Intentions of Chiropractic Interns Regarding use of Health Promotion in Practice: Applying Theory of Reasoned Action to Identify Attitudes,Beliefs, and Influencing Factors

Purpose:

The theory of reasoned action is a health behavioral theory that has been used to predict personal health behaviors and intentions as well as those of providers delivering health care. The purpose of this study was to determine interns'' future practices regarding the use of health promotion using this model to develop survey questions and to determine attitudes and perceived influences on their prospective behaviors in general, toward the use of health promotion once in practice.

Methods:

Across the course of one year, all graduating interns at a chiropractic college were queried with a 20 question survey designed using the theory of reasoned action. Frequencies and inferential statistics were performed including prediction modeling using logistic regression.

Results:

A majority (>85%) of interns indicated they would use health promotion in practice. Differences were noted based on perceived skill levels, perception of educational emphasis, various normative beliefs, and gender.

Conclusion:

Most interns will use some form of health promotion in practice. Normative influences including those seen as key influencers are as powerful a predictor as perceived education or skill levels on future practice of health promotion.Key Indexing Terms: Chiropractic, Health Promotion, Public Health Practice, Health Behavior     

Use of radiographic imaging protocols by canadian memorial chiropractic college interns

Objectives:

The purpose of this study was to determine if 4th-year interns plan to x-ray their patients, once they are in private practice, in accordance with the principles taught throughout their radiology program and with the evidence-based imaging guidelines outlined in the literature.

Methods:

Questionnaires were provided to all 4th-year interns. Each questionnaire consisted of 10 case scenarios representing possible chiropractic patients. Each intern was asked if he or she would radiograph the patient and, if so, which views would be taken. A “gold standard” was established by two chiropractic radiologists using evidence-based guidelines. Intern answers were compared with the gold standard using percent agreement.

Results:

Sixty-eight interns completed the questionnaire. Agreement between the interns and the gold standards for the question of whether or not they would take x-rays ranged from 63.2% to 100%. The percent agreement for the correct radiographic views chosen ranged from 32.6% to 48.4%.

Conclusion:

Interns are generally aware of and plan to apply the radiographic guidelines for determining whether or not radiographs are indicated, as outlined in the current literature. However, interns are inconsistent in choosing the correct views.Key Indexing Terms: chiropractic, education, radiation, ionizing, radiography, x-ray guidelines, x-rays     

Correlates of a "do not hospitalize" designation: in a sample of frail nursing home residents in Vancouver

OBJECTIVE

To explore what nursing home resident demographic, clinical, functional, and health services utilization characteristics influence a “do not hospitalize” designation.

DESIGN

Historical cohort study.

SETTING

Vancouver, BC.

PARTICIPANTS

Extended care residents in 2 hospital-based and 4 free-standing nursing homes who died between 2001 and 2007.

MAIN OUTCOME MEASURES

The designation of “do not hospitalize” on a resident’s chart.

RESULTS

Continuity of family physician care from admission to death (adjusted hazard ratio [AHR] 2.16, 95% confidence interval [CI] 1.33 to 3.49), a sudden and unexpected death (AHR 0.43, 95% CI 0.25 to 0.73), and age (AHR 1.02, 95% CI 1.01 to 1.02) were independently associated with a “do not hospitalize” designation.

CONCLUSION

The greater than 2-fold positive association of continuity of family physician care with a “do not hospitalize” designation is an interesting addition to the literature on how continuity of physician care matters.     

Collaborative practices in unscheduled emergency care: role and impact of the emergency care practitioner--qualitative and summative findings

Objective

To identify collaborative instances and hindrances and to produce a model of collaborative practice.

Methods

A 12‐month (2005–2006) mixed methods clinical case study was carried out in a large UK ambulance trust. Collaboration was measured through direct observational ratings of communication skills, teamwork and leadership with 24 multi‐professional emergency care practitioners (ECPs), interviews with 45 ECPs and stakeholders, and an audit of 611 patients

Results

Using a generic qualitative approach, observational records and interviews showed that ECPs'' numerous links with other professions were influenced by three major themes as follows. (i) The ECP role: for example, “restricted transport codes” of communication, focus on reducing admissions, frustrations about patient tasking and conflicting views about leadership and team work. (ii) Education and training: drivers for multi‐professional clinically focussed graduate level education, requirements for skill development in minor injury units (MIUs) and general practice, and the need for clinical supervision/mentorship. (iii) Cultural perspectives: a “crew room” blue collar view of inter‐professional working versus emerging professional white collar views, power and communication conflicts, and a lack of understanding of the ECPs'' role. The quantitative findings are reported elsewhere.

Conclusions

The final model of collaborative practice suggests that ECPs are having an impact on patient care, but that improvements can be made. We recommend the appointment of ECP clinical leads, degree level clinically focussed multi‐professional education, communication skills training, clinical supervision and multi‐professional ECP appointments.     

Effect of field notes on confidence and perceived competence: Survey of faculty and residents

Objective

To evaluate the effectiveness of field notes in assessing teachers’ confidence and perceived competence, and the effect of field notes on residents’ perceptions of their development of competence.

Design

A faculty and resident survey completed 5 years after field notes were introduced into the program.

Setting

Five Dalhousie University family medicine sites—Fredericton, Moncton, and Saint John in New Brunswick, and Halifax and Sydney in Nova Scotia.

Participants

First- and second-year family medicine residents (as of May 2009) and core family medicine faculty.

Main outcome measures

Residents’ outcome measures included beliefs about the effects of field notes on performance, learning, reflection, clinical skills development, and feedback received. Faculty outcome measures included beliefs about the effect of field notes on guiding feedback, teaching, and reflection on clinical practice.

Results

Forty of 88 residents (45.5%) participated. Fifteen of 50 faculty (30.0%) participated, which only permitted a discussion of trends for faculty. Residents believed field note–directed feedback reinforced their performance (81.1%), helped them learn (67.6%), helped them reflect on practice and learning (66.7%), and focused the feedback they received, making it more useful (62.2%) (P < .001 for all); 63.3% believed field note–directed feedback helped with clinical skills development (P < .01). Faculty believed field notes helped to provide more focused (86.7%) and effective feedback (78.6%), improved teaching (75.0%), and encouraged reflection on their own clinical practice (73.3%).

Conclusion

Most surveyed residents believed field note use improved the feedback they received and helped them to develop competence through improved performance, learning, reflection, and clinical skills development. The trends from faculty information suggested faculty believed field notes were an effective teaching, feedback, and reflection tool.     

Perceptions of Outpatients Regarding the Attire of Physiotherapists

Purpose:

This study investigated perceptions of patients regarding physiotherapists’ attire.

Methods:

Three hundred patients in three publicly funded outpatient physiotherapy clinics were asked to complete a questionnaire, ranking four photographed modes of attire (lab coat, tailored dress, “scrubs,” and jeans) in terms of professionalism, preference, and appropriateness and rating their level of agreement with four statements about physiotherapists’ attire.

Results:

Response rate was 63.7 %. The lab coat was ranked most professional, tailored dress most preferred, and jeans least professional and least preferred. Although jeans were deemed inappropriate (p < 0.001), strong support was shown for wearing jeans on “casual day” (p = 0.001). Age of respondents influenced the perception of the appropriateness of wearing jeans (p = 0.007 for male therapist; p = 0.017 for female therapist); only the cohort <36 years considered jeans appropriate apparel. Overall exposure to physiotherapists (number of lifetime visits) affected patients’ perceptions of the importance of attire (p = 0.039) and the appropriateness of wearing jeans (p = 0.018): as number of visits increased, perceived importance decreased and perceived propriety of jeans increased.

Conclusion:

The findings of this study, the first to examine patients’ opinions of physiotherapists’ attire, suggest that outpatients made clear distinctions between what they perceived as professional and what they preferred, as well as between the appropriateness of physiotherapists’ wearing jeans in general and the appropriateness of their doing so on “casual day.” Age and exposure to physiotherapists influenced patients’ perceptions of attire.     

Practice and payment preferences of newly practising family physicians in British Columbia

Objective

To examine the remuneration model preferences of newly practising family physicians.

Design

Mixed-methods study comprising a cross-sectional, Web-based survey, as well as qualitative content analysis of answers to open-ended questions.

Setting

British Columbia.

Participants

University of British Columbia family practice residents who graduated between 2000 and 2009.

Main outcome measures

Preferred remuneration models of newly practising physicians.

Results

The survey response rate was 31% (133 of 430). Of respondents, 71% (93 of 132) preferred non–fee-for-service practice models and 86% (110 of 132) identified the payment model as very or somewhat important in their choice of future practice. Three principal themes were identified from content analysis of respondents’ open-ended comments: frustrations with fee-for-service billing, which encompassed issues related to aggravations with “the business side of things” and was seen as impeding “the freedom to focus on medicine”; quality of patient care, which embraced the importance of a payment model that supported “comprehensive patient care” and “quality rather than quantity”; and freedom to choose, which supported the plurality of practice preferences among providers who strived to provide quality care for patients, “whatever model you happen to be working in.”

Conclusion

Newly practising physicians in British Columbia preferred alternatives to fee-for-service payment models, which were perceived as contributing to fewer frustrations with billing systems, improved quality of work life, and better quality of patient care.     

A study of police operated dispatch to acute coronary syndrome cases arising from 112 emergency calls in Aarhus county, Denmark

Background

The accuracy of the Danish police operated "112" emergency call system was studied. Dispatch of the anaesthesiologist staffed mobile emergency care unit (MECU) to acute coronary syndrome (ACS) cases was used as an indicator of accuracy of dispatch to life threatening emergencies.

Methods

This was an observational cohort study of patients given a 112 system report of heart attack and patients with a provisional diagnosis of ACS made on scene by the MECU. Sensitivity, specificity, and positive predictive value with 95% confidence intervals (CI) were calculated.

Results

There were 341 reports of “heart attack” and 205 patients with ACS. Sensitivity was 75% (95% CI 68% to 80%) specificity 90% (89% to 92%) and positive predictive value 45% (40% to 50%).

Conclusion

The accuracy of 112 dispatch of the MECU was found to be moderate. We suggest more training of dispatch staff and medical supervision.     

Clinical Specialists and Advanced Practitioners in Physical Therapy: A Survey of Physical Therapists and Employers of Physical Therapists in Ontario, Canada

Purpose:

Opportunities to expand the role of physical therapists (PTs) have evolved to include clinical specialists and advanced practitioners, although the literature on these roles is limited. We examined perceptions of PTs and PT employers in Ontario regarding clinical specialization and advanced practice.

Methods:

Using a modified Dillman approach, a cross-sectional survey was conducted with 500 PTs and 500 PT employers in Ontario. Questionnaires were tailored to address specific issues related to each cohort.

Results:

Sixty percent of PTs and 53% of PT employers responded to the survey. Thirty-three percent of PT respondents already considered themselves “clinical specialists” (CS), and 8% considered themselves “advanced practitioners” (AP), although neither role is yet formally recognized in Canada. Both groups had substantial interest in pursuing formal recognition of CS and AP status. Respondents indicated that their primary motivation to pursue such roles was to enhance clinical reasoning skills with the goal of improving client outcomes (82% for the role of CS, 71% for the role of AP). Respondents supported the involvement of academic institutions in the process (60% for CS, 70% for AP).

Conclusion:

PTs and PT employers are supportive of the roles of the CS and AP within the profession, even though there is currently no formal recognition of either role in Canada.     

Barriers to nonpharmacologic treatments for stress, anxiety, and insomnia: family physicians' attitudes toward benzodiazepine prescribing

OBJECTIVE

To explore the attitudes of FPs toward benzodiazepine (BZD) prescribing and the perceived barriers to nonpharmacologic approaches to managing stress, anxiety, and insomnia.

DESIGN

A questionnaire including 32 statements about treatment of insomnia, stress, and anxiety.

SETTING

Local quality groups for FPs in Belgium.

PARTICIPANTS

A total of 948 Belgian FPs.

MAIN OUTCOME MEASURES

Barriers to using nonpharmacologic approaches in family practice.

RESULTS

We identified 3 different groups of FPs according to their attitudes about BZD prescribing. A first relatively big group of FPs (39%) were not really concerned about the risks of BZD prescribing. Those in the second group (17%) were aware of the problems associated with BZDs, but did not perceive it to be their role to use nonpharmacologic approaches in family practice. Those in the third group (44%) were concerned about BZD prescribing and found it to be a “bad solution,” but were faced with various barriers to applying nonpharmacologic approaches. Surprisingly, we found that nearly 97% of FPs thought that most people were eligible for nonpharmacologic approaches, but experienced implementation barriers at the level of the patient, the level of the FP, and the level of the health care system.

CONCLUSION

Using different education and behavioural-change strategies for different FP groups seems important. A large group of FPs does not find prescribing BZDs to be problematic. Sensitizing and alerting FPs to this issue remains very important.     

Must we appear to be all-knowing?: Patients’ and family physicians’ perspectives on information seeking during consultations

Objective

To compare patients’ opinions about family physicians looking up medical information during consultations with family physicians’ expectations of how patients would respond to their using sources to find answers to medical questions.

Design

Survey.

Setting

North York, Ont.

Participants

One hundred fifty-three family practice patients, 54 family physicians, and 21 family practice residents.

Main outcome measures

Patients’ self-reported confidence in their family physicians and their perceptions of the quality of care after seeing physicians look up medical information, both without specifying the physician’s source of information and with reference to several specific information media. Family physicians’ predictions for how patients would respond to their using resources to answer medical questions.

Results

When the information source used by physicians was not specified, 9% and 7% of patients reported decreased confidence and perceived lower quality of care, respectively. When the information source used by physicians was specified, the proportions of negative responses for patients’ confidence and their perceptions of quality of care were 39% and 31%, respectively, for Internet search engines (ISEs); 8% and 7% for online resources designed for physicians (ORDP); 27% and 27% for personal digital assistants (PDAs); and 10% and 9% for hard-copy medical textbooks (HMTs). When the information source was not specified, 32% and 12% of physicians expected patients to report negative responses for confidence and perceptions of quality of care, respectively. When the information source was specified, 51% and 33% of physicians expected patients to report negative responses for confidence and perceptions of quality of care, respectively, for their use of ISEs; 16% and 8% for ORDP; 20% and 12% for PDAs; and 36% and 21% for HMTs. Younger patients were more likely to respond negatively to physicians’ use of resources, especially if the source was an ISE (P < .001). Physicians earlier in their careers were more likely to expect negative patient responses (P < .05).

Conclusion

Family physicians overestimated the decrease in patients’ confidence caused by seeing them look up medical questions. While most patients responded positively, a substantial proportion of younger patients reported decreased confidence. Patients believed the best sources of information were ORDP and HMTs.     

Allowing a possible margin of error when assessing student skills in spinous process location

Introduction:

Spinal palpation is subject to inconsistency between examiners. When testing students on the location of vertebral spinous processes, faculty examiners may wish to allow for a margin of error that is observed between experienced practitioners. This study attempts to determine such a margin of error for selected vertebral levels that could be allowed in testing situations at Sherman Chiropractic College. This could serve as a model for other chiropractic colleges in determining their margins of error.

Methods:

Two faculty clinicians palpated spinous processes at four different vertebral levels (C2, T3, T9, and L2) on 18 student volunteers. Differences for each vertebral level, along with one, two, and three standard deviations, were calculated.

Results:

Average differences between examiners increased caudally, as follows: C2, 4.23 ± 3.77 mm; T3, 13.41 ± 10.53 mm; T9, 18.17 ± 17.62 mm; L2, 18.70 ± 16.58 mm.

Discussion:

In this study, faculty examiners exhibited variation in their locations of spinous processes for these vertebrae. These variations could be allowed when assessing student skills in locating these spinous processes at this chiropractic college.

Conclusion:

In this study, differences between examiners plus or minus one standard deviation ranged from 4.23 ± 3.77 mm for C2 to 18.70 ± 16.58 mm for L2. The concept of margin of error should be considered by faculty examiners when assessing the skill of students in locating the spinous process of various vertebral levels.     

Type 2 Diabetes Prevention in the Real World: Three-year results of the GOAL Lifestyle Implementation Trial

OBJECTIVE

We study the effectiveness of the GOAL Lifestyle Implementation Trial at the 36-month follow-up.

RESEARCH DESIGN AND METHODS

Participants (n = 352, type 2 diabetes risk score FINDRISC = 16.2 ± 3.3, BMI 32.6 ± 5.0 kg/m²) received six lifestyle counseling sessions over 8 months. Measurements were at baseline, 12 months (88.6%), and 36 months (77.0%).

RESULTS

Statistically significant risk reduction at 12 months was maintained at 36 months in weight (−1.0 ± 5.6 kg), BMI (−0.5 ± 2.1 kg/m²), and serum total cholesterol (−0.4 ± 1.1 mmol/l).

CONCLUSIONS

Maintenance of risk reduction in this “real world” trial proves the intervention''s potential for significant public health impact.The Goal Lifestyle Implementation Trial (1,2) replicated most of the findings from the Finnish Diabetes Prevention Study (DPS) (3,4) in primary health care settings, demonstrating that lifestyle counseling can be effective and feasible in routine care. We report findings on sustainability of the results at 3 years.     

Do family physicians request ultrasound scans appropriately?

Objective

To review family physicians’ requests for abdominal, thyroid, pelvic, soft tissue, and carotid ultrasound (US) scans, and to determine whether 5% or more of these tests were not clearly indicated based on the clinical history provided.

Design

Analysis of 620 randomly chosen requests for US scans.

Setting

The Radiology Department at the Capital District Health Authority in Halifax, NS, between October 1, 2008, and June 30, 2009.

Participants

Two radiologists and 2 family physicians with clinical expertise and familiarity with the Canadian Association of Radiologists’ 2005 guidelines.

Main outcome measures

Whether US requests were “indicated,” “not clearly indicated,” or “not legible” according to the Canadian Association of Radiologists’ 2005 guidelines. Those that were illegible were discarded and replaced.

Results

More than 5% of requests for abdominal, thyroid, or carotid US scans were not clearly indicated. The percentages of requests for pelvic and soft tissue scans that were not clearly indicated were not significant. The reviewers found only 5 illegible request forms. Percentages of abdominal, thyroid, and carotid US scans not clearly indicated were 12.1%, 18.8%, and 25.2%, respectively. Reasons for inappropriate US requests included the following: wrong tests (3.2%), vague clinical questions (4.8%), and unfocused examinations (4.8%) for abdominal scans; wrong tests (3.2%), vague clinical questions (3.2%), unnecessary investigations (5.6%), and unnecessary follow-up examinations (5.6%) for thyroid scans; and unnecessary tests (10.5%), vague clinical questions (5.6%), and unnecessary tests for “dizziness” (10.5%) for carotid scans.

Conclusion

More than 5% of the abdominal, thyroid, and carotid US scans requested by family physicians were not clearly indicated based on the clinical history provided. Common trends in requesting these examinations reinforce the need to improve guidelines for requesting scans and for managing many presenting complaints in family practice.     

Stress,burnout, and strategies for reducing them: What’s the situation among Canadian family physicians?

OBJECTIVE

To ascertain Canadian family physicians’ levels of stress and burnout and the strategies they use to reduce these problems.

DESIGN

Census survey.

SETTING

Kitchener-Waterloo, an urban area with a population of approximately 300 000 in southwestern Ontario.

PARTICIPANTS

Family physicians.

MAIN OUTCOME MEASURES

Scores on the Family Physician Stress Inventory, scores on strategies to reduce personal stress, scores on strategies to reduce stress on the job, and scores on the Maslach Burnout Inventory.

RESULTS

Participation rate was 77.8% (123 of 158 surveys returned). About 42.5% of participants had high stress levels. Burnout was defined by 3 components: emotional exhaustion, depersonalization (going through the day like an “automaton”), and perceived lack of personal accomplishment. Many respondents scored high on the burnout inventory, and almost half had high levels of emotional exhaustion and depersonalization (47.9% and 46.3%, respectively). No demographic factors were associated with high scores on these components. Use of strategies to reduce personal and occupational stress was associated with lower levels of burnout. Scores on the Family Physician Stress Inventory correlated highly with scores on the Maslach Burnout Inventory.

CONCLUSION

Regardless of demographic factors, family physicians are at risk of having high levels of stress and burnout. Classic burnout is related to stress brought on by factors such as too much paperwork, long waits for specialists and tests, feeling undervalued, feeling unsupported, and having to abide by rules and regulations. Common strategies for reducing personal stress included eating nutritiously and spending time with family and friends. Common strategies for reducing stress on the job included valuing relationships with patients and participating in continuing medical education. Stress and burnout are related to the desire to give up practice and are, therefore, a human resources issue for the entire health care system.     

Validation of the Paediatric Triage Tape

Introduction

The Paediatric Triage Tape (PTT) is an easy to use major incident primary triage tool, based upon a modification of the Triage Sieve. The purpose of this study was to prospectively validate the PTT for use in paediatric major incidents.

Methods

A database of children presenting the Trauma Unit of the Red Cross Children''s Hospital, Cape Town, was developed over a nine month period. Each child was triaged using the PTT, and had an Injury Severity Score (ISS) calculated. Additionally, the New Injury Severity Score (NISS) was calculated, and the presence of interventions that may occur to the children (“Garner criteria”) was documented. The sensitivity, specificity, overtriage, and undertriage rates were calculated.

Results

3461 children were entered into the database. For identifying children with an ISS of over 15, the PTT had a sensitivity of 37.8%, specificity of 98.6%, overtriage rate of 38.8%, and an undertriage rate of 3.5%. Against the NISS and Garner criteria, the results were comparable.

Conclusion

The PTT has poor sensitivity at identifying immediate priority children by these criteria. Specificity (the ability to identify non‐T1 patients) is excellent, and the overtriage and undertriage rates are within the range deemed unavoidable by the American College of Surgeons.     

Oxygen alert cards and controlled oxygen: preventing emergency admissions at risk of hypercapnic acidosis receiving high inspired oxygen concentrations in ambulances and A&E departments

Background

Appropriate resuscitation of hypoxic patients is fundamental in emergency admissions. To achieve this, it is standard practice of ambulance staff to administer high concentrations of oxygen to patients who may be in respiratory distress. A proportion of patients with chronic respiratory disease will become hypercapnic on this.

Objectives and methods

A scheme was agreed between the authors'' hospital and the local ambulance service, whereby patients with a history of previous hypercapnic acidosis with a Pao₂ >10.0 kPa—indicating that oxygen may have worsened the hypercapnia—are issued with “O₂ Alert” cards and a 24% Venturi mask. The patients are instructed to show these to ambulance and A&E staff who will then use the mask to avoid excessive oxygenation. The scheme was launched in 2001 and this paper present the results of an audit of the scheme in 2004.

Results

A total of 18 patients were issued with cards, and 14 were readmitted on 69 occasions. Sufficient documentation for auditing purposes was available for 52 of the 69 episodes. Of these audited admissions, 63% were managed in the ambulance, in line with card‐holder protocol. This figure rose to 94% in the accident and emergency department.

Conclusion

These data support the usability of such a scheme to prevent iatrogenic hypercapnia in emergency admissions.