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PubMed1990

Altered level of consciousness: validity of a nursing diagnosis.

The purpose of this three-phase study was to examine the validity of the nursing diagnosis altered level of consciousness (ALC). The conceptual framework was diagnostic reasoning. In Phase I, 26 content experts certified in neuroscience nursing completed four rounds of a Delphi survey to identify defining characteristics and operational definitions for the nursing diagnosis. The diagnosis was divided into ALC: arousal and ALC: content. In Phase II, 30 staff nurses from two neuroscience intensive care units (NICUs) used the magnitude estimation scaling technique in judging the importance and frequency of occurrence of defining characteristics chosen in Phase I. In Phase III, 60 patients in two NICUs were assessed for frequency of occurrence of the defining characteristics for ALC: arousal and ALC: content. In Phase I, there was greater than or equal to 70% agreement on the appropriateness and clarity of 28 and 24 defining characteristics and operational definitions for ALC: arousal and ALC: content, respectively. In Phase II, there were 7 major defining characteristics identified for ALC: arousal and 6 major defining characteristics identified for ALC: content. In Phase III, there were 13 defining characteristics that occurred with significantly greater frequency in patients with an ALC: arousal and 17 defining characteristics that occurred with significantly greater frequency in patients with an ALC: content.

Attitude of Health Personnel↗

PubMed2005

Factors associated with physiotherapists' confidence during assessment of clinical cervical and lumbar spine instability.

BACKGROUND AND PURPOSE: Physiotherapists commonly encounter patients with complaints of vague, indistinguishable neck and back pain, such as clinical spine instability. Since confidence is a component of expert clinical practice, we were interested in measuring expert clinicians' confidence in diagnosing and assessing clinical spine instability. The aims of the present study were to factor out the common 'identifiers' associated with physiotherapists' objective, physical diagnosis and assessment of clinical spine instability, and to determine the association of reported diagnostic confidence to these identifiers. METHOD: The study used data from a Delphi instrument for the factor analysis and a survey of APTA Board-certified orthopaedic specialists for report of confidence. Using an ologit regression analysis, the identifier themes and clinical background characteristics were associated with confidence in diagnosis of clinical spine instability. RESULTS: Only clinical cervical spine instability obtained significant findings. The identifier 'observable or palpable abnormalities of motion during movement assessment in clinical practice' was positively associated with reported confidence in diagnosis, as was the influence of manual therapy background models: Cyriax, Maitland, McKenzie, NAIOMPT, Osteopathic, Paris and other. Male gender yielded negative association with reported confidence. No factors were associated with reported lumbar confidence. CONCLUSIONS: Multiple backgrounds of physiotherapists demonstrate confidence in detecting clinical spine instability using observable or palpable methods to detect abnormal movements.

Adult↗

PubMedDate not supplied

Casemix in an internal medicine clerkship: educational value of the clinical problems seen.

OBJECTIVE: To evaluate the casemix seen during an internal medicine clerkship and to assess the educational value of the problems seen. DESIGN: A modified Delphi-group opinion technique was used to develop a clerk log that included priority problems for internal medicine. Over a 12-month period, clerks recorded their exposure to the problems seen during their eight-week rotations. General internists rated the importance of each of the problems on a three-point scale. SETTING: The inpatient internal medicine services in six university teaching hospitals. SUBJECTS: All clinical clerks in a single undergraduate year recorded their experiences. All university-based general internists participated in rating problem importance. MEASUREMENTS AND MAIN RESULTS: The final approved log contained 72 problems, 64 of which received importance ratings greater than or equal to 2 on the three-point scale. The frequency of clerk exposure per problem was high and the correlation between frequency of exposure and importance was good. Ten important problems had relatively low exposure and four problems of lower importance had high exposure. CONCLUSIONS: The clinical clerks were exposed to a broad spectrum of diseases, but some key problems were not well represented on the wards. Alternative strategies, including increased ambulatory care exposure, will be required to complete the exposure and to assure that the quality of patient exposure matches the quantity.

Clinical Clerkship↗

PubMedDate not supplied

Fellowship training in academic general internal medicine: a curriculum survey.

OBJECTIVE: To determine whether current fellowships in general internal medicine (FGIM) meet the perceived needs and objectives of physicians entering careers in academic internal medicine. DESIGN: A modified Delphi method yielded the 18 curricular elements included in the mailed survey. Participants outlined both actual and ideal fellowship experiences by rating the degree of emphasis of each curricular element on a Likert scale. Respondents then prioritized elements by rank-ordering them on perceived importance. Current job descriptions and opinions on related issues in FGIM were collected. PARTICIPANTS: Potential fellows, current fellows, and recent graduates were surveyed. Individuals were identified through the Society of General Internal Medicine associates' mailing list and solicitation of program directors. Nonfellow associates served as the proxy group for potential fellows. MEASUREMENTS AND MAIN RESULTS: 579 surveys were mailed; 348 (60%) responses were received, of which 288 (50%) were suitable for analysis. Of all respondents, 38% were current fellows and 40% were recent graduates. When asked to prioritize educational needs during fellowship training, respondents ranked research methodology, ambulatory medicine, critical review of the literature, epidemiology, biostatistics, teaching skills, medical consultation, grant writing, preventive medicine, and design of educational curriculum as the top ten. Only minor deviations in rank order were found between graduates and nongraduates. Mean Likert scale scores for degree of emphasis of each curricular element in graduates' actual fellowships were compared with mean scores for graduates' ideal fellowship descriptions. High-priority elements that were perceived as adequately emphasized included research methodology, critical analysis of the literature, epidemiology, and biostatistics. High-priority elements that were perceived as inadequately emphasized included ambulatory medicine, teaching skills, medical consultation, grant writing, preventive medicine, and design of educational curricula. CONCLUSIONS: FGIM largely meet the expectations of their fellows for preparation for research responsibilities. However, several curricular elements concerned with preparation for future clinical and teaching responsibilities are perceived by graduates as underemphasized. These areas deserve increased emphasis during fellowship training to better prepare fellows for their future roles in academic general internal medicine.

Adult↗

PubMed2001

[Outcome measurement in musculoskeletal diseases: recommendation for a core set of scales for use in rehabilitation].

By application of a standardized core set of outcome measurement instruments, comparison between studies as well as meta-analyses in rehabilitation research can be facilitated. The German Society for Rheumatology has commissioned its working group on rehabilitation with the development of a proposal for such a core set of outcome measurement instruments. In a first step, dimensions for outcome measurement in rehabilitation were defined by a group of experts which represented rehabilitation hospitals, acute care hospitals, and research groups specialized in outcome measurement. The Delphi method was used in a multiple step consensus process. In a second step, instruments and procedures to operationalize the relevant dimensions were chosen. Reliability, validity, sensitivity to change, and practicability were used as criteria for selecting measurement instruments. The main intention of the proposed core set of outcome measurement instruments is to facilitate the processes of planning and carrying out rehabilitation research studies. Furthermore, the proposed instruments can be used for clinical documentation systems as well as for internal or external quality assurance programs.

Arthritis, Rheumatoid↗

PubMed2003

A new concept for the etiopathogenesis of the thoracospinal deformity of idiopathic scoliosis: summary of an electronic focus group debate of the IBSE.

There is no generally accepted scientific theory for the etiology of idiopathic scoliosis, and treatment is pragmatic and unrelated to such knowledge. As part of its mission to widen understanding of scoliosis etiology, the International Federated Body on Scoliosis Etiology (IBSE) introduced the electronic focus group (EFG) as a means of increasing debate of extant knowledge on important topics. This has been designated as an on-line Delphi discussion, and has proven very successful. The text for this EFG was written by Professor Sevastik and drawn from the extensive research carried out by himself and his co-workers. The thoracospinal concept of etiopathogenesis applies only to girls with right thoracic adolescent idiopathic scoliosis (Rcx-T-AIS-F). According to this concept, increased longitudinal growth of the left periapical ribs triggers the thoracic curve simultaneously in the three cardinal planes. The concept does not deal with factors involved in curve progression. Sevastik advocates mini-invasive operations on the ribs as a treatment for early progressive thoracic curves. Areas of controversy include whether or not there is overgrowth of the left periapical ribs in Rcx-T-AIS-F, and the question of whether there should be a clinical trial of mini-invasive operations on the ribs.

Adolescent↗

PubMed1985

Establishment of a reference library for evaluating computer ECG measurement programs.

As a result of an international cooperative project entitled "Common Standards for Quantitative Electrocardiography" (CSE), an ECG reference data base has been established with the aim of standardizing computer-derived ECG measurements. The objective of the project is to reduce the wide variation in wave measurements currently obtained by ECG analysis programs. A library of 250 ECGs with selective ECG abnormalities was established and a comprehensive reviewing scheme was devised for the visual determination of the onsets and offsets of P, QRS, and T. This task was performed by a board of cardiologists on highly amplified, selected complexes from the library. A subset was examined in order to study beat-to-beat and intraobserver variability. By using a modified Delphi approach, individual outlying point estimates were eliminated in four successive rounds. In this way final referee estimates were obtained which proved to be highly reproducible and precise. A reference library has thereby been developed which allows testing of the performance of ECG measurement programs and is a useful instrument in establishing recommendations for more precise measurement rules and definitions.

Computers↗

PubMed1993

Cognitive-behavioral techniques to reduce pain: a validation study.

The purpose of this study was to identify and validate specific activities considered important in the implementation of three non-pharmacologic pain management interventions--relaxation, distraction and guided imagery. Using a two-round Delphi survey, nurses selected for their expertise in pain management were asked to validate definitions and activities considered important in the implementation of each of these strategies. Data were analyzed using a modification of Fehring's diagnostic content validity method. From this process, a list of activities for each intervention evolved that has implications for nursing research, practice and education.

Analgesia↗

PubMed1994

Validation of cutaneous stimulation interventions for pain management.

The purpose of this study was to identify and validate specific activities considered important in the implementation of selected cutaneous stimulation pain management interventions including heat and cold application, massage and Transcutaneous Electrical Nerve Stimulation (TENS). A two-round Delphi survey was completed by nurses selected for their expertise in pain management. Data were analyzed using a modification of Fehring's diagnostic content validity method. Consistently high scores were obtained by the raters for each intervention and activity, with most activities perceived as critical to the intervention. From this process, a list of activities for each cutaneous stimulation intervention evolved that are applicable to education, clinical practice and clinical nursing research.

Cryotherapy↗

PubMed1987

A grant rationing model for a health care system.

Most public health programs are created through a political process and the health administrator's resource allocation decision is influenced not only by the relative performance of the subunits but also by political considerations. This paper presents a goal programming model for rationing available grants to competing health care subunits on the basis of performance subject to resource and political constraints. Performance is defined in terms of output adjusted for non-compliance on the identified quality of care and administrative efficiency criteria. The quality and efficiency criteria are those specified by the Federal agency as amended by local funding authorities and subunit administrators through a Delphi process. The model has the advantage of flexibility and can be easily adapted to suit prevailing financial and political conditions. In particular, it can be used as a viable analytical tool in health care and other public service agencies where political considerations are important in resource allocation decisions.

Community Health Centers↗

PubMed1991

Cost implications of alternative treatments for AIDS patients with cryptococcal meningitis. Comparison of fluconazole and amphotericin B-based therapies.

The extra demands placed upon health care resources by management of AIDS patients have increased the focus on cost implications of therapeutic alternatives. Cryptococcal meningitis is a common life-threatening infection in AIDS patients, usually treated with amphotericin B, often in combination with flucytosine. Administered intravenously, this therapy is associated with frequent and often severe side effects. Fluconazole is a new alternative which can be given orally once daily and has fewer such side effects. The purpose of this study was to examine the cost implications of these different therapies for both primary and maintenance treatment of cryptococcal meningitis. Comparison of these two therapies in recent clinical trials has indicated that fluconazole is at least as effective as amphotericin B, and therefore cost-minimisation analysis is an appropriate method to study the economic consequences of the alternative treatments. Patient management and resource-use information for both treatments was obtained using a modified Delphi technique with a panel of European physicians experienced in the treatment of this disease, and three models were developed to reflect the variability of practice evident among the panel members. U.K. health care costs were used to value these resources. The results indicated that, despite the higher cost of the drug itself, the costs associated with fluconazole were likely to be markedly less than those for amphotericin B for primary treatment, and similar or slightly cheaper for maintenance treatment. Over 1 year of treatment, the saving from the use of fluconazole would be in the range of 4000-14,000 pounds.

Acquired Immunodeficiency Syndrome↗

PubMed1983

GMENAC report on U.S. physician manpower policies: recommendations and reactions.

After four years of study in the United States, the Graduate Medical Education National Advisory Committee (GMENAC) concluded that an excess of approximately 70,000 physicians will exist in 1990. Faced with a future surplus, GMENAC recommends that U.S. medical schools decrease enrollment levels by 10 percent relative to the 1978-79 level and severely restrict entrance of foreign medical graduates. Flaws identified in the GMENAC approach relate to the use of the delphi technique, the future role of nonphysician providers, and a lack of reliable data. The GMENAC report may provide impetus for an abrupt shift from expansionism to reductionism in U.S. physician manpower policy. Long range physician manpower planning has erred in the past, necessitating periodic reevaluation of national policy. A continuing balance between supply and demand, although ideal, can probably never be attained. Thus small adjustments in total supply and specialty mix will always be necessary. The GMENAC report, which is the most comprehensive study of U.S. physician manpower to date, requires serious consideration in this context.

Delphi Technique↗

PubMed1995

Development of a numeric Health Care Worker Risk-Assessment Scale to evaluate potential for blood-borne pathogen exposures.

BACKGROUND: An attempt to develop a Health Care Worker Risk Assessment Scale to evaluate potential for exposure to blood-borne pathogens was made in late 1989 through 1990. The research questions were as follows: (1) Can a scale be developed to assign weights to variables that influence health care workers' risk of exposure to blood-borne pathogens? (2) If so, what variables would be included? METHODS: A five-round Delphi technique was used with 26 panel members from 15 U.S. states and the United Kingdom who were recognized experts in strategies to reduce health care workers' risk of exposure to blood-borne pathogens. The scale included four elements, each scored up to 40 points. Elements were as follows: (1) potential route of exposure, (2) experience of health care worker and cooperation of patient, (3) prevalence of blood-borne pathogens, and (4) difficulty in managing the situation. A minimum score of 20 indicated an extremely low-risk situation; a maximum score of 160 indicated an extremely high-risk situation. RESULTS: Consensus was achieved among the panel members in identifying the elements that contributed to risk for exposure to blood-borne pathogens and in applying the scale to carefully worded vignettes. This required several modifications of both the scale and the vignettes to ensure consistent interpretation of the terms used. In all vignette situations, the risk-abatement strategy was specific to the situation depicted in the vignette and not to the task itself; the value of a numeric scale is thus questionable. CONCLUSIONS: Even with the participation of 26 expert panelists, we were unable to develop a numeric scale to objectively quantify risk in such a way that risk-reduction strategies could be based on the scale rather than on the specific risk elements in a situation. Instead of attempting to use a scale such as this to quantify risk objectively, educators or clinicians may be better advised to teach health care workers the four scale elements so that health care workers can subjectively use these elements to evaluate and modify their own risk situations.

Blood-Borne Pathogens↗

PubMed1992

The perceptions of nurse teachers regarding the preparation for their role in Project 2000 programmes.

This paper discusses the findings related to the perceptions of nurse teachers regarding the preparation for their role in Project 2000 programmes. Data were collected by utilising three rounds of a Delphi survey with a panel of experts made up of Grade 2 nurse teachers. The panel of 201 respondents was obtained from 25 of the 28 colleges of nursing and midwifery that had implemented Project 2000 between September 1989 and April 1991. The profile of the respondents revealed that 68% work in general nurse courses, 18% in mental health, 8% in mental handicap and 6% in child care. Over half of the respondents hold a degree related to health care and over a quarter are studying for one. The findings suggest that the nurse teachers working in Project 2000 programmes consider their teacher preparation course an important means of preparation for the activities within their role. Degree and diploma courses are also considered important along with additional professional qualifying courses and subject related courses. What did not appear evident was any preparation for the many specific activities they carry out apart from teaching. Experience came out strongly as an important means of preparation for all the activities. Staff development programmes were said by 52% of respondents to be organised within their colleges and perceived by many as an important means of preparation.

Attitude of Health Personnel↗

PubMed1995

Learning needs of hospitalized veteran patients: developing a tool for practice.

The purpose of the study was to develop a practical tool for easy administration by staff to identify Veteran patients' perceived learning needs. Initial development of the tool was based upon a comprehensive literature review, an expert panel review using a modified Delphi Method, and pilot testing of select patients. Two study phases each involved 200 patient interviews from the Department of Veterans Affairs Medical Center in Buffalo, New York. The first phase showed that the tool, the 'Perceived Health Education Needs Scale' had strong internal consistency. Exploratory factor analysis suggested one dominant factor of health. Similar results showing strong internal consistency and one dominant factor were found during a second phase. Veteran patients placed importance on a wide range of educational learning needs, independent of their immediate health concerns.

Adult↗

PubMedDate not supplied

Determining the National Flight Nurses Association's research priorities.

INTRODUCTION: Increased federal attention to nursing research has prompted professional nursing organizations to develop research programs identifying areas of scientific knowledge most needed for professional and clinical practice. The study purpose was to identify the National Flight Nurses Association's (NFNA's) research priorities. METHODS: A two-round Delphi technique was used, with systematic surveys in Round I mailed to 500 NFNA members. Responses from 127 members were coded to form the Round II survey that was completed by members at the NFNA meeting in St. Louis in October 1993. RESULTS: According to frequency scores, issues of highest priority relate to specialty and nonspecialty team, crew configurations, clinical indications for transport, airway management, educational preparation and continuing education. CONCLUSION: Identified priorities support development of research studies and programs that lead to increased knowledge, facilitate collaborative studies and also provide a basis for research funding.

Air Ambulances↗

PubMed2006

Radiology curriculum topics for medical students: students' perspectives.

RATIONALE AND OBJECTIVE: We sought to establish medical students' perspectives of a set of curriculum topics for radiology teaching. MATERIALS AND METHODS: A multicenter study was conducted in New Zealand. A modified Delphi method was adopted. Students enrolled in two New Zealand Universities received a questionnaire. Each learning topic was graded on a scale of 1 (very strongly disagree) to 6 (very strongly agree). Students could also put forward and grade suggestions that were not on the questionnaire. RESULTS: Of 200 questionnaires, 107 were returned. Fifty male and 57 female students participated, with an average age of 23.7 years. The five highest ranking curriculum topics in order of importance were developing a system for viewing chest radiographs (5.77, SD 0.7), developing a system for viewing abdominal radiographs (5.66, SD 0.8), developing a system for viewing bone and joint radiographs (5.56, SD 0.8), distinguishing normal structures from abnormal in chest and abdominal radiographs (5.38, SD 0.9), and identifying gross bone or joint abnormalities in skeletal radiographs (5.29, SD 0.9). CONCLUSION: Medical students want to know how to look at radiographs, how to distinguish normal from abnormal, and how to identify gross abnormalities.

Adult↗

PubMed2005

The potential impact of a low-nitrosamine smokeless tobacco product on cigarette smoking in the United States: estimates of a panel of experts.

OBJECTIVE: To predict the impact on tobacco use in the US of a "harm reduction" policy that requires that the smokeless tobacco product meet low nitrosamine standards, but could be marketed with a warning label consistent with the evidence of relative health risks. METHODS: Low nitrosamine smokeless tobacco (LN-SLT) and cigarette use are predicted by a panel of experts using a modified Delphi approach. We specify a thought experiment to isolate the changes that would occur after the new LN-SLT policy was implemented. RESULTS: The panel predicted that the new policy would accelerate a decrease in smoking prevalence from 1.3 to 3.1 percentage points over 5 years compared to the current SLT product policy, with greater effects on males than females. Introduction of the new product was also predicted to result in modest additional use of SLT overall, with the greatest increases among males who initiated tobacco use under the new policy. CONCLUSION: An overall consensus was reached that the introduction of a new LN-SLT product under strict regulations would increase SLT use, but reduce overall smoking prevalence. This reduction would likely yield substantial health benefits, but uncertainties surround the role of marketing and other tobacco control policies.

Adolescent↗