Promoting patient safety through informatics-based nursing education

The Institute of Medicine (IOM) Committee on Quality of Health Care in America identified the critical role of information technology in designing safe and effective health care. In addition to technical aspects such as regional or national health information infrastructures, to achieve this goal, healthcare professionals must receive the requisite training during basic and advanced educational programs. In this article, we describe a two-pronged strategy to promote patient safety through an informatics-based approach to nursing education at the Columbia University School of Nursing: (1) use of a personal digital assistant (PDA) to document clinical encounters and to retrieve patient safety-related information at the point of care, and (2) enhancement of informatics competencies of students and faculty. These approaches may be useful to others wishing to promote patient safety through using informatics methods and technologies in healthcare curricula.     

Technology assessment and biomedical engineering education

Technology assessment is research that is intended to help decisionmakers deal with the development, acquisition and utilisation of healthcare technologies. Healthcare professionals now recognise the need for assessment information in decisionmaking. Among these professionals are biomedical and clinical engineers who need to manage technology assessment activities and use assessment information appropriately. It is imperative therefore that proper educational programmes be developed to prepare engineers for a broader role in healthcare. The paper elaborates on aspects of technology assessment and the need for training of engineers in specific concepts and principles.     

Mental health diagnosis by nurses using the Global Mental Health Assessment Tool: a validity and feasibility study.

BACKGROUND: The Global Mental Health Assessment Tool-Primary Care Version (GMHAT/PC) has been developed to assist health professionals to make a quick and comprehensive standardised mental health assessment. It has proved to be a reliable and valid tool in a previous study involving GPs. Its use by other health professionals may help in detecting and managing mental disorders in primary care and general health settings. AIM: To assess the feasibility of using a computer-assisted diagnostic interview by nurses and to examine the level of agreement between the GMHAT/PC diagnosis and psychiatrists' clinical diagnosis. DESIGN OF STUDY: Cross-sectional validation study. SETTING: Primary care, general healthcare (cardiac rehabilitation clinic), and community mental healthcare settings. METHOD: A total of 215 patients between the ages of 16 and 75 years were assessed by nurses and psychiatrists in various settings: primary care centre (n = 54), cardiac rehabilitation centre (n = 98), and community mental health clinic (n = 63). The time taken for the interview, and feedback from patients and interviewers were indicators of feasibility, and the kappa coefficient (kappa), sensitivity, and specificity of the GMHAT/PC diagnosis were measures of validity. RESULTS: Mean duration of interview was under 15 minutes. The agreement between nurses' GMHAT/PC interview-based diagnosis and psychiatrists' International Classification of Diseases (ICD)-10 criteria-based clinical diagnosis was 80% (kappa = 0.76, sensitivity = 0.84, specificity = 0.92). CONCLUSION: The GMHAT/PC can assist nurses to make accurate mental health assessment and diagnosis in various healthcare settings and it is acceptable to patients.     

How well do healthcare professionals know of the priorities of their older patients regarding treatment outcomes?

ObjectivesFor shared decision making, it is crucial to identify patients’ priorities regarding health outcomes. Our aim was to study whether healthcare professionals know these priorities.MethodsIn this cross-sectional study we included older patients who had to make a treatment decision, their general practitioners (GPs) and their medical specialists. Agreement between the patients’ main health outcome as prioritised by using the Outcome Prioritization Tool (OPT) and the perception of the same outcome by their healthcare professionals.ResultsEighty-seven patients were included. Median age was 76 years, 87.4% of patients presented with malignant disease. The majority prioritised maintaining independence (51.7%), followed by extending life (27.6%). The agreement between patients and healthcare professionals was low (GPs 41.7%, kappa 0.067, p = 0.39), medical specialists 40.3%, kappa 0.074, p = 0.33). Positively related to agreement was patient’s age > 75, and a longer relation with their patients (for GPs), and the patient having no partner (for medical specialist). Having a malignant disease, dependent living and functional deficits were negatively related to agreement.ConclusionsHealthcare professionals have poor perceptions of their patients’ priorities.Practice implicationsTo realise patient-centered care, it is crucial to discuss priorities explicitly with all patients.     

External quality assessment for warfarin dosing using computerised decision support software

AIM: To establish and evaluate an external quality assessment scheme for warfarin dosing for users of a computerised decision support system, BAP-PC. DESIGN: Analysis of 12 months of clinical data from 10 primary care centres using BAP-PC within an oral anticoagulation clinic. Data were analysed for individual centres and compared with aggregated data for all practices. Individual feedback forms were provided to participating centres. RESULTS: A total patient population of 367 (range, 17-65/centre) was analysed. On average, patients spent 69% of time in the therapeutic range (range, 60-76%). Patients were seen on average every 27 days (range, 24-30). The average point prevalence was 86% (range, 76-100%). In total, 33 adverse events were reported (0-13/practice). Serious adverse events ranged from 0 to 1 for each practice. This translates into a serious adverse event rate of 1.6/100 patient years. CONCLUSIONS: Practices were successful in maintaining good therapeutic international normalised ratio control, with centres achieving 60% or higher time in range. There are some doubts about the quality of data collection at a practice level because there were no reported events in half of the participating centres. The observed event rates do concur with previously reported data, however. Further cycles of the scheme are necessary to establish it as a useful research and benchmarking tool.     

Knowledge,attitude and practices of health personnel with regard to HIV/AIDS in Tamatave (Madagascar)

BACKGROUND: Health care workers are key players in the prevention and management of HIV-infection. We surveyed HIV/AIDS-related knowledge, attitudes and practices of health care workers in Tamatave (Madagascar), to assess the feasibility of voluntary counselling and testing for HIV infection in antenatal care. MATERIALS AND METHOD: A Knowledge Attitude and Practice study was conducted during July 2000 in the antenatal health care centres and the hospital of Tamatave. The health workers completed a self-administrated questionnaire on HIV transmission, attitudes and practices regarding AIDS testing and counselling, HIV risk perception and attitudes regarding patients with HIV disease. RESULTS: A 90% response rate was obtained, with completed questionnaires from 45 health care workers. The sample included physicians, midwives, nurses, medical students and nursing auxiliaries. Scientific knowledge about transmissibility of HIV infection was poor: transmission was believed possible by living together without having sex (7%), by breastfeeding a HIV-positive child (9%), by using toilets after a HIV-positive patient (13%) and by blood donation (76%). 73% of the health staff believed a child born of an HIV-positive woman would systematically be infected and interventions to reduce this risk were unknown. Sixty one per cent of the health-workers reported never having advised patients to be tested and less then 10% mentioned correct counselling precautions. Seventy nine percent believed that they were at risk of acquiring AIDS, mainly through occupational exposure. Negative attitudes towards HIV-positive patients were also noted: twenty per cent of the health workers mentioned that AIDS patients should be isolated in quarantine. Physicians and paramedical staff differed only in their better knowledge about transmissibility of HIV. Physicians had the same restrictive attitude towards patients with HIV as paramedical health workers and did not differ by their counselling practice. CONCLUSIONS: Our study revealed gaps in the knowledge of health care workers about HIV infection. Before implementing voluntary counselling and testing in antenatal care, additional HIV/AIDS training for health staff seems necessary.     

Antibiotic use from formal and informal healthcare providers in the Democratic Republic of Congo: a population-based study in two health zones

ObjectiveIn the Democratic Republic of Congo and other low-resource countries, community-acquired pathogens are increasingly resistant to most locally available antibiotics. To guide efforts to optimize antibiotic use to limit antibiotic resistance, we quantified healthcare provider–specific and community-wide antibiotic use.MethodsFrom household surveys, we estimated monthly healthcare visit rates by provider. From healthcare visit exit surveys, we estimated prevalence, defined daily doses, and access/watch/reserve distribution of antibiotic use by provider. Combining both, we estimated community-wide antibiotic use rates.ResultsOf 88.7 (95% CI 81.9–95.4) healthcare visits per 1000 person-months (n = 31221), visits to private clinics (31.0, 95% CI 30.0–32.0) and primary health centres (25.5, 95% CI 24.6–26.4) were most frequent. Antibiotics were used during 64.3% (95% CI 55.2–73.5%, 162/224) of visits to private clinics, 51.1% (95% CI 45.1–57.2%, 245/469) to health centres, and 48.8% (95% CI 44.4–53.2%, 344/454) to medicine stores. Antibiotic defined daily doses per 1000 inhabitants per day varied between 1.75 (95% CI 1.02–2.39) in rural Kimpese and 10.2 (95% CI 6.00–15.4) in (peri) urban Kisantu, mostly explained by differences in healthcare utilisation (respectively 27.8 versus 105 visits per 1000 person-months), in particular of private clinics (1.23 versus 38.6 visits) where antibiotic use is more frequent. The fraction of Watch antibiotics was 30.3% (95% CI 24.6–35.9%) in private clinics, 25.6% (95% CI 20.2–31.1%) in medicine stores, and 25.1% (95% CI 19.0–31.2%) in health centres. Treatment durations <3 days were more frequent at private clinics (5.3%, 9/169) and medicine stores (4.1%, 14/338) than at primary health centres (1.8%, 5/277).DiscussionPrivate healthcare providers, ubiquitous in peri-urban settings, contributed most to community-wide antibiotic use and more frequently dispensed Watch antibiotics and shortened antibiotic courses. Efforts to optimize antibiotic use should include private providers at community level.     

The supervisory relationship from an attachment perspective: Connections to burnout and sense of coherence in health professionals

Supervision is an essential part of the training and work environment of health professionals, especially of psychotherapists and clinical/health psychologists. However, although the supervisory process is always a relational one and may therefore be influenced by attachment dynamics, the importance of the supervisory relationship for the professional's performance and the well-being of the supervisee has yet to be fully examined. In this cross-sectional observational study, the Experiences in Close Relationships-Revised (ECR-RD; avoidant and anxious attachment), the Supervisory Relationship Questionnaire (SRQ), the Maslach Burnout Inventory (MBI) and the Sense of Coherence Scale (SOC-13) were analysed for 346 (81.8% female) health professionals. Considering professional experience and number of supervision sessions as control variables, a better supervisory relationship negatively predicted burnout symptoms (β = −.31) but positively predicted sense of coherence (β = .31, both p < .01). The final model, including avoidant and anxious attachment as additional predictors, explained 30% of the variance in burnout symptoms and 41% of the variance in sense of coherence. The results underline the importance of the supervisory relationship for the well-being and the professional performance of health professionals. Interactions between the supervisory relationship and underlying attachment parameters should be further explored in future studies.     

Distributed health informatics graduate education for working professionals

This paper describes a new distributed Master of Science degree program stream in health informatics (HI) at the University of Victoria, Canada, aimed at healthcare and information technology professionals working in the health setting. This is a part-time graduate program where students are required to complete 10 courses and a research project for the degree over 2 years. The course delivery is through a mixture of real-time virtual classes, asynchronous online forums/resources, two capstone courses each summer as a 2-week intensive on-campus workshop, and a major workplace related field research project. Examples of innovation include the use of Web-based conferencing for real-time virtual classes, simulated tele-debriefing for policy/decision makers, roundtable sessions with chief information officers, modularized professional development courses, and joint field research project oversight with employers. The paper then discusses the need to refine the program/course offering to ensure its consistency to current HI curriculum and competency standards, pleas for a coordinated approach to HI capacity building in Canada, and outlines planned next steps for the School in the coming year.     

Preconception care: who needs it,who wants it,and how should it be provided?

BACKGROUND: Preconception care (PC) aims to identify and reduce a number of modifiable factors that can adversely affect pregnancy outcome. AIM: To ascertain both knowledge of the attitudes towards PC among members of primary health care teams (PHCTs) and registered women of childbearing age in a representative sample of general practices in Harrow. METHOD: A questionnaire survey was conducted in a randomly selected group of nine general practices in the London borough of Harrow. Subjects included all relevant health professionals and female patients of childbearing age registered with the practices. RESULTS: A total of 62/88 (70.5%) health professionals and 811 women (1 in 20 of the entire target population) completed the questionnaires. Nurses' knowledge matched that of the doctors, except in the area of genetics. Over 85% of all health professionals believed that PC could be of benefit to both mother and baby. Women were generally well informed; Asian women, those born outside the UK, those who had never been pregnant, and those who had not undertaken education beyond the age of 18 years were significantly less well informed. Health professionals considered PC to be best delivered opportunistically by nurses, and this method appeared to be acceptable to most female patients of childbearing age, although it was significantly less acceptable among Asians. CONCLUSION: Among health professionals and women of childbearing age, there is generally a good level of knowledge of PC, although certain groups are less well informed than others and could benefit from a targeted education approach. Widespread agreement that PC is worthwhile was found among PHCT members, but this view is less strongly held by the female public, with the acceptability of providing PC opportunistically differing significantly between ethnic groups.     

What works in genomics education: outcomes of an evidenced-based instructional model for community-based physicians

PurposeEducation of practicing health professionals is likely to be one factor that will speed appropriate integration of genomics into routine clinical practice. Yet many health professionals, including physicians, find it difficult to keep up with the rapid pace of clinical genomic advances and are often uncomfortable using genomic information in practice.MethodsHaving identified the genomics educational needs of physicians in a Silicon Valley–area community hospital, we developed, implemented, and evaluated an educational course entitled Medicine’s Future: Genomics for Practicing Doctors. The course structure and approach were based on best practices in adult learning, including interactivity, case-based learning, skill-focused objectives, and sequential monthly modules.ResultsApproximately 20–30 physicians attended each module. They demonstrated significant gains in genomics knowledge and confidence in practice skills that were sustained throughout and following the course. Six months following the course, the majority of participants reported that they had changed their practice to incorporate skills learned during the course.ConclusionWe believe the adult-learning principles underlying the development and delivery of Medicine’s Future were responsible for participants’ outcomes. These principles form a model for the development and delivery of other genomics educational programs for health professionals.     

Nursing curriculum and continuing education: future directions

Redefinition of roles and functions in the healthcare systems of the future requires embracing to the value of continuing education. Within this framework healthcare professional education and continuing education, there are several core competencies described by Institute of Medicine (IOM) [A.C. Greiner, E. Knebel (Eds.), Health Professionals Education: Bridge to Quality, IOM, available at, May 2003] that form the foundation for practice for nurses and other healthcare professionals. An overarching sentence in the document says "All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics" (p. 45). These IOM core competencies are: (1) Common value for respecting patients' differences, values, preferences and expressed needs. (2) Ability to cooperate, collaborate, communicate and integrate care using interdisciplinary teams. (3) Knowledge of and willingness to employ evidence-based practice principles. (4) Capability to apply quality and safety improvement approaches in care. (5) Understand, value and use informatics to all areas of health care, to reduce errors, manage knowledge and information, and make decisions and communicate. In enveloping these core competencies in basic and continuing education, it is necessary to build an evidence base for education itself, demand that faculty are prepared for the future. A crucial need is for healthcare professional students (including nursing students) learn interdisciplinary collaboration in the education of patients. A global strategy, using these competencies for preparing faculty is necessary; and some models already exist that can be further developed to meet future needs that are informatics driven in our increasingly technological future care systems.     

Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: stress and psychological impact among frontline healthcare workers

BACKGROUND: The outbreak of severe acute respiratory syndrome (SARS) posed an unprecedented threat and a great challenge to health professionals in Hong Kong. The study reported here aimed at investigating the origin of stress and psychological morbidity among frontline healthcare workers in response to this catastrophe. METHOD: Self-administered questionnaires were sent to frontline healthcare workers in three hospitals. The General Health Questionnaire was used to identify psychological distress. Socio-demographic and stress variables were entered into a logistic regression analysis to find out the variables associated with psychological morbidity. RESULTS: The response rate was 40 %. Sixty-eight per cent of participants reported a high level of stress. About 57 % were found to have experienced psychological distress. The healthcare workers' psychological morbidity was best understood by the perceptions of personal vulnerability, stress and support in the workplace. CONCLUSION: These findings shed light on the need for hospital administrators to be aware of the extent and sources of stress and psychological distress among frontline healthcare workers during disease outbreak.     

Occupational violence against dental professionals in southern Nigeria

Objective

To determine the prevalence of workplace violence in Oral healthcare centres against Nigerian dental professionals.

Methods

A questionnaire-based cross-sectional survey of 175 randomly selected dental professionals working in Oral healthcare centres of University Teaching Hospitals in Southern Nigeria was conducted.

Results

The survey response rate was 78.9%. The respondents were dentists (58.0%), dental nurses (18.1%), dental technologists (12.3%), dental therapists (8.0%) and dental record officers (3.6%). The prevalence of violence in Nigerian Oral healthcare centres was 31.9%. There was no statistically significant difference in the prevalence of violence against dentist and dental auxiliaries. Violence was often associated with long waiting time (27.3%), cancellation of appointment (13.6%), outcome of patient''s treatment (11.4%), alcohol intoxication (9.1%), psychiatric patient (6.8%,) patient''s bill (4.5%) and others (27.3%). Non-physical violence in form of loud shouting (50.0%) threat (22.7%), sexual harassment (6.8%) and swearing (2.3%) constituted the majority while physical violence in form of bullying and hitting constituted the remaining 18.2%. The main perpetrators of the violence were patients (54.5%) and patient''s relatives/friends (18.2%). The expressed impact of violence among the respondents include fear (18.2%), impaired job performance (15.9%), psychological problems (13.6%) and off duty (9.1%). No impact was declared by 43.2% of respondents.

Conclusion

The prevalence of workplace violence in Oral healthcare centres against dental professionals in Southern Nigeria was significant and had a substantial effect on dental professionals'' well-being thus necessitating urgent attention.     

Impact of adding a video to patient education on quality of life among adults with atrial fibrillation: a randomized controlled trial

ObjectiveTo assess whether adding a video on atrial fibrillation (AF) to a face-to-face educational session improves quality of life (QoL), knowledge, and health resource utilization (HRU) among AF patients.MethodsIn this parallel clinical trial, adults with AF received a face-to-face educational session on AF and were randomly allocated to watch an educational video or not. Self-reported questionnaires measured QoL (primary outcome; score 0–100), AF knowledge (score 0–25), and HRU. Data were collected before and after interventions. Within- and between-group changes were estimated by mixed models.ResultsSixty participants (age: 56 ± 13 years; men: n = 41) were allocated to watch the video after education (n = 30) or to receive education only (n = 30). Within groups over time, QoL and knowledge significantly improved. Knowledge increased by 2.3 units (95% confidence interval: 0.5–4.1) more in participants who watched the video than in others (P = 0.014). Changes in QoL and HRU were not different between groups.ConclusionComplementing education with a video on AF did not result in additional positive impacts on QoL and HRU among AF adults but led to greater improvements in AF knowledge.Practice ImplicationsThe video on AF could be used as part of educational sessions to increase AF knowledge in AF patients.     

A novel stress and coping workplace program reduces illness and healthcare utilization

OBJECTIVE: The purpose of this study was to determine if a novel workplace stress management program, delivered either face-to-face or by self-help, would reduce illness and health services utilization among participants. METHODS: Five hundred one volunteers were randomly allocated to one of three groups: full intervention, which received assessment and personalized self-study feedback and was offered six face-to-face, small-group sessions; partial intervention, a self-help group that received assessment and personalized feedback by mail; and a wait-list control group. All participants completed questionnaires for stress, anxiety, and coping at the start of the study and 6 and 12 months later. Health reports were completed at 0, 3, 6, 9, and 12 months. A subsample of subjects who subscribed to a single health maintenance organization provided objectively recorded doctor visit data across the study year. RESULTS: All three groups reported significant improvement in their stress, anxiety, and coping across the year. Full intervention participants showed a more rapid reduction in negative responses to stress than did participants from the other groups. Full-intervention subjects also reported fewer days of illness than subjects in the other groups. Objectively measured physician visits showed a large (34%) reduction in healthcare utilization for full intervention subjects in the HMO subsample. CONCLUSIONS: These results indicated that a work-site program that focuses on stress, anxiety, and coping measurement along with small-group educational intervention can significantly reduce illness and healthcare utilization.     

Critical appraisal skills training for health care professionals: a randomized controlled trial [ISRCTN46272378]

Introduction

Critical appraisal skills are believed to play a central role in an evidence-based approach to health practice. The aim of this study was to evaluate the effectiveness and costs of a critical appraisal skills educational intervention aimed at health care professionals.

Methods

This prospective controlled trial randomized 145 self-selected general practitioners, hospital physicians, professions allied to medicine, and healthcare managers/administrators from the South West of England to a half-day critical appraisal skills training workshop (based on the model of problem-based small group learning) or waiting list control. The following outcomes were assessed at 6-months follow up: knowledge of the principles necessary for appraising evidence; attitudes towards the use of evidence about healthcare; evidence seeking behaviour; perceived confidence in appraising evidence; and ability to critically appraise a systematic review article.

Results

At follow up overall knowledge score [mean difference: 2.6 (95% CI: 0.6 to 4.6)] and ability to appraise the results of a systematic review [mean difference: 1.2 (95% CI: 0.01 to 2.4)] were higher in the critical skills training group compared to control. No statistical significant differences in overall attitude towards evidence, evidence seeking behaviour, perceived confidence, and other areas of critical appraisal skills ability (methodology or generalizability) were observed between groups. Taking into account the workshop provision costs and costs of participants time and expenses of participants, the average cost of providing the critical appraisal workshops was approximately £250 per person.

Conclusions

The findings of this study challenge the policy of funding 'one-off' educational interventions aimed at enhancing the evidence-based practice of health care professionals. Future evaluations of evidence-based practice interventions need to take in account this trial's negative findings and methodological difficulties.

     

An evaluation of the Rural Medical Education Program of the State University Of New York Upstate Medical University, 1990-2003.

PURPOSE: The Rural Medical Education Program (RMED) of the State University of New York (SUNY) Upstate Medical University is a 36-week clinical experience in rural communities for medical students that began in 1989. The authors sought to assess RMED's success in providing a valuable educational experience for students that assists rural communities recruit physicians. METHOD: In 2004, the authors used the Physician Masterfiles of the American Medical Association to compare practice locations of SUNY Upstate graduates who completed RMED with those who did not; surveyed former RMED students to assess their satisfaction with their practice location and the importance of RMED in helping them choose a location; interviewed hospital administrators in communities that have hosted RMED students to understand the impact of RMED on host communities; and compared United States Medical Licensing Examination Step 2 scores of RMED students with those of non-RMED students to evaluate educational attainment. RESULTS: A greater percentage of former RMED students practiced in rural locations [22/86 (26%)] than did non-RMED students [95/1,307 (7%)]. Ninety-one percent (69/76) of former RMED students were satisfied with their location, and 84% (64/76) believed that RMED was important in helping them choose a location. Hospital administrators viewed the program highly because it helped them recruit physicians and benefitted their medical staff. RMED students had higher adjusted mean Step 2 scores than did non-RMED students (212.3 versus 199.1). CONCLUSION: The RMED program has successfully met its goals of providing a valuable educational experience for medical students and assisting rural communities recruit physicians.