Assessment of Healthcare Professionals’ Knowledge About Warfarin-Vitamin K Drug-Nutrient Interactions

Objective: Dietary vitamin K can interact with oral anticoagulant drugs and interfere with their therapeutic safety and efficacy. Therefore, knowledge about drug-nutrient interactions involving vitamin K possessed by physicians, pharmacists, dietitians and nurses practicing anticoagulant therapy was assessed.

Methods: Healthcare practitioners were surveyed using a 30-question, 98-item questionnaire on the most common and/or important food interactions with warfarin, drug interactions with warfarin and general drug-nutrient interactions involving vitamin K. The study sample included 160 randomly selected healthcare providers (40 physicians, pharmacists, dietitians and nurses) from 10 hospitals with 200 to 1000 beds from six Massachusetts regions. Random selection was conducted from a pool of selected healthcare providers practicing anticoagulant therapy who counsel patients receiving warfarin.

Results: All surveys were completed within three months of the start of the study, and all participants provided usable data for statistical analysis. The mean scores (±SD) on the overall test were 72.5±9.0 for pharmacists, 62.5±10.6 for physicians, 56.9±8.8 for dietitians and 50.2±9.3 for nurses, with 100 being a perfect score. Pharmacists scored significantly higher in the area of drug interactions (75.9±11.3, p<0.05). Dietitians scored higher in the area of food interactions (73.0±10.3). No significant differences between physicians and pharmacists were evident on general drug-nutrient interactions. While over 87% of the healthcare professionals correctly identified some common foods containing large amounts of vitamin K, such as broccoli and spinach, fewer than 25% were able to identify others such as pea soup, coleslaw and dill pickles.

Conclusions: Although the healthcare professionals surveyed in this study appear to have demonstrated some proficiency in their respective areas of expertise, they exhibited less knowledge in others. Therefore, additional training and integration of knowledge and expertise about drug-nutrient interactions among healthcare professionals are essential to provide appropriate patient counseling and optimal therapeutic outcomes.     

The Shrinking of Formalized Nutrition Education in Health Professions Curricula and Postgraduate Training

The quantity of formalized nutrition education is shrinking in curricula of health professions, such as physicians, nurses, dietitians, and pharmacists. The current nutrition education being taught in U.S. schools of healthcare professionals does not appropriately prepare students for identification of patients at nutrition risk or management of undernourished hospitalized patients with specialized nutrition therapies. In U.S. schools of pharmacy, parenteral nutrition is considered a highly specialized and advanced practice so little time is devoted to this area and more attention is focused on chronic disease state management (ie, hypertension, diabetes mellitus, and congestive heart failure). Nutrition support fellowships for physicians and nutrition support residency programs for pharmacists have dwindled in number over the years so that only a handful of these healthcare professionals are produced each year from the remaining formalized programs. Physicians, nurses, pharmacists, and dietitians can positively affect patient care, but each profession must first determine how best to integrate basic and applied nutrition concepts into their professional curricula and training programs. There must also be consensus among the healthcare professions as to the depth of nutrition education and the stage of training at which these integrations should occur. Only by having these crucial conversations among all disciplines will we be able to develop new strategies to expand nutrition education in the training of future medical practitioners.     

Exploring Differences in Patient-Centered Practices among Healthcare Professionals in Acute Care Settings

There is limited evidence of the extent to which Healthcare professionals implement patient-centered care (PCC) and of the factors influencing their PCC practices in acute care organizations. This study aimed to (1) examine the practices reported by health professionals (physicians, nurses, social workers, other healthcare providers) in relation to three PCC components (holistic, collaborative, and responsive care), and (2) explore the association of professionals’ characteristics (gender, work experience) and a contextual factor (caseload), with the professionals’ PCC practices. Data were obtained from a large scale cross-sectional study, conducted in 18 hospitals in Ontario, Canada. Consenting professionals (n = 382) completed a self-report instrument assessing the three PCC components and responded to standard questions inquiring about their characteristics and workload. Small differences were found in the PCC practices across professional groups: (1) physicians reported higher levels of enacting the holistic care component; (2) physicians, other healthcare providers, and social workers reported implementing higher levels of the collaborative care component; and (3) physicians, nurses, and other healthcare providers reported higher levels of providing responsive care. Caseload influenced holistic care practices. Interprofessional education and training strategies are needed to clarify and address professional differences in valuing and practicing PCC components. Clinical guidelines can be revised to enable professionals to engage patients in care-related decisions, customize patient care, and promote interprofessional collaboration in planning and implementing PCC. Additional research is warranted to determine the influence of professional, patient, and other contextual factors on professionals’ PCC practices in acute care hospitals.     

The knowledge of healthcare professionals with regard to the treatment and prevention of head lice

This study examined the knowledge and practice of healthcare professionals regarding the prevention and treatment of head lice 18 months after dissemination of local guidelines. A self-administered postal questionnaire was sent to all primary healthcare professionals (general practitioners and practice nurses), community healthcare professionals (community paediatricians, health visitors and school nurses) and pharmacists in South Staffordshire health district, UK. The overall response rate was 48% (range 24-63%). Compared to other groups: community healthcare professionals were more likely to refer to the guidelines and have adequate knowledge of treatment and prevention; pharmacists were least likely to refer to the guidelines; and primary healthcare professionals were most likely to have poor knowledge about prevention and treatment. Overall, healthcare professionals' knowledge regarding prevention methods was significantly better than their knowledge of treatment methods (63% vs. 5%, P <0.00001). In conclusion, the results of this study suggest that healthcare professionals' knowledge of control methods for head lice varies widely and is sub-optimal and may contribute to ineffective head lice control.     

Prevalence of dietitian burnout

Background: Burnout is the result of unmanaged stress that has been shown to affect those working in the healthcare professions. Although much research has been conducted on burnout among nurses, physicians and other health professionals, there is limited documentation on the phenomenon among dietitians. The purpose of this study was to establish the prevalence of burnout among dietitians in Ontario, Canada, determine the demographic variables associated with burnout, and compare these results with burnout data for other healthcare professionals. Methods: The Maslach Burnout Inventory–Human Services Survey and a demographic questionnaire were emailed to registered dietitians. Results: The dietitians surveyed experienced a moderate amount of emotional exhaustion (mean = 19.96), a low level of depersonalisation (mean = 4.31) and a moderate sense of personal accomplishment (mean = 38.61). Statistically significant relationships were found between years as a dietitian and personal accomplishment (r = 0.16; P = 0.05), age and personal accomplishment (r = 0.15; P = 0.01), hours worked per week and emotional exhaustion (r = 0.17; P = 0.01) and hours worked per week and depersonalisation (r = 0.14; P = 0.01). There were no significant differences in mean burnout scores across the five areas of practice. Over 57% of dietitians had scores indicative of moderate to high levels of burnout overall. Conclusions: Although dietitians have lower levels of burnout compared to other healthcare professionals, moderate levels of emotional exhaustion and only moderate levels of personal accomplishment remain workplace issues for this professional group.     

Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care

Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals—nurses, physicians, advanced practice providers, pharmacists, and dietitians—identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization’s Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software.     

成都市二级以上综合性医院医务人员手卫生执行情况及影响因素调查

目的 了解成都市二级以上综合性医院医务人员手卫生执行状况及影响因素.方法 现场观察医务人员手卫生执行情况和手卫生设施,调查医务人员手卫生知识.结果 医务人员手卫生执行率为17.8％(接触患者前执行率为12.8％、接触患者周围物品及环境后执行率为21.0％、接触患者后执行率为27.3％,脱手套后执行率为31.5％);2.2％的医疗室有脚踏或感应式水龙头、24.5％有洗手产品,6.3％有干手物品;92.8％的医务人员知道六步洗手法,对手掌、手背、手指和指背等洗手部位的认知率均在90.0％以上,仅22.8％的人知道搓手时间为≥15s.副主任以上医师(14.6％)、主治医师(9.2％)和医师(15.6％)以及主管以上护师(25.0％)、护师(26.3％)和护士(20.5％)之间手卫生执行率差异均无统计学意义(P＞0.05).副主任以上医师平均知识得分(12.4±3.2)、主治医师(13.6±3.3)和医师(13.4±2.9)以及主管以上护师(15.2±2.0)、护师(14.8±2.1)和护士(14.3±2.6)之间差异亦无统计学意义(P＞0.05).护士的手卫生执行率(22.7％)明显高于医生(13.6％);≥50岁者(7.4％)明显低于＜50岁各年龄组(17.1％～25.0％);女性(19.5％)显著高于男性(13.8％);差异均有统计学意义(P＜0.05).护士的平均知识得分( 14.7±2.3)显著高于医生(13.2±3.1);50～ 59岁年龄组平均知识得分(12.2±3.8)显著低于20～29岁(14.0±2.6)、30～39岁(14.3±2.9)和40～ 49岁(13.8±2.7)组;女性(14.5±2.5)得分显著高于男性(12.7±3.2);差异均有统计学意义(P＜0.05).结论 成都市二级以上综合性医院医务人员手卫生知识水平相对较高,但手卫生执行率偏低,医院手卫生设施不完善.应通过进一步加强培训,改善手卫生设施,以进一步提高手卫生执行率.     

Factors that influence the participation of healthcare professionals in advance care planning for patients with terminal cancer: A nationwide survey in Taiwan

A nationwide study was undertaken to investigate participation in advance care planning (ACP) by cancer care professionals following the enactment of the Natural Death Act in Taiwan in 2000. This multi-center study surveyed 600 physicians and nurses working in oncology care wards or palliative care units using a structured mailed questionnaire. Logistic regression analysis revealed that working in a hospice, attitudes about the Natural Death Act and knowledge about the Natural Death Act were three independent factors that positively influenced the participation in ACP. The results demonstrate that the enactment of the Natural Death Act in Taiwan contributes to promoting the participation in ACP. Educating cancer care professionals about practicing palliative care and building positive attitudes toward the Act should be strongly encouraged.     

Thanatophobia and opiophobia of hospice nurses compared with that of other caregivers

In meeting national needs for our terminally ill, health care educators need to become more aware of their students' aptitudes for hospice work. For these reasons we measured hospice nurses' attitudes toward caring for the terminally ill and their views on using opioids, and compared them to those of other health care personnel and their students. Thirty-eight hospice nurses, 64 other nurses, 93 physicians, and 676 senior medical students participated in this study. Our primary measures were scales assessing thanatophobia and opiophobia and a battery of personal and professional role trait measures. Our results indicated that in providing end-of-life care, hospice nurses expressed less discomfort, helplessness, and frustration, and indicated less reluctance to use opioids than did any of the other groups surveyed. Overall, these hospice nurses had 35 percent lower opiophobia and 55 percent lower thanatophobia scores than the other health care professionals. Despite dealing with issues of death and dying on a daily basis, hospice nurses also scored lower on depressed mood. In caring for the terminally ill, hospice nurses' other personal traits were also less maladaptive than those of the other health professionals. Psychiatrists exhibited the most opiophobia, not only scoring higher than physicians practicing oncology, but also higher than senior medical students. To assure cancer patients that they can expect to live their lives free of pain, medical educators can use these thanatophobia and opiophobia scales to develop better teaching, counseling, and monitoring strategies.     

Knowledge about the assessment and management of undernutrition: a pilot questionnaire in a UK teaching hospital.

BACKGROUND & AIMS: The detection, prevention and treatment of undernutrition in hospitals is often poor. This study assesses the knowledge about undernutrition of staff in a UK teaching hospital. METHODS: Twenty nine doctors, 65 final year medical students, 45 nurses, 11 dietitians, and 11 pharmacists anonymously completed a questionnaire of 20 multiple choice questions. One of five possible answers was considered correct. Twelve questions were about adult nutritional assessment and requirements, five about oral/enteral nutrition and three about parenteral nutrition. RESULTS: Dietitians scored significantly more (median 16) than the other groups (doctors: seven, medical students: eight, nurses: seven and pharmacists: nine) (P < 0.0001). Medical students scored more than doctors (P < 0.001). Examples of areas in which knowledge could be improved are: 67% respondents thought the prevalence of hospital undernutrition to be less than 30%. While 91% of respondents correctly chose a well 70 kg man to need about 2000 kcal/day, only 23% knew that approximately the same amount was needed for a febrile post-operative patient. Sixteen percent knew antibiotic treatment to be the most common reason for enteral feeding-related diarrhoea. CONCLUSIONS: Knowledge about the assessment and management of undernutrition among doctors, medical students, nurses and pharmacists was poor. This questionnaire provides a framework for teaching and auditing the effectiveness of an educational program.     

New Food and Drug Administration requirements for inclusion of vitamin K in adult parenteral multivitamins

The newly amended requirements by the Food and Drug Administration (FDA) for an effective adult parenteral multivitamin drug product increase the amounts of vitamins B1, B6, C, and folic acid currently in the product to better meet estimated needs, and specifies the inclusion of 150 microg of vitamin K. Infuvite Adult Multiple Vitamins for Infusion is the first adult parenteral multivitamin product to meet the revised FDA requirements. The inclusion of vitamin K in adult parenteral multivitamin products is intended to afford patients a consistent daily supply of vitamin K approximating usual levels of intake. This is a change to clinical practice in the United States, where vitamin K has not been included in adult parenteral vitamin preparations, and physicians prescribe vitamin K separately. The reformulation of adult parenteral multivitamins required by the FDA raises questions about the potential impact that inclusion of vitamin K will have on patient management. One clinical practice change is that patients on parenteral nutrition receiving Infuvite Adult should no longer need weekly subcutaneous (SC) or intramuscular (IM) vitamin K injections. In addition, the consistent and modest level of vitamin K provided by the reformulated adult parenteral multivitamins may make it easier for physicians to maintain the desired level of hypoprothrombinemia (low levels of prothrombin) in those patients also on anticoagulant therapy with warfarin. However, for physicians accustomed to administering vitamin K separately, it is important to highlight that it may be more difficult to titrate anticoagulant therapy, especially among patients receiving dual feeding or vitamin K from another source. If marketed globally, these clinical practice issues may be more pronounced outside of the United States, where dual feeding is common, and patients may receive vitamin K from other sources.     

Professional roles of a health team: a view of its components

Based on the Theory of Roles, this study aimed to examine health team professionals' views on the role played by their colleagues. We interviewed 39 health professionals: 01 nutritionist, 02 psychologists, 02 nurses, 03 physiotherapists, 04 pharmacists, 10 dentists and 17 physicians. The results showed that the participants considered that teamwork shares responsibility, which relieves stress and is a way of learning; they also indicate that expectations regarding the professionals' role are not very clear and that most participants have little knowledge about their colleagues' professional role. The most clearly described professional roles are those of physicians, nurses and pharmacists. The most obscure is the psychologist's role.     

Unsuspected Source of Vitamin K in Patients Treated with Anticoagulants: A Case Report

The administration of warfarin requires careful attention. Theconcurrent intake of drugs can either enhance or compete withits anticoagulant effect. Less frequently encountered are theeffects from vitamin K added to food, intake of foods with naturallyoccurring high levels of vitamin K and diets deficient in vitaminK. We report a case in which loss of anticoagulant control wascaused by a dietary supplement taken during a weight reducingdiet by a patient who was receiving warfarin following a pulmonaryembolus. A review of the literature reveals several similarcases. Amounts of vitamin K in food supplements and in foodswith large amounts of naturally occurring vitamin K are tabulatedalong with suggestions for surveillance of patients taking anticoagulants.     

Knowledge translation in interprofessional education: what difference does interprofessional education make to practice?

Cancer Care Nova Scotia developed an Interprofessional Core Curriculum for Nova Scotia health professionals, using a provincial educational needs assessment of health professionals caring for patients with cancer. This paper reports on the educational outcomes of the Interprofessional Core Curriculum programme, particularly the translation of learning into changes in practice and interprofessional interaction, and factors influencing change. The evaluation was guided by Kirkpatrick's model for assessing educational outcomes and Green and Kreuter's PRECEDE model of factors promoting and impeding change. In total, 411 participants attended the sessions, including nurses (54%), pharmacists (23%), and physicians (11%). We used self-report questionnaires to assess the transfer of learning into changes in practice and interprofessional interactions. High percentages of participants reported changes in both clinical practice and interprofessional interactions 3 months after the sessions. Frequently reported changes to interprofessional interactions were improved communication, increased confidence and assertiveness in interactions with other health professionals and being more respectful of other professions. Participants identified time and work-load as major barriers to change as well as lack of micro- and macro-system level support. The most common reported enabler of change was having attended the educational session. Overall, participants were highly supportive of interprofessional education, although when compared to nurses and pharmacists, physicians were less supportive and had proportionately lower attendance.     

Management of osteoporosis: a national survey of Israeli dietitians' knowledge and perceptions

The aim of this study was to assess Israeli dietitians' knowledge and attitudes regarding osteoporosis. Participants were 320 dietitians responding to a mail survey. Israeli dietitians scored highly on the Facts on Osteoporosis Quiz-FOOQ. Israeli dietitians' dietary knowledge regarding calcium (recommended dietary allowance, content in food and in supplements) was fairly high; unlike knowledge regarding vitamin D. Israeli dietitians had a firm positive opinion of their role in the prevention and treatment of osteoporosis.     

Knowledge and attitudes toward breast-feeding: Differences among dietitians, nurses, and physicians working with WIC clients

We assessed the knowledge of and attitude toward breast-feeding of dietitians, nurses, and physicians who work with individuals in the Alabama Special Supplemental Food Program for Women, Infants, and Children. On a scale of 0 to 100, dietitians expressed stronger interest in lactation (78.6) and exhibited greater knowledge (79.6) of the questions asked than nurses (74.5 and 73.0, respectively). Attitude and knowledge scores of physicians (70.2 and 75.5, respectively) were not statistically different from those of dietitians or nurses. Respondents disagreed greatly about the relationship of breast-feeding to weight loss and the appropriateness of oral contraceptive during breast-feeding 6 weeks postpartum. Professionals were more knowledgeable about benefits to infants than about maternal concerns. Results of this study suggest that professional breast-feeding education programs should address maternal concerns such as weight loss, contraception, and mastitis as well as benefits to the infant.     

Development of a self-assessment instrument to determine daily intake and variability of dietary vitamin K

OBJECTIVE: To develop and validate a brief, self-assessment instrument (K-Card) to determine daily variations in dietary vitamin K1 (phylloquinone) intake for use in patients receiving oral warfarin anticoagulant therapy. METHODS: The K-Card was designed to include a checklist of selected common foods and beverages providing > or = 5 microg vitamin K per serving in American diets and items with lower vitamin K content typically consumed in quantities which contribute significantly to total vitamin K intake. The K-Card was validated against records of weighed food intake from thirty-six healthy volunteers, 20 to 40 and 60 to 80 years of age, whose phylloquinone intakes and plasma concentrations had been previously measured by the Metabolic Research Unit, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA USA. Future use of the K-Card by patients was simulated by a single investigator using 108 one-day weighed food records to estimate phylloquinone intakes. Dietary phylloquinone calculated from the K-Card was compared to the values of phylloquinone intake from the diet records collected on the same days, and to fasting plasma phylloquinone concentrations obtained from the same individuals on the following day. RESULTS: The mean dietary phylloquinone intake (+/- SEM) was 138.8 +/- 15.7 microg for the K-Cards compared to 136.0 +/- 15.8 microg for the diet records (p = 0.067). Bland-Altman limits of agreement between quantities of dietary phylloquinone calculated from the K-Card and values obtained from the weighed food records were +/- 38 microg. CONCLUSION: In this simulation, the K-Card provided an accurate estimate of dietary phylloquinone intake and therefore deserves further testing for use by patients receiving coumarin-based anticoagulant therapy to determine whether variability in dietary patterns contributes to disruptions in anticoagulant drug efficacy and safety.     

Expanding the clinical role of community pharmacy: A qualitative ethnographic study of medication reviews in Ontario,Canada

Medication reviews by community pharmacists are an increasingly common strategy to improve medication management for chronic conditions, and are part of wider efforts to make more effective use of community-based health professionals. To identify opportunities to optimize the medication review program in Ontario, Canada, we explored how providers and clients interpret and operationalize medication reviews within everyday community pharmacy practice. We conducted a qualitative ethnographic study at four pharmacies in Ontario, Canada, including non-participant observation of provider and client activities and interactions with specific attention to medication reviews, as well as brief ethnographic interviews with providers and clients, and in-depth, semi-structured interviews with providers. We report on 72 h of field research, observation of 178 routine pharmacist-client interactions and 29 medication reviews, 62 brief ethnographic interviews with providers and clients, and 7 in-depth, semi-structured interviews with providers. We found that medication reviews were variably conducted across the dimensions of duration, provider type, location, and interaction style, and that local contexts and system-wide developments influence their meaning and practice. Medication reviews are exemplary of policy efforts to enhance the role of community pharmacies within health systems and the scope of practice of pharmacists as healthcare professionals. Our study highlights the importance of the local structure of community pharmacy practice and the clinical aspirations of pharmacists in the delivery of medication reviews.     

Leadership in clinical dietetics: meeting the challenge to roles in nutritional support

The success of efforts to improve nutrition training of other health professionals poses a threat to the position of clinical dietitians as authorities in nutrition. In situations in which no dietitians are present or dietitians' skills are not recognized, pharmacists and nurses are especially likely to take over nutritional support roles traditionally assigned to the clinical dietitian. At the University of California, San Francisco, where dietitians are included in nutrition education and patient care programs and where understanding of the role of the dietitian is a stated educational goal, a preliminary survey suggests that conflicts occur in roles that are shared by members of nutritional support teams. Factors contributing to role conflicts include not only inadequate education of other health professionals but also problems of job expectations, education, training, and self-image among dietitians. Improved training in clinical nutrition, acquisition of better team and patient care skills, documentation of the effectiveness of dietetic services, and efforts to improve status and visibility would help alleviate role conflicts and ensure clinical dietitians a more rewarding place in the health care system.