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Executive competencies in healthcare administration: preceptors of the Army-Baylor University Graduate Program.

The purpose of this research was to identify the mentoring and executive competencies required among preceptors of the Army-Baylor University Graduate Program in Health and Business Administration, and to specify the requisite skills, knowledge, and abilities (SKAs) needed to achieve those competencies. In the first wave of inquiry, a list of 123 competencies and associated SKAs was elicited from a network of 80 current and past preceptor executives employing a Delphi methodology using e-mail. An expert panel, which consisted of seven past program directors, examined and sorted the list into four preceptor content domains, viz., Health Systems Management (HS Management), Leadership, Residency Administration, and Community Involvement. Frequency analyses showed that the HS Management domain constituted over half of the competencies, with particular emphasis on strategic thinking, planning, billing, finance, manpower, and contracting. In the second wave, the preceptor Delphi network reviewed the expertpanel list and made 7-pointSKA importance ratings on an 80-item structured questionnaire representative of the four domains. Findings indicated thataverage SKA ratings were reliable and agreed upon to a high degree among preceptors. Results, rank ordered by SKA item means within preceptor content domains and overall, suggested that the most important rated items centered on teamwork, negotiation, interpersonal skills, communication, leadership vision, and customer and healthcare business operations. Outcomes from the competency list are expected to be useful for preceptor mentoring, self-assessment, and for professional development. Additionally, specific SKAs can provide a means for developing job requirements and career performance criteria at a behavioral task level, and can contribute information for identifying continuing education and conference topical needs.

Competency-Based Education↗

Development and validation of diagnostic criteria for carpal tunnel syndrome.

PURPOSE: To develop clinical diagnostic criteria for carpal tunnel syndrome (CTS) that modeled the clinical diagnostic practices of experts. METHODS: Fifty-seven clinical findings associated with CTS had been ranked previously in order of diagnostic importance using Delphi as a method of establishing consensus among a panel of expert clinicians. The 8 most highly ranked criteria then were placed into all possible combinations to create 256 unique case histories. Two new panels of experts rated these case histories. One panel made a binary evaluation as to whether the case history did or did not represent CTS. This allowed the development of a logistic regression model that had the probability of carpal tunnel syndrome as the dependent variable and the weighted diagnostic criteria as the independent variables. This model then was validated against the judgments of the second panel of clinicians who estimated the probability of CTS for each of the same case histories. RESULTS: The correlation between the probability of CTS predicted by the model and the panel of clinicians was 0.71. CONCLUSIONS: The most important clinical diagnostic criteria for CTS as identified from a larger pool of potential diagnostic items through a consensus approach using Delphi were weighted and found to correlate well with the judgments of a new panel of clinicians. By improving the consistency of the diagnosis of CTS these criteria should lead to more effective treatment and a better understanding of the effect of workplace exposures in the development of this condition. A methodology that emphasizes a rigorous approach to item generation and item reduction through expert consensus, followed by validation, may represent a template for establishing consensus among experts on other controversial clinical issues. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic, Level I.

Carpal Tunnel Syndrome↗

[Personality disorders in the elderly: diagnostic aspects].

This article describes the usefulness of the DSM personality disorders. In conclusion the presence of personality disorders during a lifetime is not always an enduring pattern of (the same) conduct disorders. Despite this, the DSM describes a static course of mainly interpersonal behaviour. Next to this, the utility of the DSM-Axis-II assessment and general personality assessment in relation to older adults will be discussed. In general these instruments are not very suitable for the assessment of the disposition and gravity of personality disorders in the elderly. It is proposed to develop specific profiles with regard to personality disorders in the elderly by applying the Delphi-technique on existing personality assessment. A Delphi panel of experts in the field of personality pathology in older adults can be asked to mention a certain personality disorder and describe this on a certain personality selfreport list, like the shortened version of the TCI.

Aged↗

Consumer-centered nursing with ICT: A futuristic viewpoint.

The purpose of this paper is to describe the views of health care and information technology professionals and patients about the future use and scenarios of information and communication technologies (ICT) in nursing practice. The perspective was set at the year 2010. The Delphi method was used, and the data were gathered during the years 2001 and 2002 with three Delphi rounds from a Finnish expert panel (N = 81). The experts consisted of clinical nurses, clinical nurse managers, nurse educators, professionals of development, research and information technology and patients. The data were gathered and analysed with qualitative and quantitative methods. The use of ICT was observed from the viewpoints of probability and desirability. The experts agreed more often about the desirability than the probability of the use of ICT. Three future nursing scenarios were outlined based on the results: nursing knowledge management and development, patient orientation and self-care, and technology vs. the human being. The scenarios will be take-off points for development in nursing practice and education.

Delphi Technique↗

Promotion criteria for family practice residents: perceptions of program directors.

This study utilized a modified Delphi technique to identify criteria considered important in the promotion of family practice residents. A designated expert panel consisting of the directors of the family practice residency programs in the State of Texas was used as the data source for the study. The Delphi results revealed a marked degree of consensus among the state program directors for 16 of 20 criteria evaluated. The criteria identified did not define comprehensive competency areas or goals. Further studies utilizing this information to develop comprehensive goals or to evaluate a program's current policies are proposed.

Delphi Technique↗

Perceptions of CRNAs: current and future roles--Part II.

The purpose of this study was twofold. First, to identify current roles and future role perceptions for Certified Registered Nurse Anesthetists (CRNAs) using the delphi methodology. Second, to analyze the level of agreement or disagreement of anesthesiologists and CRNAs with the identified roles. A survey instrument was developed using the delphi methodology which involved five CRNAs and five anesthesiologists. The instruments with a dimensional rating scale were labeled "Current Roles for CRNAs" and "Future Role Perceptions for CRNAs." The former instrument contained 26 items and the latter contained 28 items. Participants in this study were randomly selected from the active memberships of the American Association of Nurse Anesthetists and the American Society of Anesthesiologists. Usable responses were obtained from 369 of the 684 CRNAs and 354 of the 1,400 anesthesiologists. Analysis of the data revealed there were significant differences between the two professions on all roles. There was evidence of extreme polarity on roles relating to expanded practice, independent practice, the role of CRNAs on the anesthesia care team, and nontraditional practice settings. CRNAs differed from anesthesiologists in their role as nurse anesthesia educators. Anesthesiologists who worked with CRNAs were influenced in their support of CRNA roles, except for roles in independent and expanded practice, and responded differently from anesthesiologists who did not work with CRNAs. The conclusions were as follows: 1. CRNAs and anesthesiologists differ in support for expanded practice in both current and future perceptions. 2. CRNAs and anesthesiologists differ on the issue of independent practice. 3. The perception of anesthesiologists relative to the anesthesia care team appeared to be influenced by a working relationship with CRNAs.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesiology↗

Skills for the beginning family medicine investigator.

The purpose of this study was to identify the necessary skills for a beginning researcher in family medicine, utilizing the views of those currently conducting research in the specialty. A Delphi study, involving three questionnaires, was conducted to determine skills needed in the following areas: designing a research project, conducting a research project, statistical knowledge and/or skills, and computer skills. Participants were 32 family physicians who had published at least one article in the Journal of Family Practice (1983-84) or Family Medicine (1983-84). The Delphi technique was successful in achieving consensus among study participants. A total of 77 skills were identified in the four areas as being at least somewhat important to the beginning family medicine investigator. Thirty-eight of these skills were identified as important to extremely important.

Clinical Competence↗

Manpower planning for physical medicine and rehabilitation: comment on GMENAC process.

Although physical medicine and rehabilitation (PM&R) was not analyzed by the Graduate Medical Education National Advisory Committee (GMENAC) Delphi Adjusted Needs Based Modeling process completed in 1980, a provisional manpower requirement estimate of 3,200 physiatrists was included in the final report. In late 1981 and early 1982, the GMENAC model was used and an official 1990 estimate of 4,060 physiatrists needed, with only 2,400 physiatrists available, was determined. This report summarizes the initial correspondence and the assessment study methods for PM&R utilized to attain these estimates. Considerable variability of the numbers determined by the Delphi Panel is apparent. These estimates have been accepted by the Office of Graduate Medical Education and although no official action has ensued, the results are on record for future manpower planning and may be a factor in the current interest of medical students in the specialty of PM&R.

Delphi Technique↗

Assessment of computer learning needs and priorities of registered nurses practicing in hospitals.

The purpose of this study was to identify computer learning needs of practicing nurses at the bedside. Knowles' adult learning theory clearly implies that learners have a role in identifying their learning needs. Expert opinion is the second source of needs identification and complements learner input. This principle served to underpin the conceptual framework of this study. A Delphi technique was used to solicit expert opinions from nurse informaticians about the computer learning needs of practicing nurses. A 75 knowledge/skill item questionnaire was developed from the expert consensus of the Delphi and distributed to 150 registered nurses considered to be computer novices. Novices' responses were compared to the experts' responses to identify content essential for nurses to be able to use computers in their practice. Further, sequence for content delivery was postulated through the comparison of expert and novice opinion relative to the essential/nonessential nature of the content.

Clinical Competence↗

[Social isolation in the psychiatric department].

In this article account is given of a validation study, according to the nursing diagnosis 'social isolation'. The label, definition and cluster of defining characteristics according to cluster of defining characteristics according to Townsend (1990) are the starting point, the related factors are left out of consideration. The validation mentioned above was carried out in accordance with the Delphi-method, that consisted of three Delphi rounds. A panel of experts was asked particularly to compile defining characteristics that are relevant for 'social isolation' and to indicate the critical defining characteristics. This procedure generated a cluster of seven defining characteristics for 'social isolation' of which the content validity turned out to be considerably increased with regard to the cluster formulated by Townsend. The distinction between critical defining characteristics and supporting defining characteristics was not clarified by this study.

Delphi Technique↗

A comparison of three methods for estimating the requirements for medical specialists: the case of otolaryngologists.

OBJECTIVE: To compare three methods of computing the national requirements for otolaryngologists in 1994 and 2010. DATA SOURCES: Three large HMOs, a Delphi panel, the Bureau of Health Professions (BHPr), and published sources. STUDY DESIGN: Three established methods of computing requirements for otolaryngologists were compared: managed care, demand-utilization, and adjusted needs assessment. Under the managed care model, a published method based on reviewing staffing patterns in HMOs was modified to estimate the number of otolaryngologists. We obtained from BHPr estimates of work force projections from their demand model. To estimate the adjusted needs model, we convened a Delphi panel of otolaryngologists using the methodology developed by the Graduate Medical Education National Advisory Committee (GMENAC). DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Wide variation in the estimated number of otolaryngologists required occurred across the three methods. Within each model it was possible to alter the requirements for otolaryngologists significantly by changing one or more of the key assumptions. The managed care model has a potential to obtain the most reliable estimates because it reflects actual staffing patterns in institutions that are attempting to use physicians efficiently. CONCLUSIONS: Estimates of work force requirements can vary considerably if one or more assumptions are changed. In order for the managed care approach to be useful for actual decision making concerning the appropriate number of otolaryngologists required, additional research on the methodology used to extrapolate the results to the general population is necessary.

Data Interpretation, Statistical↗

Executive skills 21: a forecast of leadership skills and associated competencies required by naval hospital administrators into the 21st century.

Those in the Naval Medical Department are experiencing an exciting time of bridled chaos and creative change. Many mid-career officers are uncertain of the leadership behaviors and skills that will be necessary for successful managerial careers. Changes in the method of health care delivery of this nation combined with the reengineering of the armed forces' world-wide mission has driven military medical leaders to expand their professional skills, knowledge, and abilities beyond the clinical sciences. This research identifies the most critical domains in the science of health care administration and differentiates and ranks job skill, knowledge, and ability requirements that will be necessary for successful health care management into the 21st century. Top Naval hospital executives responded to two iterations of a Delphi inquiry. These medical leaders identified 106 unique issues that were content-analyzed into nine domains by a neutral, expert panel. Domains, in order of ranked importance, were leadership, health care delivery systems, cost-finance, technology, accessibility, professional staff relations, marketing, quality-risk management, and ethics. In the second Delphi iteration, hospital executives reviewed domain results and rated identified job requirements on their required job importance. The top-10 rated skills, knowledge, and abilities are reported. Results indicated that although a business orientation is needed for organizational survival, an emphasis on person-oriented skills, knowledge, and abilities is required for future success as a health care administrator in the Naval health care system.

Delphi Technique↗

Orthopaedic nursing research priorities: a replication and extension.

PURPOSE: This study identified current orthopaedic nursing research priorities that should be investigated to advance the practice of orthopaedic nursing. The study was accomplished by the National Association of Orthopaedic Nurses' (NAON) Research Committee via a national survey of selected NAON members. DESIGN: A descriptive design was used to determine research priorities. SAMPLE: The sample consisted of a random sample of 133 NAON members. The sample was stratified for either graduate degrees (> or = master's), other than a graduate degree (< or = bachelor's) (to insure representation from "frontline" practicing nurses), and registrants in the NAON Researcher Database and recipients of NAON Foundation or American Academy of Orthopaedic Surgeons (AAOS)/NAON grants. METHOD: A three round Delphi survey technique was used to build consensus by systematically generating, synthesizing, and analyzing opinions of a group of experts while maintaining confidentiality of the individuals. MAIN RESEARCH CLASSIFICATIONS: Nursing research priorities, Delphi method, Orthopaedic nursing. FINDINGS: The nine target research questions for orthopaedic nursing identified as high priority were grouped into the following categories: patient acuity, care delivery models, staffing issues, patient complications, pain management (in the elderly and those with altered mental status), and patient mobility. These research priority items are intended to direct the orthopaedic nurse researcher to study specific questions within these categories. CONCLUSION: Results reflect the dramatic changes occurring in orthopaedic nursing practice. Research priorities reveal the need for more research on pain and patient complications (e.g., deep vein thrombosis (DVT)) despite a preponderance of existing, published research on these topics. IMPLICATIONS FOR NURSING RESEARCH: This study identified target research questions for orthopaedic nursing. These questions may be used by orthopaedic nurses to develop nursing research proposals as well as collaborative research endeavors with other members of the orthopaedic health care team. An ongoing and wider dissemination of results of existing research to the NAON membership needs to be implemented.

Delphi Technique↗

Methodological differences in clinical trials evaluating nonpharmacological and pharmacological treatments of hip and knee osteoarthritis.

CONTEXT: Randomized controlled trials have been developed essentially in the context of pharmacological treatments (ie, oral drugs; intra-articular injection; and topical, intramuscular, and intravenous treatments), but assessment of the effectiveness of nonpharmacological treatments (ie, surgery, arthroscopy, joint lavage, rehabilitation, acupuncture, and education) presents specific issues. OBJECTIVES: To compare the quality of articles of nonpharmacological and pharmacological treatments of hip and knee osteoarthritis and to identify specific methodological issues related to assessment of nonpharmacological treatments. DESIGN AND SETTING: We searched MEDLINE and the Cochrane Central Register of Controlled Trials for articles of randomized controlled trials published between January 1, 1992, and February 28, 2002, in 28 general medical and specialty journals with high impact factors and assessing nonpharmacological and pharmacological treatments in patients with hip or knee osteoarthritis. MAIN OUTCOME MEASURES: The quality of the methods reported in the selected articles was assessed by 2 independent reviewers using the Jadad scale, the Delphi list, and guidelines found in the Users' Guides to the Medical Literature. Investigators also used a checklist of items developed by the authors to analyze study characteristics. RESULTS: A total of 110 articles were included in the analysis; 50 (45.5%) assessed nonpharmacological treatments and 60 (54.5%) assessed pharmacological treatments. Reports of nonpharmacological treatments had a lower global quality score than did reports of pharmacological treatments as measured by the Jadad scale (mean [SD] score, 1.4 [1.3] vs 3.0 [1.3]) and the Delphi list (mean [SD] score, 5.2 [1.5] vs 7.5 [1.1]). Lack of reporting adequate random sequence generation and intention-to-treat analyses were found in both nonpharmacological and pharmacological articles. Nonpharmacological treatments were less often compared with a placebo than were pharmacological treatments (28.0% of articles vs 71.7%). Compared with pharmacological articles, nonpharmacological articles less often described blinding of patients (26.0% vs 96.7%), care providers (6.0% vs 81.7%), and outcome assessors (68.0% vs 98.3%). Care providers' skill levels could influence treatment effect in 84.0% of nonpharmacological articles vs 23.3% of pharmacological articles. CONCLUSIONS: In this analysis of reports of hip and knee osteoarthritis therapy, nonpharmacological articles scored lower than pharmacological articles in terms of quality. Assessments of nonpharmacological treatments must take into consideration additional methodological issues.

Complementary Therapies↗

The role of polar interactions in the molecular recognition of CD40L with its receptor CD40.

CD40 Ligand (CD40L) is transiently expressed on the surface of T-cells and binds to CD40, which is expressed on the surface of B-cells. This binding event leads to the differentiation, proliferation, and isotype switching of the B-cells. The physiological importance of CD40L has been demonstrated by the fact that expression of defective CD40L protein causes an immunodeficiency state characterized by high IgM and low IgG serum levels, indicating faulty T-cell dependent B-cell activation. To understand the structural basis for CD40L/CD40 association, we have used a combination of molecular modeling, mutagenesis, and X-ray crystallography. The structure of the extracellular region of CD40L was determined by protein crystallography, while the CD40 receptor was built using homology modeling based upon a novel alignment of the TNF receptor superfamily, and using the X-ray structure of the TNF receptor as a template. The model shows that the interface of the complex is composed of charged residues, with CD40L presenting basic side chains (K143, R203, R207), and CD40 presenting acidic side chains (D84, E114, E117). These residues were studied experimentally through site-directed mutagenesis, and also theoretically using electrostatic calculations with the program Delphi. The mutagenesis data explored the role of the charged residues in both CD40L and CD40 by switching to Ala (K143A, R203A, R207A of CD40L, and E74A, D84A, E114A, E117A of CD40), charge reversal (K143E, R203E, R207E of CD40L, and D84R, E114R, E117R of CD40), mutation to a polar residue (K143N, R207N, R207Q of CD40L, and D84N, E117N of CD40), and for the basic side chains in CD40L, isosteric substitution to a hydrophobic side chain (R203M, R207M). All the charge-reversal mutants and the majority of the Met and Ala substitutions led to loss of binding, suggesting that charged interactions stabilize the complex. This was supported by the Delphi calculations which confirmed that the CD40/CD40L residue pairs E74-R203, D84-R207, and E117-R207 had a net stabilizing effect on the complex. However, the substitution of hydrophilic side chains at several of the positions was tolerated, which suggests that although charged interactions stabilize the complex, charge per se is not crucial at all positions. Finally, we compared the electrostatic surface of TNF/TNFR with CD40L/CD40 and have identified a set of polar interactions surrounded by a wall of hydrophobic residues that appear to be similar but inverted between the two complexes.

Amino Acid Sequence↗

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock.

OBJECTIVE: To develop management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. DESIGN: The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along 5 levels to create recommendation grades from A-E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management. PARTICIPANTS: Participants included 44 critical care and infectious disease experts representing 11 international organizations. RESULTS: A total of 46 recommendations plus pediatric management considerations. CONCLUSIONS: Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that will hopefully translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually, and even more rapidly when some important new knowledge becomes available.

Adult↗

Consensus guidelines on sedation and analgesia in critically ill children.

OBJECTIVE: The United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group is a multi-disciplinary expert panel created to produce consensus guidelines on sedation and analgesia in critically ill children and forward knowledge in these areas. Sedation and analgesia are recognised as important areas of critical care practice and adult clinical practice guidelines in these fields remain amongst the most popular of those produced by the Society of Critical Care Medicine. However, similar clinical practice guidelines have not previously been produced for the critically ill paediatric patient. DESIGN: A modified Delphi technique was used to allow the Working Group to anonymously consider draft recommendations in three Delphi rounds with predetermined levels of agreement. This process was supported by a total of four consensus conferences. Once consensus had been reached, a systematic review of the available literature was carried out. OUTCOME: A set of consensus guidelines was produced including 20 key recommendations, 10 relating to the provision of analgesia and 10 relating to the sedation of critically ill children. An evaluation of the existing literature supporting these recommendations is provided. CONCLUSIONS: Multi-disciplinary consensus guidelines for maintenance sedation and analgesia in critically ill children have been successfully produced and are supported by levels of evidence (excluding sedation and analgesia for procedures and excluding neonates). The working group has highlighted the paucity of high-quality evidence in these important clinical areas and this emphasises the need for further randomised clinical trials in this area.

Analgesia↗

Anthropogenic and natural organohalogen compounds in blubber of dolphins and dugongs (Dugong dugon) from northeastern Australia.

A range of organohalogen compounds (10 polychlorinated biphenyl [PCB] congeners, DDT and metabolites, chlordane-related compounds, the potential natural organochlorine compound Q1, toxaphene, hexachlorobenzene, hexachlorocyclohexanes, dieldrin, and several yet unidentified brominated compounds) were detected in the blubber of four bottlenose dolphins (Tursiops truncatus), one common dolphin (Delphinus delphis), and seven dugongs (Dugong dugon), as well as in adipose tissue of a green turtle (Chelonia mydas) and a python (Morelia spilota) from northeast Queensland (Australia). The green turtle and dugongs accumulated lower organohalogen levels than the dolphins. Lower levels in dugongs were expected because this species is exclusively herbivorous. Highest PCB and DDT levels recorded in dugongs were 209 and 173 microg/kg lipids, respectively. Levels of the nonanthropogenic heptachlorinated compound Q1 (highest level in dugongs was 160 microg/kg lipids) were estimated using the ECD response factor of trans-nonachlor. Highest organohalogen levels were found in blubber of dolphins for sumDDT (575--52,500 microg/kg) and PCBs (600--25,500 microg/kg lipids). Furthermore, Q1 was a major organohalogen detected in all samples analyzed, ranging from 450--9,100 microg/kg lipids. The highest concentration of Q1 determined in this study represents the highest concentration reported to date in an environmental sample. Levels of chlordane-related compounds were also high (280--7,700 microg/kg, mainly derived from trans-nonachlor), but concentrations of hexachlorobenzene, hexachlorocyclohexanes, dieldrin, and toxaphene were relatively low and contributed little to the overall organohalogen contamination. Furthermore, a series of three major (BC-1, BC-2, and BC-3) and six minor (BC-4 through BC-9) unknown brominated compounds were observable by extracting m/z 79 and m/z 81 from the GC/ECNI-MS full scan run. Structural proposals were made for the two major recalcitrant compounds (referred to as BC-1 and BC-2). BC-2 appears to be a tetrabromo-methoxy-diphenylether (512 u) and BC-1 has 14 u (corresponding with an additional CH(2) group) more relative to BC-1. In general, the organohalogen pattern observed in blubber of dolphins was different compared to similar samples from other locations in the world, which is apparent from the fact that the four major abundant signals in the GC/ECD chromatogram of D. delphis originated from the four unknown compounds Q1, BC-1, BC-2, and BC-3.

Adipose Tissue↗