unpacking the black box.

This paper reports on a longitudinal study of continuing professional education (CPE) in nursing using a case study approach operationalised within an illuminative evaluation model. Using a short focussed programme as an instrumental case study, the project gathered data from three major groups of stakeholders over an 18 month period in order to explore the context within which CPE operates, and to highlight those factors which appear to influence the outcomes of CPE over time. Data were collected using documentary analysis and in-depth semi-structured interviews with educators, students on the programme (the ENB 941), and their managers. The latter two groups were interviewed at four points in time (prior to the course, immediately post course, 6 and 12 months post course). Data analysis revealed that a complex set of factors interact to influence the outcomes of CPE, including the nature of the selection process, students' expectations of the programme, the nature of the educational experience, and the receptivity of the practice environment to change. This paper identifies those factors that shape the outcomes of CPE and considers their implications for policy and practice.

Attitude↗

PubMed2000

Telemedicine and pediatric surgery.

The practice of pediatric surgery has become increasingly demanding, requiring longer working hours with less reimbursement. Although manpower in this field is adequate, there are still areas that are underserved. Advances in technology offer the pediatric surgeon tools to improve efficiency of practice, cover wider areas of practice, and service underserved locations. The purpose of this report is to introduce the pediatric surgeon to telemedicine technology and its potential impact on the practice environment. The history, key components, and current applications of telemedicine are presented. The ability to integrate this technology in pediatric surgical practice holds great potential.

Child↗

PubMed2000

An assessment of the attention demands during random- and blocked-practice schedules.

The reported study used the dual-task methodology to assess the attention demands associated with high and low contextual interference (CI) practice environments. Two specific issues were addressed. First, is there a difference in the attention demands during random and blocked schedules of practice? Second, what is the time course of any differential attention demands that emerge during random and blocked training? In order to address these questions two specific temporal loci were probed during practice: a pre-response interval and the inter-trial interval. It was assumed that the pre-response interval contained the reconstructive activity that is central to the reconstruction position. In contrast, the inter-trial interval has been interpreted in previous work to be the interval in which critical intra- and inter-item processing is performed during random practice. The data revealed a typical CI effect for the primary key-pressing task. Specifically, blocked-practice participants displayed superior performance during training but performed less well than the random-practice individuals at the time of retention. The poorer acquisition performance of the random-practice participants was associated with higher cognitive demand during both the pre-response and the inter-trial intervals than that of individuals assigned to blocked practice. The greater attention demands for random-practice individuals are discussed with respect to processes that might occur in both the pre-response and the inter-trial intervals.

Adult↗

PubMed2003

Agency characteristics most valued by home care nurses: findings of a nationwide study.

The demand for home care services is continuing to rise at such a rate that the home care nursing workforce will need to double by 2020. Struggling to recruit and retain an adequate clinician supply in the midst of a severe shortage, administrators may find help in the magnet hospital approach, which focuses on creating a professional practice environment. This study identified, in a national sample of home care nurses, organizational traits reported most important in supporting nurses' professional practice and job satisfaction.

Adult↗

PubMed1992

Probing plume protection problems in the health care environment.

This paper presents pragmatic particulars pertaining to plume protection problems with special emphasis on the health care environment. Practical approaches to optimizing protection are discussed with an eye toward facilitating the safety of personnel and the general health care environment from particulates, parasites, viruses and other undesirable entities, elements and compounds.

Equipment Safety↗

PubMed1994

Who needs clinical audit?

Clinical audit focuses on self--and, more importantly, peer assessments of the performance of practitioners and the service they provide to patients. Some practitioners may feel threatened by audit; however, when conducted as intended and viewed as a form of education, it may become recognised as an integral, cost-effective element of everyday clinical practice. This article highlights ways in which practitioners may increasingly appreciate the need to understand and apply clinical audit processes in their practice environments.

Clinical Competence↗

PubMed1993

The focused use of posters for graduate education in the complex technological nursing environment.

Posters are increasingly recognised as both a method of professional communication and a strategy for learning and assessment in nurse education. Rapid technological developments in health care and the nursing practice environment are generating specific educational needs in relation to the use of technology. There is a move to incorporate within the traditional rational technical focus a broader, more comprehensive understanding of technology, technological equipment and procedures. Technological innovations are an ideal subject matter for poster presentations at the graduate level particularly as broader dimensions such as the impetus for introduction, the research base, the evaluation strategy and the cost can be incorporated. Each poster can become a teaching focus for a student presentation to classmates or other professional forums in order to catalyse discussions of these wider dimensions. A description of the use of posters for these purposes with examples and comments by participants is included.

Audiovisual Aids↗

PubMed1993

Perceptions of acute care physical therapy practice: issues for physical therapist preparation.

BACKGROUND AND PURPOSE: Acute care physical therapists have experienced the effects of dramatic changes in health care reimbursement systems and population demographics. Acute care hospitals now serve a patient population of much older, chronically ill patients who are hospitalized for shorter periods of time in a practice environment in which physical therapy staffing resources are often inadequate. The purposes of this study were to document common experiences in the practice of acute care physical therapy and to identify differences in the perceptions of physical therapists with varying levels of experience and in various sizes of acute care facilities. SUBJECTS AND METHODS: A survey questionnaire was mailed to 500 randomly selected physical therapists employed in acute care facilities. The therapists answered questions regarding the frequency of various physical therapy evaluation and treatment practices, problems encountered in delivering physical therapy services, coordination of the discharge planning process, and perceptions of staffing trends in the acute care setting. The responses of 188 physical therapists who completed the survey were compared by their experience levels and the size of the institutions in which they practiced. RESULTS: Subjects reported that patient factors, such as medical complications and cooperation; organizational factors, such as staffing shortages and large caseloads; and health care system constraints, such as difficulty changing orders and limited time in which to work with the patient interfered with patients reaching physical therapy goals. CONCLUSION AND DISCUSSION: Inadequate skills for successful acute care practice and maladaptive therapist beliefs about acute care career possibilities may adversely affect physical therapist career longevity in the acute care setting.

Acute Disease↗

PubMed1986

The prognosis for the hospital-based pathologist--Part 2.

Last month the authors diagnosed the condition of the hospital-based pathologist and prescribed a large dose of competitive activities to improve security and financial well-being. In this concluding article the complications of this treatment are examined, highlighting the issues that pathologists must resolve as they venture forth into a new practice environment.

Hospital Departments↗

PubMed1994

A comparative study of radiographic quality with five periapical techniques in general dental practice.

The use of film holders for intraoral radiography is advocated in current guidelines to British dentists. No assessment of the use of film holders has been carried out in a general dental practice environment. The aim of this study was to compare the performance of a range of film holders for periapical radiography in general dental practices in terms of the diagnostic quality of the radiographs. Twelve general dental practitioners (GDPs) were recruited to participate in the study. Each GDP was asked to perform 50 periapical radiographs using their conventional (bisecting angle) technique (BAT) followed by 50 using, in turn, four film holders: the Stabe (S), the Eggen (E), the Rinn (R) and the 'Superbite' devices (SB). Each radiograph was examined simultaneously by two assessors, scored for film faults and diagnostic acceptability. With BAT, 44.5% of radiographs were diagnostically unacceptable, while using film holders 32.8% (S), 33.7% (E), 38.2% (R) and 35.8% (SB) were unacceptable. These reductions in unacceptable films were highly significant (P < 0.01) for S and E techniques, significant (P < 0.05) for SB, while with R the reduction was not statistically significant. These results give support for the use of film holders for periapical radiography. However, their effectiveness may be improved by better manufacturers' instructions and practical training of GDPs.

Adult↗

PubMed1999

Exploring instructional quality indicators in ambulatory medical settings: an ethnographic approach.

BACKGROUND AND OBJECTIVES: As medical education moves to community settings, the quality of learning is influenced by differences in the practice environment, organization, resources, patient case mix, and demographics. This ethnographic study identified experiences and processes that influence student learning in community-based practice settings. METHODS: Trained field researchers conducted participant observation in eight community teaching sites. Data were analyzed using a qualitative, grounded theory approach. RESULTS: Three dominant themes emerged: 1) the preceptor's role in situating learning opportunities, 2) the learner's role in transforming experience into learning, and 3) the practice organization as a classroom setting. The findings highlight the importance of exploiting learning opportunities and the contributions of other medical staff and patients in facilitating unique learning experiences. CONCLUSIONS: This research suggests the need to move beyond the typical student ratings of teacher effectiveness to consider and assess additional important factors and processes that affect instructional quality.

Anthropology, Cultural↗

PubMed1994

Evidence-based care: 4. Improving performance: how can we improve the way we manage this problem? Evidence-Based Care Resource Group.

The first step in improving physician performance when there are gaps between what physicians are doing and what they should be doing is to diagnosis the causes of suboptimal care. This "diagnosis" then guides the selection of the most efficient and effective strategies to improve performance. Some behaviours may be easy to change, but the factors that cause suboptimal care often present formidable barriers. Physicians are most likely to improve their performance in these situations if they use a combination of strategies that predispose them to provide improved care, enable them to do so and reinforce these changes in behaviour. Feedback on progress is always important, to ensure that physicians adapt and to provide personal satisfaction and positive reinforcement when performance does improve. Individualized strategies are also important: there are differences in physicians' learning experiences, practice environments and needs. Therefore, each physician must tailor his or her methods for learning and improving performance to his or her individual clinical practice.

Attitude of Health Personnel↗

PubMed2000

Management of women who are Rhesus D negative in Northern Ireland.

In 1998, all 15 maternity hospitals in Northern Ireland participated in a retrospective survey of the management of pregnant women who were Rhesus D (RhD) negative. This area of clinical practice was chosen for study in the knowledge that a policy of routine antenatal prophylaxis had been proposed at the RCP/RCOG Consensus Conference, and that a change in current clinical practice was likely to follow. It was therefore felt prudent to survey critically current practice in order to collect baseline data before the introduction of new guidelines. Data were analysed on 3274 RhD negative women. The findings from this study show that current management of women who are RhD negative is suboptimal. In particular, there is poor adherence to the guidelines relating to the management of potentially sensitising events in pregnancy. Testing to assess the size of a feto-maternal bleed was often omitted, and it was therefore impossible to ascertain whether an appropriate dose of anti-D immunoglobulin had been administered. Recent publications have also identified this as an area of concern. Trauma during pregnancy was often not managed appropriately, as a potentially sensitising event. Better compliance with the current guidelines was noted when management after delivery was considered. The reasons for this apparent inconsistency should be addressed. New guidelines, recommending the use of routine antenatal prophylaxis to all women who are RhD negative, have recently been published. Providers of antenatal care will need to address this issue within the context of their own practice environment. In doing so they should be mindful of current deficits in guideline compliance which may need to be remedied, to avoid building new practices upon fragile foundations.

Journal Article↗