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PubMed2004

The discipline of improvement: something old, something new?

In response to calls to improve the efficacy of health care services, there is an increasing focus on the processes of achieving a continuous improvement of services and practices. One specific response is that of the NHS Modernization Agency and National Health Service University in relation to the Discipline of Improvement in Health and Social Care. This paper draws on a study that explored the underpinning knowledge base of the Discipline of Improvement and focuses on describing the framework that was developed. The two-dimensional framework is composed of five primary categories, which cross-link to 11 competencies. The study concludes that the Discipline of Improvement draws together a group of ideas that together cohere to form a distinctive model to aid the improvement of health care. While some of these ideas are well-established, the way in which the Discipline of Improvement makes connections between them offers something new to our understanding of change in the complex world of health care provision, and to nursing management.

Benchmarking↗
PubMed2001

Student outcomes of the healing web: evaluation of a transformative model for nursing education.

The Healing Web is a transformative nursing model, bridging gaps between nursing education and practice, baccalaureate and associate degree education, and public and private educational institutions. It is an educational prototype in which nursing students experience collaborative clinical practice in a differentiated practice model. Based on the Healing Web framework, it was hypothesized that the educational partnership model would influence specific student competencies (i.e., caring abilities, leadership skills, assertiveness, and professional nursing behaviors). Students in the Healing Web program scored higher in caring knowing, caring courage, leadership, and assertiveness than their counterparts who participated in traditional clinical experiences. Students identified collaboration, partnership with students and staff, and learning to value different nursing roles as primary benefits of the experience. Findings support the contribution of Healing Web experiences to selected student outcomes, but the research is limited by instrumentation, small numbers, and the question of adequate "dosage." Future research will emphasize qualitative methods to explicate significant concepts more completely.

Analysis of Variance↗
PubMed1995

Literature and medicine: contributions to clinical practice.

Introduced to U.S. medical schools in 1972, the field of literature and medicine contributes methods and texts that help physicians develop skills in the human dimensions of medical practice. Five broad goals are met by including the study of literature in medical education: 1) Literary accounts of illness can teach physicians concrete and powerful lessons about the lives of sick people; 2) great works of fiction about medicine enable physicians to recognize the power and implications of what they do; 3) through the study of narrative, the physician can better understand patients' stories of sickness and his or her own personal stake in medical practice; 4) literary study contributes to physicians' expertise in narrative ethics; and 5) literary theory offers new perspectives on the work and the genres of medicine. Particular texts and methods have been found to be well suited to the fulfillment of each of these goals. Chosen from the traditional literary canon and from among the works of contemporary and culturally diverse writers, novels, short stories, poetry, and drama can convey both the concrete particularity and the metaphorical richness of the predicaments of sick people and the challenges and rewards offered to their physicians. In more than 20 years of teaching literature to medical students and physicians, practitioners of literature and medicine have clarified its conceptual frameworks and have identified the means by which its studies strengthen the human competencies of doctoring, which are a central feature of the art of medicine.

Clinical Medicine↗
PubMed2006

Who is maintaining certification in internal medicine--and why? A national survey 10 years after initial certification.

BACKGROUND: The American Board of Medical Specialties (ABMS) adopted a framework, called Maintenance of Certification (MOC), for all certifying boards to evaluate physicians' competence throughout their careers, with the goal of improving the quality of health care. The MOC participation rates of the American Board of Internal Medicine (ABIM) show that 23% of general internists and 14% of subspecialists choose not to renew their respective certificates. OBJECTIVE: To study U.S. internists' perceptions about the forces driving them to maintain certification. DESIGN: Mail survey. SETTING: A nationally representative sample of certified internists in the United States. PARTICIPANTS: Physicians originally certified in internal medicine, a subspecialty, or an area of added qualifications in 1990, 1991, or 1992. RESULTS: The overall rate of response to the survey was 51%. Although 91% of all participants are still working in internal medicine or its subspecialties, this percentage is notably lower among general internists (79%). Of those still working in the field of internal medicine or its subspecialties, approximately half report being required to maintain their specialty certificate by at least 1 employer, but only approximately one third of those who completed or enrolled in MOC report this requirement as a reason for participating. Those who completed or enrolled in MOC do so more for positive professional reasons than for monetary benefits or professional advancement. The most common reasons for not participating are the perceptions that it takes too much time, is too expensive, and is not required for employment. LIMITATIONS: Respondents were volunteers from an early cohort of diplomates entering the program, and those with less positive attitudes may have responded at higher rates. Results are based on self-reported data, and misconceptions about program requirements may have led to some inaccurate responses. CONCLUSIONS: The relatively large percentage of general internists who left internal medicine mostly to work in another medical field explains why rates of MOC participation for general internists seem lower than those for subspecialists (77% vs. 86%). Although positive professional reasons clearly have a compelling internal influence on program participation, it is less clear whether employers' requirements are an equally compelling external influence. Although half of all respondents report that MOC is required by 1 of their employers, only one third of those who participate in the program describe it as a reason for participating.

Attitude of Health Personnel↗
PubMed2001

Knowledge integration: insight through the E-portal.

Data become information when they can be summarized and organized into logical patterns; information becomes knowledge when it can be manipulated for actionable decision making; knowledge becomes insight when contextually relevant and temporarily appropriate. This article describes how information technology can now be used to provide clinicians with access to both insight and information that is context- and event-sensitive. Collaboration between the American College of Physicians, medical knowledge experts, Oregon Health Sciences University (OHSU), and shared medical systems for framework and infrastructure combine to create the ideal environment of complementary and synergistic competencies. This article describes the research that is under way at OHSU to determine how to deploy medical knowledge derived from these sources and integrate it into the clinical workflow; it also examines a vision of how medical knowledge can be integrated in the future.

Education, Medical, Continuing↗
PubMedDate not supplied

Sharp debridement: the need for training and education.

Until recently there has been a lack of courses demonstrating how to undertake sharp debridement. The clinical governance framework has highlighted that nurses frequently perform the procedure without having received formal education and training (Fairbairn et al, 2002). Clinical governance, which includes risk management, clinical audit and evidence-based practice, aims to help all clinicians to improve quality and safeguard standards of care. The framework seeks to ensure that health professionals have the right training, skills and competencies to deliver the care needed by patients.

Clinical Competence↗
PubMed2003

Teaching practical procedures in general practice. A primer for supervisors of medical students and registrars.

BACKGROUND: Practical procedures are central to many general practitioners' job satisfaction and their ability to provide comprehensive care. Despite this, students lack opportunities to learn skills and fewer GPs perform them. OBJECTIVE: This article develops a framework for teaching practical skills and their assessment in general practice. DISCUSSION: True competence means more than performing a task in isolation: knowledge, skills and attitudes are needed to perform in the workplace. Teaching should be closely related to assessment in general practice. A four stage method of instruction can facilitate learning of task skills. This should be followed by a series of case discussions, scenarios or simulations to teach and assess the learners' ability to manage tasks in the work environment. Linking teaching, assessment and feedback is integral to improving learning opportunities in general practice.

Clinical Competence↗
PubMed1994

Intelligent diagnostic monitoring using trend templates.

In previous work we have defined our trend template epistemology for clinically significant trends and we have illustrated and tested a program TrenDx that monitors time-ordered process data by matching the data to trend templates. Our initial application domain was pediatric growth monitoring. In continuing work we have explored monitoring hemodynamic and respiratory parameters of intensive care unit patients. This application has highlighted the needs for advances in our representation and monitoring algorithms. In particular, we have added reasoning with uncertainty to the trend template epistemology, and a new control structure allowing numerical ranking of competing trend templates. Furthermore, intelligent monitoring in any medical domain requires a coherent framework for diagnostic monitoring. In this paper we show how TrenDx can be extended to a framework including sending alarms, changing clinical context, and filtering data streams.

Diagnosis, Computer-Assisted↗
PubMed1999

The day the lights went out: one charge nurse's nightmare.

The synergy model can be applied to many clinical situations. As nursing leaders evolve, competencies required to effectively respond to unexpected events silently develop. Applying the Synergy Model to this exemplar helped to articulate the charge nursing's leadership in ensuring a safe practice environment. The model provides a framework to more fully describe the multiple dimensions of a charge nurse's role, and acknowledges the richness of knowledge and competence that charge nurses often contribute to complex clinical situations.

Adaptation, Psychological↗
PubMed1987

Three applications of the Role Delineation Project 1985 Curriculum Framework.

Colleges are beginning to use the Role Delineation Project Curriculum Framework for curricular reform at the graduate and undergraduate levels. This paper describes the efforts of three universities to revise their curricula based on the Framework. At Towson State University, it is being used with other national and state standards to assess health educators. At the University of Alabama at Birmingham, it provided the structure by which the faculty determined the competence of exiting health majors. At the University of Georgia, it was used in strategic planning and graduate education restructuring. The Framework, while lacking material in certain professional development areas, provides the structure for departments to begin the process of health education curricula reform.

Curriculum↗
PubMedDate not supplied

Guns and dolls: an exploration of violent behavior in girls.

As demonstrated by several studies, there is an increase in levels of female violence. This study attempts to more fully understand the increasing phenomenon of violence in girls by exploring motivations to engage in violent behavior. The hypothesis that a girl's perceived sense of competence is influenced by social and environmental variables that motivate her to engage in violent behavior is tested. Research studies of female adolescent violence have focused on the study of risk factors predisposing the individual to violent behavior. This study uses a health behavior framework (C.L. Cox, Advances in Nursing Science, October 1982, 41-56) to explore the links between perceived sense of competence and both the risk and protective factors that motivate girls to act violently.

Adaptation, Psychological↗
PubMed1974

Clinical studies on a transformation test for identification of Acinetobacter (Mima and Herellea).

Deoxyribonucleic acid (DNA) from 250 strains of aerobic, nonfermentative, gram-negative coccobacilli and rods were tested for the ability to transform a stable competent auxotroph of Acinetobacter (strain trp E 27) to prototrophy by using the method established by Juni. Several modifications of Juni's original procedure were made to adapt it for use in a clinical diagnostic laboratory. These modifications were directed primarily towards shortening the procedure to allow completion in a time framework consistent with current procedures. The modifications included changes in sterilization temperature, incubation time and temperature of the competent auxotroph and DNA preparation, overnight incubation temperature, and variations in the age of the auxotroph culture when used. Under these conditions, the transformation can easily be performed in 24 h, the final 16 to 18 h being an overnight uninterrupted incubation period. When used in conjunction with the glucose oxidative fermentative basal metabolism test, it provided a rapid highly efficient means for grouping and identifying acinetobacters which is far superior to a biochemical schema. Without exception, the 141 strains of DNA from Acinetobacter species were able to transform the auxotroph to prototrophy. None of the 105 oxidase-positive nonfermenters possessed DNA which was able to transform the Acinetobacter auxotroph to prototrophy.

Acinetobacter↗
PubMedDate not supplied

Where to look? Automating attending behaviors of virtual human characters.

This research proposes a computational framework for generating visual attending behavior in an embodied simulated human agent. Such behaviors directly control eye and head motions, and guide other actions such as locomotion and reach. The implementation of these concepts, referred to as the AVA, draws on empirical and qualitative observations known from psychology, human factors and computer vision. Deliberate behaviors, the analogs of scanpaths in visual psychology, compete with involuntary attention capture and lapses into idling or free viewing. Insights provided by implementing this framework are: a defined set of parameters that impact the observable effects of attention, a defined vocabulary of looking behaviors for certain motor and cognitive activity, a defined hierarchy of three levels of eye behavior (endogenous, exogenous and idling) and a proposed method of how these types interact.

Attention↗
PubMed2000

Technological competence as a fundamental structure of learning in critical care nursing: a phenomenological study.

Post-registration education programmes are frequently informed by nationally agreed curriculum frameworks. Although these aim to promote comparability between similarly focused clinical courses, inconsistencies have recently been identified across a range of critical care curricula. This suggests that broad-based frameworks may be insufficiently sensitive to local learning needs. This study was concerned with the extent to which the curriculum met the learning needs of 10 post-registration critical care students and, in particular, aimed to explore the meaning of learning to the students themselves. The study revealed technological competence to be a necessary foundation to the development of clinical practice and this is discussed from a philosophical perspective which allows the nature of contemporary nursing practice to be reconceptualized. It is argued that curriculum development for clinically based, post-registration courses can be constructively informed by local consultation and that phenomenological study can complement more traditional approaches often relied upon in educational research.

Clinical Competence↗
PubMed2002

Conceiving harm: disability discrimination in assisted reproductive technologies.

Applying the Americans with Disabilities Act (ADA) to denials of treatment by assisted reproductive technology (ART) practitioners raises particularly challenging legal and ethical issues. On the one hand, the danger that physicians will inappropriately deny treatment to patients with disabilities is especially worrisome in the context of ARTs, given the widespread stigma associated with reproduction by individuals with disabilities. On the other hand, patients' disabilities may sometimes have potentially devastating implications for any child resulting from treatment, including the possibility that the child will be born with life-threatening or seriously debilitating impairments. Some physicians have strong ethical objections to helping patients become pregnant in the face of such risks. In this Article, Professor Coleman develops a framework for applying the ADA to disability-based denials of ARTs that addresses these competing considerations. In recognizing risks to the future child as a potential defense to a disability discrimination claim, Professor Coleman rejects the view of some commentators that such risks are relevant to reproductive decisions only if the child is likely to suffer so much that he or she would prefer not to exist. Instead, he proposes that, when a patient's disabilities create significant risks to the future child, the question should not be whether the child's life is likely to be so awful that nonexistence would be preferable, but how the risks and benefits of the requested treatment compare to those associated with other available reproductive and parenting options. Professor Coleman provides a theoretical justification for adopting this comparative framework, and examines how ADA precedents developed in other contexts should be applied to decisions about ARTs.

Persons with Disabilities↗