Applying evidence-based health care to musculoskeletal patients as an educational strategy for chiropractic interns (a one-group pretest-posttest study)

OBJECTIVE: To describe and measure the effectiveness of a problem-based educational strategy for teaching evidence-based health care (EBHC) to chiropractic interns, which focused on the development and appraisal of answerable clinical questions using actual musculoskeletal patients. METHODS: A 1-group pretest-posttest design (simple panel design) with investigator-blinded survey administration was used to measure effectiveness of educational activities using adult learning theory with a study population of interns (n=31) at a chiropractic college (Los Angeles College of Chiropractic, Southern California University of Health Sciences [LACC/SCUHS]) teaching clinic. Activities included 2 workshops on constructing clinical questions and critical appraisal of published research and independent patient-based EBHC assignments. A qualitative self-assessment survey was administered before and after a 6-week period of EBHC activities to measure their effectiveness. Sign tests and paired t tests were utilized to determine P values for significant difference of score results. RESULTS: Eighty-one percent of subjects completed the pretest-posttest surveys. All survey item responses showed an average increase in subjects' self-rating of skills and attitudes from pretest to posttest. There were statistically significant differences in interns' self-assessed ability to construct an answerable clinical question and appraise research articles and apply them to patient management, as well as their rating of importance of EBHC in patient decision making. CONCLUSIONS: The results of this study suggest that having chiropractic interns apply EBHC to actual musculoskeletal patients along with attending EBHC workshops had a positive impact on interns' perceived ability to practice EBHC.     

Models for combining random and systematic errors. assumptions and consequences for different models.

A series of models for handling and combining systematic and random variations/errors are investigated in order to characterize the different models according to their purpose, their application, and discuss their flaws with regard to their assumptions. The following models are considered 1. linear model, where the random and systematic elements are combined according to a linear concept (TE = absolute value(bias) + z x sigma), where TE is total error, bias is the systematic error component, sigma is the random error component (standard deviation or coefficient of variation) and z is the probability factor; 2. squared model with two sub-models of which one is the classical statistical variance model and the other is the GUM (Guide to Uncertainty in Measurements) model for estimating uncertainty of a measurement; 3. combined model developed for the estimation of analytical quality specifications according to the clinical consequences (clinical outcome) of errors. The consequences of these models are investigated by calculation of the functions of transformation of bias into imprecision according to the assumptions and model calculations. As expected, the functions turn out to be rather different with considerable consequences for these types of transformations. It is concluded that there are at least three models for combining systematic and random variation/errors, each created for its own specific purpose, with its own assumptions and resulting in considerably different results. These models should be used according to their purposes.     

The care encounter: pondering caring, honest communication and control

The proposition presented in this paper is that caring, underpinned by beneficence and non-maleficence, assumes that nurses will make determinations about another's best interests and act accordingly. With some emphasis on high-level (nursing home) aged care, it is the author's contention that nurses give priority to communication that controls the care encounter rather than acting in another's best interests. This view is supported in the literature, which suggests that nurses perceive honesty and information-sharing as less important in caring than do patients, and nurses' perception that telling another the truth is harmful and, therefore, contravenes the duties of beneficence and non-maleficence.     

Even broken clocks are right twice a day: The utility of models in the clinical reasoning process

The use of cognitive neuropsychological models in rehabilitation has been widely debated among professionals in a variety of disciplines. Some believe that models can be used to develop “model-based” treatment, while others maintain that the role of models in rehabilitation is more limited in scope. Despite the debate, it is widely accepted that models do contribute to the rehabilitation process. While models can assist in clinical decision making, it is important to understand the underlying assumptions of the model and be aware that the “truth” of a model is something we seek and rarely achieve, and this evolution remains a continuing process. This article compares the Praxis Model of Rothi and Heilman () and the Sketch Model of de Ruiter (), highlighting the contrasting underlying assumptions regarding the relationship of gesture and language. The limitations of these models is then used as segue for the discussion of the current debate regarding cognitive neuropsychological models and rehabilitation. We conclude with our view that models are assistive rather than directive.     

Ability of pulse contour and esophageal Doppler to estimate rapid changes in stroke volume

OBJECTIVE: Two technologies to acquire beat-to-beat stroke volume values exist, pulse contour analysis and esophageal Doppler monitoring. Pulse contour analysis assumes fixed aortic impedance. Esophageal Doppler assumes a constant proportional descending aortic flow and diameter. These assumptions may not be correct as arterial tone or myocardial contractility vary. We tested these relationships in the setting of rapidly changing stroke volumes and different cardiovascular states over a period of 10-15 cardiac cycles. DESIGN AND SETTING: In a university research facility we compared beat-to-beat changes in stroke volume as measure by aortic root flow probe or conductance catheter to pulse contour analysis and stroke distance as measured by esophageal Doppler. SUBJECTS: Five purpose-bred research hounds. INTERVENTIONS: To obtain a wide range of rapidly changing stroke volumes measurements were made during transient inferior vena cava occlusion. Data were gathered under baseline conditions and during norepinephrine, nitroprusside, and dobutamine infusions. MEASUREMENTS AND RESULTS: The pulse contour stroke volumes and esophageal Doppler stroke distance paralleled flow probe stroke volumes under all conditions (R(2)=0.89 for all measures). However, the absolute changes and proportional changes and the absolute values for both surrogate measures differed from absolute stroke volumes. Bland-Altman analysis showed no consistent bias or degree of precision across all animals under any given cardiovascular state. CONCLUSIONS: Both pulse contour stroke volumes and esophageal Doppler derived stroke distance estimates yield significant correlations with aortic root flow probe. However, the absolute values, absolute changes, or proportional changes may not reflect actual stroke volumes as cardiovascular state varies, making their use in estimating absolute changes in stroke volume potentially inaccurate.     

Clinical attrition due to biased preclinical assessments of potential efficacy

Unless it is carefully controlled, bias often distorts the results of clinical trials, usually exaggerating the magnitude of true efficacy. For that reason, procedures to limit bias have been mandated by the FDA when assessing efficacy in clinical trials. The present review shows that the effects of bias in preclinical studies are at least as large as in clinical trials, and since bias is not usually controlled in preclinical proof of concept studies, compounds that actually have little or no therapeutic potential may often be advanced into clinical trials. This possibility is supported by the fact that lack of efficacy is the single biggest reason why compounds fail in the clinic. The shift to target-based discovery during the last 10-15 years may have further increased the effects of bias on preclinical assessments of potential efficacy, and contributed to the continuing decline in clinical success rates. Procedures are available to control for bias during preclinical assessments of potential efficacy, and their use could dramatically increase clinical success rates and substantially reduce the costs of drug discovery and development.     

Analytical quality specifications for serum lactate dehydrogenase isoenzyme 1 based on clinical goals.

The aim of the study was to deduce analytical quality specifications for the determination of catalytic concentration of serum lactate dehydrogenase isoenzyme 1 (S-LD-1) according to clinical goals (the clinical utility model). We defined clinical goals for false positive and false negative S-LD-1 measurements in the monitoring of patients with testicular germ cell tumors (TGCT), clinical stage I, on a surveillance only program. The absolute S-LD-1 catalytic concentrations were routinely corrected for contamination from preanalytical hemolysis. A reference group of 37 men had a near In-Gaussian distribution for the absolute S-LD-1 catalytic concentration. The geometric mean was 76 U/l and an S-LD-1 >128 U/l (99.72 percentile, the decision limit) indicated a high risk of a relapse of TGCT. We have previously shown that an S-LD-1 >160 U/l (treatment limit) was associated with a suboptimal outcome from the treatment of metastatic TGCT. The maximum allowable analytical positive bias was 5 U/l, and the maximum allowable analytical negative bias was -32 U/l. The maximum allowable analytical coefficient of variation, CV(A), was 11% (approximately 14 U/l) at a bias = -5 U/l. For S-LD-1 measurements not corrected for hemolysis, the decision limit was 145 U/l, the maximum allowable negative bias -19 U/l, and CV(A) 8%(approximately 12 U/l). A routine correction for hemolysis had a large impact on the analytical quality specifications.     

Deriving proper measurement uncertainty from Internal Quality Control data: An impossible mission?

Measurement uncertainty (MU) is a “non-negative parameter characterizing the dispersion of the quantity values being attributed to a measurand, based on the information used”. In the clinical laboratory the most convenient way to calculate MU is the “top down” approach based on the use of Internal Quality Control data. As indicated in the definition, MU depends on the information used for its calculation and so different estimates of MU can be obtained. The most problematic aspect is how to deal with bias. In fact bias is difficult to detect and quantify and it should be corrected including only the uncertainty derived from this correction. Several approaches to calculate MU starting from Internal Quality Control data are presented. The minimum requirement is to use only the intermediate precision data, provided to include 6 months of results obtained with a commutable quality control material at a concentration close to the clinical decision limit. This approach is the minimal requirement and it is convenient for all those measurands that are especially used for monitoring or where a reference measurement system does not exist and so a reference for calculating the bias is lacking. Other formulas including the uncertainty of the value of the calibrator, including the bias from a commutable certified reference material or from a material specifically prepared for trueness verification, including the bias derived from External Quality Assessment schemes or from historical mean of the laboratory are presented and commented. MU is an important parameter, but a single, agreed upon way to calculate it in a clinical laboratory is not yet available.     

Incorporating standardized patients into a psychosocial nurse practitioner program

Interactions with standardized patients (SPs) provide customized, immediate clinical learning for graduate nursing students. SPs are lay persons trained to portray a role in a faculty-designed health care scenario for a series of students. Student learning results from the experience of the encounter, performance feedback from the SP, subsequent classroom discussion with peers, faculty critique, and review of the videotaped interaction. Design and implementation of an SP experience involves clarification of goals for the encounter, development of the clinical scenario, recruitment and training of SPs, preparation of students, and management of the logistics of the exercise. Although the process is labor-intensive, we have found SP experiences versatile, valuable, and popular with students.     

Living with dementia: communicating with an older person and her family

This article is designed to explore and examine the key components of communication that emerged during the interactional analysis of a role play that took place in the classroom. The 'actors' were nurses who perceived the interaction to reflect an everyday encounter in a hospital ward. Permission to tape the interaction was sought and given by all persons involved. The principal 'players' in the scenario were: the patient, a 70-year-old-woman who had been admitted with dementia, her son and daughter, and the nurse in charge of the ward. The fundamental dynamics of the use of power and restriction, truth telling, family stress, interpersonal conflict, ageism, sexism, empathy and humanism surfaced during the analysis. The findings show that therapeutic communication should be the foundation on which nursing should stand. The article continues with an exploration of the theoretical frameworks that guided the analysis of interaction and concludes by suggesting tentatively some meaningful implications for nursing practice. It plans to furnish provocative new insights into the sometimes covert communication dynamics occurring within the nurse-patient relationship. Finally, it aims to generate discussion on this little-charted realm of human social interaction.     

Clinimetrics corner: the many faces of selection bias

Selection bias, also known as susceptibility bias in an intervention study or spectrum bias in a diagnostic accuracy study, is present throughout clinically applicable evidence in various forms. Selection bias implies that the intervention or diagnostic test has been studied in a less representative sample population, which can lead to inflated overall effect sizes and/or inaccurate findings. Within the literature, there are over 40 forms of selection bias that can influence the external validity of results. Recognition of selection bias is essential in the translation of evidence into effective clinical practice. This clinimetrics corner outlines the major biases that readers encounter and discusses key examples regarding pertinent orthopedic and manual therapy literature.     

Potential Pitfalls of Clinical Prediction Rules

Abstract

Selection bias, also known as susceptibility bias in an intervention study or spectrum bias in a diagnostic accuracy study, is present throughout clinically applicable evidence in various forms. Selection bias implies that the intervention or diagnostic test has been studied in a less representative sample population, which can lead to inflated overall effect sizes and/or inaccurate findings. Within the literature, there are over 40 forms of selection bias that can influence the external validity of results. Recognition of selection bias is essential in the translation of evidence into effective clinical practice. This clinimetrics corner outlines the major biases that readers encounter and discusses key examples regarding pertinent orthopedic and manual therapy literature.     

Is non-judgemental care possible in the context of nurses' attitudes to patients' sexuality?

Developments in nursing practice in the United Kingdom are increasingly focusing on holistic models and approaches to care The recognition of the importance of sexuality and sexual orientation of patients is a significant aspect of holistic care This paper explores and discusses the literature in the arena of nurses' attitudes to patients' sexuality From this discussion the concept emerges that nursing needs to recognize the effect that attitudes towards patients' sexuality has on nursing care, and develop strategies that allow this to be reflected on The use of reflection facilitated by clinical supervision will be presented as a potential way forward     

Academic and clinical dissonance in nursing education: are we guilty of failure to rescue?

The experience of cognitive dissonance in novice clinical nursing students is examined. These students often confront an incongruity between the rule-bound academic ideal of nursing with which they have been prepared and the more flexible, intuition-driven clinical reality they encounter. Without insightful guidance from clinical faculty, the students' response to this dissonance could include disillusionment with clinical nursing practice or devaluation of the academic ideal of nursing. Cognitive Dissonance Theory, the Novice to Expert Model, and the Neuman Systems Model provide insight into this phenomenon and serve as a theoretical foundation for recommended strategies and interventions for optimal response to dissonance between academic ideal and clinical reality in nursing students.     

From wholes to fragments to wholes—what gets lost in translation?

The highly demanding and, in a certain sense, unique, working conditions of general practitioners (GPs) are characterized by two phenomena: First, they involve an increasing familiarity with individual patients over time, which promotes a deepening of insight. Second, they enable the GP to encounter all kinds of health problems, which in turn facilitates pattern recognition, at both individual and group levels, particularly the kind of patterns currently termed “multimorbidity.” Whereas the term “comorbidity” is used to denote states of bad health in which 1 disease is considered to predate and evoke other ailments or diseases, the term multimorbidity is applied when finding several presumably separate diseases in a person who suffers from them either sequentially or simultaneously. Encounters with patients whose suffering fits the biomedical concept and terminology of multimorbidity are among the most common which GPs face, presenting them with some of their most demanding tasks. The term multimorbidity needs to be examined, however. As it alludes to a multiplicity of diseases, it rests on an assumption of separateness of states of bad health that might not be well founded. An adequate determination of what to deem a “separate” state of bad health would require that the biomedical concept of causation be scrutinized.     

The strengths and weaknesses of quantitative and qualitative research: what method for nursing?

The overall purpose of research for any profession is to discover the truth of the discipline This paper examines the controversy over the methods by which truth is obtained, by examining the differences and similarities between quantitative and qualitative research The historically negative bias against qualitative research is discussed, as well as the strengths and weaknesses of both approaches, with issues highlighted by reference to nursing research Consideration is given to issues of sampling, the relationship between the researcher and subject, methodologies and collated data, validity, reliability, and ethical dilemmas The author identifies that neither approach is superior to the other, qualitative research appears invaluable for the exploration of subjective experiences of patients and nurses, and quantitative methods facilitate the discovery of quantifiable information Combining the strengths of both approaches in triangulation, if time and money permit, is also proposed as a valuable means of discovering the truth about nursing It is argued that if nursing scholars limit themselves to one method of enquiry, restrictions will be placed on the development of nursing knowledge     

To tell or not to tell: attitudes of Chinese oncology nurses towards truth telling of cancer diagnosis

Aims and objectives. To investigate the attitude of oncology nurses towards whether and how to disclose diagnoses to patients with early‐stage cancer or terminal illness. Background. The attitudes of patients and doctors towards the disclosure of cancer diagnosis differed from culture to culture. However, little research has focused on the attitudes of Chinese oncology nurses. Design. Survey. Methods. A questionnaire investigating nurses’ attitudes towards truth telling was delivered to 243 Chinese oncology nurses. Results. One hundred and ninety‐nine (81?9%) nurses completed the questionnaire. 81?4% of the nurses reported that patients with early‐stage cancer should be informed of the diagnosis, while only 44?2% believed that patients with terminal illnesses should know the truth (p < 0?001). Nurses who preferred truth telling reported that patients with early or terminal stages of cancer should be informed by the doctor in charge (76?5% vs. 73?9%, respectively; p > 0?05), immediately after the diagnosis (75?9% vs. 79?5%, respectively) and in a quiet and undisturbed room (80?9% vs. 70?5%, respectively; p > 0?05). Nurses’ attitudes towards truth telling of terminal cancer were influenced by their educational level and work experience. Conclusion. Oncology nurses differed in their attitudes towards truth telling of different stages of cancer. Nurses who preferred disclosure reported that cancer patients should be informed by the doctor in charge immediately after the diagnosis and in a quiet and undisturbed room. Relevance to clinical practice. Many Chinese doctors, patients and their relatives believed that patients with terminal illness should not know their diagnosis. Thus, oncology nurses need additional training to deal with these situations.     

Clinical simulations: Let's get real!

Simulations have been recommended when clinical facilities are scarce because they provide a similar experience to that which a student would encounter. Pasco-Hernando Community College nursing faculty designed a role-playing home care simulation for students. The students interact with community theater actors in an improvised simulated home health environment. The home care visit interaction is followed by a debriefing session. Here, students identify concerns in the scenario and verbalize their feelings about the experience.     

Medical complications of substance abuse.

Substance abuse is involved in many instances of intentional and unintentional injury. It can also cause medical complications that affect various organ systems--among them, the cardiac, vascular, neurologic, pulmonary, gastrointestinal, immunologic, and reproductive systems. Even though there is pressure to create a new medical specialty to specifically address substance-abuse issues, the truth is that any physician, regardless of specialty, may encounter patients with substance-abuse problems. Alcoholism and drug abuse, with their associated psychosocial and clinical ramifications and complications, cut across all specialty fields. Consequently, all physicians need to be familiar with the spectrum of clinical problems associated with substance abuse and comfortable with addressing these problems prudently and promptly.