SEARCH · PubMed Health

Results for “practice environment”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 397 records · Page 22Linked to original sources

PubMed2006

Clinical leadership in contemporary clinical practice: implications for nursing in Australia.

BACKGROUND: Leadership in the clinical practice environment is important to ensure both optimal patient outcomes and successive generations of motivated and enthusiastic clinicians. AIM: The present paper seeks to define and describe clinical leadership and identify the facilitators and barriers to clinical leadership. We also describe strategies to develop clinical leaders in Australia. Key drivers to the development of nursing leaders are strategies that recognize and value clinical expertise. These include models of care that highlight the importance of the nursing role; evidence-based practice and measurement of clinical outcomes; strategies to empower clinicians and mechanisms to ensure participation in clinical decision-making. KEY ISSUES: Significant barriers to clinical leadership are organizational structures that preclude nurses from clinical decision making; the national shortage of nurses; fiscal constraints; absence of well evaluated models of care and trends towards less skilled clinicians. CONCLUSIONS: Systematic, strategic initiatives are required to nurture and develop clinical leaders. These strategies need to be collegial collaborations between the academic and health care sectors in order to provide a united voice for advancing the nursing profession.

Australia↗

PubMed1994

Healthcare reform and practice choices: a survey of osteopathic medical students.

Medical students are major stakeholders in the changing world of healthcare. Initiatives to change the specialty makeup and geographic distribution of the physician workforce, changes in the organization of healthcare delivery systems, and financing systems for healthcare will profoundly alter their practice environment while they are in school and just beginning to make career decisions. The decisions of osteopathic medical students, who currently make up 30% of the profession, will shape the profession's response to the new initiatives and determine its place in emerging healthcare systems. The authors surveyed first- and second-year osteopathic medical students to ascertain their perceived knowledge, opinions, and intentions as they relate to healthcare reform. They discovered that increasing numbers of students intend to practice in primary care fields. The student respondents support some of the major changes proposed by reformers in greater numbers than physicians as a whole, and have different priorities that they would like to see addressed in reform. This study reveals links between respondents' intentions to practice primary care and support for specific reform items, but the results show no link between anticipated indebtedness and respondents' intentions to enter primary care or specialty fields. The authors conclude that healthcare reform, although still in debate, has already exerted an influence on the decision-making processes of medical students.

Attitude↗

PubMed1989

Comparison of criteria derived by government and patients for evaluating general practitioner services.

A study was carried out to see whether patients' criteria of good health care in general practice were different from those of the government and doctors. A total of 711 patients in a semirural group practice evaluated the importance of 20 criteria describing different facets of care. Half the criteria were derived from Promoting Better Health (health education, easy to change doctors, all children vaccinated, health checks for adults and children under 5, regular screening for cancer, woman doctor available, doctor goes on courses, well decorated premises, convenient surgery times); the other 10 were taken from a preliminary interview study of 24 patients (staff friendly and know me, doctor listens and sorts out problems, same doctor for consultations, nurse on premises, appointments available within 48 hours, waiting time less than 20 minutes, small surgery premises, tests available at surgery). Questionnaires containing 10 pairs of criteria assigned by computer were drawn up and patients asked to give their preference in each pair. The number of times each criterion was preferred was scored and its comparative importance ranked. The three criteria most highly ranked by all patients were having a doctor who listens, having a doctor who sorts out problems, and usually seeing the same doctor (all criteria originated by patients). The three least highly valued were health education, being able to change doctor easily, and well decorated and convenient premises (all criteria originated by the government). The criteria originated by patients as a group scored significantly more highly than those originated by government as a group. In a more competitive general practice environment, in which doctors will be more inclined to satisfy the wishes of patients, officially supported indicators of good quality care might not get the encouragement that the government and doctors think that they deserve.

Adult↗

PubMed1999

Decreasing supply of family physicians and general practitioners. Serious implications for the future.

OBJECTIVE: To document a decrease in the supply of family physicians (FPs) and general practitioners among Canadian graduates of medical schools since rotating internships ceased to serve as a route to national licensure. DESIGN: Review of data from the Association of Canadian Medical Colleges, the Canadian Post-M.D. Education Registry, and the Canadian Institute for Health Information to track final training fields and eventual types of practice of graduates of Canadian faculties of medicine from 1987 to 1997. SETTING: Canadian faculties of medicine and residency training programs. MAIN OUTCOME MEASURES: Number of Canadian medical graduates entering family medicine training programs from 1991 to 1998, number of Canadian graduate physicians exiting from these training programs, and proportion of each graduating class (1987 to 1994) practising as FPs or GPs in Canada in 1997. RESULTS: In 1993, 890 physicians (51% of graduates) were trained as FPs or GPs. By 1994, although the proportion remained at 40%, the number of Canadian graduates entering family medicine had dropped to 646, and by 1998, to 619. CONCLUSIONS: A deficit of FPs is already noticeable in the practice environment. For the way in which medical care is delivered in Canada, with FPs serving as first contact for patients, the authors conclude that the number of graduating FPs in Canada will not be sufficient to provide the primary care services Canadians need.

Canada↗

PubMed1977

Effective patient scheduling.

Patient appointments and scheduling of patients and physicians are the first step in any health-care delivery system. This paper deals with the conventional method usually found in preprinted appointment books, and the "wave" method. A method of testing this system is any practice environment is described, together with the comparative benefits of the wave method over the conventional method of scheduling. This paper also exemplifies one kind of research that can be accomplished in the private, ambulatory sector of medicine.

Appointments and Schedules↗

PubMed1991

Evaluation of a hygiene monitor for detection of contamination in dental surgeries.

Routines for disinfecting working surfaces in dental surgeries are difficult to monitor without time-consuming and labour-intensive microbiological techniques, yet effective monitoring is a vital part of cross-infection control. Easy to use, on-site methods would be valuable in this context. This study evaluates a portable monitor, the Biotrace Hygiene Monitor, which uses bioluminescence to measure adenosine triphosphate (ATP) on surfaces. Under laboratory conditions, the ability of the monitor to detect whole saliva and Streptococcus sanguis was determined and, in the general practice environment, the level of ATP on surfaces in five dental surgeries was assessed. The minimum amount of saliva detectable was 0.5 microliters and in surgeries, the monitor readily identified numerous surfaces with fairly high levels of ATP. Routine cleaning methods sometimes left ATP on surfaces at levels which represented a cross-infection risk, if it is assumed that the ATP derived from patients' saliva. Modification of cleaning methods resulted in a reduction of ATP levels to within that which could be considered reasonably practicably safe. It is concluded that the Biotrace Hygiene Monitor offers a simple and valuable means of monitoring dental practice cleaning routines.

Adenosine Triphosphate↗

PubMed2000

Gender and age bias in triage decisions.

INTRODUCTION: Recently it has been recognized that women are less likely than men to be diagnosed with a myocardial infarction (MI) or to receive early or aggressive treatment and are more likely than men to die of an MI. The purpose of this qualitative study was to examine the triage decisions made by ED nurses for persons with symptoms suggestive of MI. The theoretical framework for this investigation was Hammond's lens model for clinical inference and Evan's two-stage reasoning model. METHOD: Four focus group sessions were conducted. The participant's oral descriptions were tape-recorded, transcribed verbatim, and analyzed using the Krueger method. RESULTS: Content analysis revealed several important issues influencing triage decisions: patient presentation, nursing knowledge and experience, practice environment, intuition, the fear of liability, and gender-specific behaviors. ED nurses held different perceptions regarding the significance and likelihood of MI for male and female patients seeking evaluation and treatment. In addition, ED nurses admitted that MI is not the first diagnosis considered for middle-aged women. DISCUSSION: The inability of ED nurses to associate middle-aged women's presenting symptoms with MI may contribute to the increased morbidity and mortality experienced by this population. The findings of this study have implications for nursing research, education, and practice.

Adult↗

PubMed2005

Designing and implementing an electronic health record system in primary care practice in sub-Saharan Africa: a case study from Cameroon.

OBJECTIVE: To review the key issues related to the design and implementation of an electronic health record (EHR) system in urban primary health care (PHC) practice in Cameroon. METHODOLOGY: The goal of the project was to assess EHR as a tool to improve providers' performance, quality and continuity of care, and the availability of data in PHC practice in Cameroon. A locally designed EHR system called MEDCAB was developed. The system was based on the International Classification for Primary Care (ICPC) and was designed taking into consideration the PHC practice environment in Cameroon. An original cohort of 14 users was involved in the experiment. RESULTS: Users generally showed good acceptance of the system. Monitoring the use of the system at the early stages of implementation was important to ensure immediate response to users' comments and requests. Some of the key issues identified during the development and implementation of the system were: user involvement, the choice of an appropriate terminology, pre-existing data collection culture and leadership issues. Some positive achievements brought about by the system included promotion of good medical practice and routine availability of consultation data. CONCLUSION: Strengthening the medical record in general, and the EHR in particular, could contribute to its position as a valuable source of information for healthcare delivery, public health and policy making in Cameroon. Challenges to adoption are huge and successful implementation for any specific setting will require a comprehensive modelling of the local medical practice, the choice of an appropriate terminology and a co-ordinated approach involving all stakeholders.

Africa South of the Sahara↗

PubMed1993

The doctor is in.

The growing trend toward an overproduction of specialists and an underproduction of generalists (i.e., family physicians, general internists, and general pediatricians) in the United States has prompted many in medicine and academic medicine to endorse the goal that 50% of the United States's physician graduates should be generalists. The author discusses (1) the definition of the term generalist; (2) the number of generalists presently being produced (as estimated by three methods) and why the 50% goal is an informed and reasonable one; (3) changes needed in graduate medical education of the three main categories of generalist physicians; (4) changes needed in medical education; (5) changes needed in the practice environment; and (6) overall implementation strategies and the question of how much the federal government or some central authority should be involved. He concludes by reflecting that the 50% goal is worthwhile, although challenging, and that it is better to have a goal--even if it is not met--then to have no goal at all.

Education, Medical, Graduate↗

PubMed2004

Changing the use of electronic fetal monitoring and labor support: a case study of barriers and facilitators.

BACKGROUND: Decreasing the use of continuous electronic fetal monitoring and increasing professional labor support for low-risk pregnancies are recommended by the Society of Obstetricians and Gynecologists of Canada. This study explored factors influencing the successful (and unsuccessful) introduction of an evidence-based fetal health surveillance guideline. METHODS: This qualitative case study was conducted at two tertiary and one community hospital. Data were collected in 14 clinician focus groups (51 nurses), followed by 8 interviews with nurse administrators and educators. Analysis of verbatim transcripts and unit records included coding and categorizing data to form profiles that were compared across hospitals. RESULTS: Implementation of the guideline recommendations in the hospital settings was affected by many different factors originating in the practice environment, with the potential adopters, and related to the characteristics of the guideline. The influences of these diverse factors interacted sometimes to magnify or counteract each other's effect. The physical setting, adopter concerns, and the medicolegal issues surrounding the guideline played critical roles in uptake. In addition, changes preceding the introduction of the recommendations, the institution's agenda, and nursing and medical leadership influenced the uptake of guideline recommendations. The number and experience of nurses in each setting and availability of equipment also affected guideline acceptance and use. CONCLUSIONS: When implementing best practice, it is important to identify organizational barriers to the change that will need managing by the appropriate level of administration in the organization. Careful tailoring of implementation interventions to the barriers originating with the potential adopters is also necessary. Be prepared for unanticipated effects.

Communication Barriers↗

PubMed1994

Primary care physician turnover in HMOs.

OBJECTIVE: We assess whether physician turnover stems from incorrect physician expectations about the practice environment or from actual constraints or rewards in that environment. DATA SOURCES: Our primary data source contains information about individual HMOs' primary care physicians incentive mechanisms and general HMO characteristics. Our secondary data source is the area resource file (ARF), which contains countywide information about the HMOs' market areas, including physician characteristics, population characteristics, and other market characteristics. DATA COLLECTION: Our primary data source is from a nationwide survey of all HMOs in operation in 1987-1988, as reported to Interstudy. PRINCIPAL FINDINGS: We find that turnover is higher on the part of physicians whose HMO enrollment comprises a greater percentage of their total practice. Our results further indicate that physicians whose compensation is dependent on the behavior of a group of other physicians are more likely to leave the plan than those who bear the risk (and control it) more directly. On the other hand, turnover is increased by basing bonuses on individual productivity and by not sharing surpluses among a group. Market characteristics also are significant in explaining physician turnover in HMOs. CONCLUSIONS: It appears that physicians accurately forecast how they will react to individual financial risk, although they dislike restrictions imposed by HMOs.

Attitude of Health Personnel↗

PubMed2004

Information technologies: when will they make it into physicians' black bags?

CONTEXT: Physicians in the United States are only slowly adopting information technology (IT) tools, despite studies demonstrating their clinical benefits. More is known about IT use within institutional settings than by individual physicians. OBJECTIVES: This study investigates physicians' current use of, future plans for, and perceived barriers to adopting electronic medical records (EMRs), computerized prescribing and order entry, clinical decision support systems, and electronic communication (email) with other physicians and with patients. DESIGN: Self-administered mail surveys were completed between March and May 2003 among a national random sample of physicians involved in direct patient care of adults. A total of 1837 surveys were returned for a response rate of 52.8%. RESULTS: Physicians most commonly use IT for billing. For clinical management, the most common tool is computerized access to laboratory results (59%). Other tools are less prevalent: Twenty-seven percent of respondents use EMRs routinely or occasionally; 27% prescribe or order tests electronically; and 12% receive electronic alerts about potential drug-prescribing problems. Only 24% of surveyed physicians practice in a "high-tech" office setting. Physicians in groups of 50 or more are significantly more likely to use any IT tools and to practice in a high-tech office, as compared with physicians in solo practice (odds ratio = 7.7). The top 3 barriers to adoption of IT are start-up costs (56%), lack of uniform standards (44%), and lack of time (39%). CONCLUSION: Most physicians do not use EMRs and related technologies. Adoption is uneven, and a technologic divide exists between physicians depending on their practice environment and mode of compensation. Cost remains the most important barrier to adoption. Attention needs to be focused on policies and business models that will make IT tools accessible and affordable to all physicians.

Decision Support Systems, Clinical↗

PubMed2005

Best practice in occupational therapy: program characteristics that influence vocational outcomes for people with serious mental illnesses.

BACKGROUND: Despite the known benefits of work for people with mental illnesses, vocational outcomes of this group remain poor. Attempts at comparing the efficacy of various models of service delivery have met with limited success due to variations across studies. PURPOSE: The purpose of this paper is to provide information about key characteristics related to outcomes in the field of vocational rehabilitation for people with serious mental illnesses. METHOD: A comprehensive review of literature published between 1990 and 2003 was conducted, resulting in 39 articles for analysis. RESULTS: A set of twelve characteristics was identified that appear to influence vocational outcomes across models. These characteristics relate to the types of services offered, the manner in which services are delivered, and the work environment. PRACTICE IMPLICATIONS: The authors suggest these characteristics can be incorporated across models and practice settings. The findings are discussed in terms of implications for best practice in occupational therapy.

Humans↗

PubMed2001

HIV prevention in primary care: impact of a clinical intervention.

Discomfort, lack of confidence in skills, and environmental constraints may cause primary care providers to miss opportunities to discuss human immunodeficiency virus (HIV) risk with patients. We used a systems approach to address both intrapersonal and environmental barriers to HIV risk assessment and prevention counseling in a managed care clinical setting. The design was one-group pretest/posttest. The study took place in two primary care clinics of a large Pacific Northwest managed care organization. Participants (n = 49) included physicians, physician assistants, nurse practitioners, registered nurses, and social workers. The intervention included training, clarification of provider/staff roles, assess to tools and materials, and reminders/reinforcers. Outcome measures were provider attitudes, beliefs, outcome expectations, knowledge, confidence in skills, and perceived supports and barriers, measured by written pretest/posttest surveys administered 12 months apart. Seven months after the most intensive part of the intervention, providers' attitudes and beliefs were more favorable to HIV risk assessment and prevention counseling. They were less likely to express frustration with high-risk patients (decrease from 100% to 79% agreement, p = 0.001) and more confident that their advice would be effective with gay men and single adult heterosexuals (p = 0.002 and 0.005, respectively). They reported more confidence in their training in sexual history taking (p = 0.0003) and their skills assessing readiness for change (p = 0.007), and more support in practice environments. This study demonstrated that it is possible to affect important personal and environmental factors that influence primary care providers' HIV prevention behavior using an interactive, real-world systems approach. Further research is needed on providers' impact on patient behavior.

Adult↗

PubMed2004

Medical professionalism and continuing professional development for medical specialists.

The present paper briefly describes a growing trend in continuing professional development (CPD) for medical practitioners, examines some recent published contributions related to professionalism in medicine and describes the theoretical platform of a CPD framework based on medical professionalism that has been developed for use in a variety of medical specialties. The work arises from a project funded by The Commonwealth Department of Health and Ageing and conducted by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists on behalf of the Committee of Presidents of Medical Colleges. Overall, the aim of the project was to design and develop a framework that can be considered 'best practice' in the field of medical specialist CPD, and which could be applicable to a wide variety of medical specialties and practice environments. The project was informed by available literature in areas such as the ways in which medical practitioners learn and the effectiveness of CPD, as well as consultations with a variety of stakeholders in the health-care field, including medical boards, medical defence organisations, health complaints organisations, specialist medical colleges and practising specialists. Overwhelmingly, the primary purpose of specialists participating in ongoing CPD was, according to the project consultations conducted, the maintenance, development and improvement of skills that enable consumers of healthcare to be confident of the level of care that they receive. Coupled with the need to recognise CPD as contributing to the wider context of professional practice, the resulting framework is underpinned by a theoretical platform based on the concept of medical professionalism. It is this theoretical platform, which articulates the nature of and responsibilities associated with the practice of specialist medicine, that enables a CPD framework to be constructed that can accommodate a wide range of specialist disciplines and practice settings, while also framing ongoing education expectations from the viewpoint of a range of stakeholders, rather than a single perspective; that of practitioners themselves.

Australia↗

PubMed2005

Changing habits of practice. Transforming internal medicine residency education in ambulatory settings.

PURPOSE: The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change. METHODS: The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance. RESULTS: Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education. CONCLUSION: This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.

Ambulatory Care↗

PubMed1998

International comparisons of professional assessments in orthodontics: Part 2--treatment outcome.

The opinion of 97 orthodontists in 9 countries has been surveyed with respect to the judgment of treatment outcome. Ninety-eight pretreatment and posttreatment study casts were examined by each orthodontist who gave a judgment of the degree of improvement and whether they thought the result was acceptable. It was found that there was at least 80% agreement on the acceptability of the outcome for only 45.5% of the sample. Logistic regression was used to identify predictive indicators for the judgment of acceptance. It was found that the posttreatment scores for dental esthetics, crossbite, buccal segment sagittal relation, lower arch crowding, centerline, and left and right buccal segment vertical relationship were most important predictor variables. These six traits correctly assigned the decision with 70% accuracy. The judgment of outcome did not seem to take account of the treatment complexity as judged by the practitioners. It was also found that judgments are significantly affected by the country and payment methods, practice environment, and experience of the practitioner. The occlusal traits identified can be usefully incorporated into a index for assessing both treatment need and outcome, and may serve the purposes for audit and research in orthodontics.

Attitude of Health Personnel↗

PubMed2000

The Texas Children's Medication Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part II: Tactics. Attention-Deficit/Hyperactivity Disorder.

OBJECTIVES: Expert consensus methodology was used to develop a medication treatment algorithm for attention-deficit/hyperactivity disorder (ADHD). The algorithm broadly outlined the choice of medication for ADHD and some of its most common comorbid conditions. Specific tactical recommendations were developed with regard to medication dosage, assessment of drug response, management of side effects, and long-term medication management. METHOD: The consensus conference of academic clinicians and researchers, practicing clinicians, administrators, consumers, and families developed evidence-based tactics for the pharmacotherapy of childhood ADHD and its common comorbid disorders. The panel discussed specifics of treatment of ADHD and its comorbid conditions with stimulants, antidepressants, mood stabilizers, alpha-agonists, and (when appropriate) antipsychotics. RESULTS: Specific tactics for the use of each of the above agents are outlined. The tactics are designed to be practical for implementation in the public mental health sector, but they may have utility in many practice settings, including the private practice environment. CONCLUSIONS: Tactics for psychopharmacological management of ADHD can be developed with consensus.

Adrenergic alpha-Agonists↗