Graduate Medical Education and Knowledge Translation: Role Models, Information Pipelines, and Practice Change Thresholds

This article reflects the proceedings of a workshop session, Postgraduate Education and Knowledge Translation, at the 2007 Academic Emergency Medicine Consensus Conference on knowledge translation (KT) in emergency medicine (EM). The objective was to develop a research strategy that incorporates KT into EM graduate medical education (GME). To bridge the gap between the best evidence and optimal patient care, Pathman et al. suggested a multistage model for moving from evidence to action. Using this theoretical knowledge‐to‐action framework, the KT consensus conference group focused on four key components: acceptance, application, ability, and remembering to act on the existing evidence. The possibility that basic familiarity, along with the pipeline by Pathman et al., may improve KT uptake may be an initial starting point for research on GME and KT. Current residents are limited by faculty GME role models to demonstrate bedside KT principles. The rapid uptake of KT theory will depend on developing KT champions locally and internationally for resident physicians to emulate. The consensus participants combined published evidence with expert opinion to outline recommendations for identifying the barriers to KT by asking four specific questions: 1) What are the barriers that influence a resident's ability to act on valid health care evidence? 2) How do we break down these barriers? 3) How do we incorporate this into residency training? 4) How do we monitor the longevity of this intervention? Research in the fields of GME and KT is currently limited. GME educators assume that if we teach residents, they will learn and apply what they have been taught. This is a bold assumption with very little supporting evidence. This article is not an attempt to provide a complete overview of KT and GME, but, instead, aims to create a starting point for future work and discussions in the realm of KT and GM.     

Using consciousness-raising principles to inform modern knowledge translation practices in women's health

In traditional models of knowledge translation in health care, the "expert" researcher disseminates empirical knowledge in a top-down manner to practitioners. Newer approaches extend our view of who needs to be involved in knowledge translation, what counts as evidence, and how knowledge exchange can be facilitated. Multisectoral participation and processes for collective synthesis of evidence increase the potential for the application of knowledge in practice and policy in ways that are mutually reinforcing and address structural inequities. The author examines the use of feminist consciousness-raising practices in virtual communities of practice as a viable framework for knowledge translation on complex health issues. Using the preliminary findings ofa study, she discusses how collective analysis in collaborative processes--which is at the heart of feminist action research--leads to engaged action by participants.     

Intuition in emergency nursing: a phenomenological study

The evidence of experience of intuitive knowing in the clinical setting has to this point only been informal and anecdotal. Reported experiences thus need to be either validated or refuted so that its place in emergency nursing can be determined. The history, nature and component themes captured within the intuitive practice of emergency nursing are described. This study was informed by the philosophy and method of phenomenology. Participants were 14 experienced emergency nurses. Through their narrative accounts and recall of events their experience of knowing was captured. Through a Van Manen process and a Gadamerian analysis, six themes associated with the ways in which the participants experienced intuition in clinical practice, were identified. This paper reveals the six emerging themes as knowledge, experience, connection, feeling, syncretism and trust.     

Demystifying research and evidence-based practice for consumers and carers: development and evaluation of an educational package

Increasingly, consumers and carers are involving themselves in many aspects and levels of mental health services. However, one area in which active involvement has been less prominent is research. This paper describes an educational initiative that sought to increase consumers' and carers' understanding of the way research is conducted and its role in evidence-based practice. Information regarding participants' attitudes towards research, knowledge about research practice and participation was also examined. The findings provide evidence that workshop attendance increases knowledge and encourages participation in future research projects, particularly when participants have confidence in the researcher.     

The role of comparative effectiveness research in transfusion medicine clinical trials: proceedings of a National Heart, Lung, and Blood Institute workshop

Comparative effectiveness research (CER) is the study of existing treatments or ways to deliver health care to determine what intervention works best under specific circumstances. CER evaluates evidence from existing studies or generates new evidence, in different populations and under specific conditions in which the treatments are actually used. CER does not embrace one research design over another but compares treatments and variations in practice using methods that are most likely to yield widely generalizable results that are directly relevant to clinical practice. Treatments used in transfusion medicine (TM) are among the most widely used in clinical practice, but are among the least well studied. High-quality evidence is lacking for most transfusion practices, with research efforts hampered by regulatory restrictions and ethical barriers. To begin addressing these issues, the National Heart, Lung, and Blood Institute convened a workshop in June 2011 to address the potential role of CER in the generation of high-quality evidence for TM decision making. Workshop goals were to: 1) evaluate the current landscape of clinical research, 2) review the potential application of CER methods to clinical research, 3) assess potential barriers to the use of CER methodology, 4) determine whether pilot or vanguard studies can be used to facilitate planning of future CER research, and 5) consider the need for and delivery of training in CER methods for researchers.     

General emergency medicine skills (GEMS) training for rural physicians: evaluation of a pilot project

The objective of GEMS (General Emergency Medicine Skills) is to deliver an emergency skills program relevant to rural physicians. The cognitive component was disseminated by four interactive CD-ROM modules while the practice component consisted of skill practice on a human patient simulator (HPS) at a rural hospital. During the pilot year, 16 participants completed the program and filled in an evaluation survey to collect participant feedback. Modules facilitated maintenance of current knowledge, new knowledge acquisition, and confidence in dealing with emergencies. The HPS reinforced module knowledge, allowed practice of skills, and was necessary to fully benefit from the modules. The application process was easy and program administration was good. GEMS positively affected participants' delivery of emergency medicine and their willingness to continue the practice of rural emergency medicine. GEMS provides rural physicians relevant, interactive skills training at a rural setting.     

Demystifying Research and Evidence-Based Practice for Consumers and Carers: Development and Evaluation of an Educational Package

Increasingly, consumers and carers are involving themselves in many aspects and levels of mental health services. However, one area in which active involvement has been less prominent is research. This paper describes an educational initiative that sought to increase consumers' and carers' understanding of the way research is conducted and its role in evidence-based practice. Information regarding participants' attitudes towards research, knowledge about research practice and participation was also examined. The findings provide evidence that workshop attendance increases knowledge and encourages participation in future research projects, particularly when participants have confidence in the researcher.     

A human cadaveric workshop: One solution to competence in the face of rarity

Competent performance of cricothyroidotomy, lateral canthotomy and resuscitative thoracostomy is an expected standard for Australasian emergency physicians, but infrequent exposure to these procedures could impair physician confidence, reducing the likelihood of their execution in a critical timeframe. Training to perform these procedures is a recognised challenge for non‐surgeons, and cadaver‐based training is one method of addressing this need. We describe a 1 day cadaver‐based workshop for emergency medicine doctors and briefly report on its impact on physician confidence. This workshop appeared effective in increasing the confidence of emergency medicine physicians to carry out rarely performed life and sight‐saving procedures and also provides an opportunity for senior clinicians to increase compliance with continuing profession development schemes.     

Outcome measurement in complementary and alternative medicine: unpicking the effects

The issues of what outcomes to measure and how this is central to the development of a sound knowledge base for evidence-based practice are examined. Within complementary and alternative medicine (CAM) there is a crucial debate over what is meant by an "effect" of a set of CAM treatment sessions. The goal of this paper is promote debate and reflection on why outcome measurement is important, the range of specific effects that need to be measured, and ways to take forward their measurement. It is argued that monitoring the achievement of desired outcomes needs to be recognized as an essential step in evidence-based practice, with effectiveness, achieved effects/outcomes--both positive and negative--and quality assurance inextricably linked together in an evidence spiral. The choice of outcome measures must also match the desired outcomes of the key participants, specifically those of the user. Three types of effects of a CAM intervention are conceptualized: (1) those arising from the philosophy and practice of health and healing; (2) factors arising from the relationship between user and practitioner: and (3) those factors brought about by the set of techniques used to enhance the healing process. Their conceptual separation clarifies what should be measured and raises questions about the adequacy of available measuring instruments. This delineation of effects has relevance beyond CAM to conventional medicine and discussions over the nature of the placebo effect. Measurement of all three types of effect is essential, in research and in practice, if the full effect of a CAM discipline is to be recognized. Further work is needed to develop and validate measures that address the multiple effects of CAM and to explore the nature and form of the three types of effect within different CAM disciplines.     

Supporting ethics educators in Canadian occupational therapy and physical therapy programs: A national interprofessional knowledge exchange project

Ethics education is the cornerstone of professional practice, fostering knowledge and respect for core ethical values among healthcare professionals. Ethics is also a subject well-suited for interprofessional education and collaboration. However, there are few initiatives to gather experiences and share resources among ethics educators in rehabilitation. We thus undertook a knowledge exchange project to: 1) share knowledge about ethics training across Canadian occupational and physical therapy programs, and 2) build a community of educators dedicated to improving ethics education. The objectives of this paper are to describe this interprofessional knowledge exchange project involving ethics educators (with a diversity of professional and disciplinary backgrounds) from Canadian occupational and physical therapy programs as well as analyze its outcomes based on participants’ experiences/perceptions. Two knowledge exchange strategies were employed: an interactive one-day workshop and a wiki platform. An immediate post-workshop questionnaire evaluated the degree to which participants’ expectations were met. Structured telephone interviews 9–10 months after the workshop collected participants’ perceptions on whether (and if so, how) the project influenced their teaching or led to further interprofessional collaborations. Open-ended questions from the post-workshop questionnaires and individual interviews were analyzed using qualitative methods. Of 40 ethics educators contacted, 23 participated in the workshop and 17 in the follow-up interview. Only 6 participants logged into the wiki from its launch to the end of data collection. Five themes emerged from the qualitative analysis: 1) belonging and networking; 2) sharing and collaborating; 3) changing (or not) ways of teaching ethics; 4) sustaining the network; and 5) envisioning the future of ethics education. The project attained many of its goals, despite encountering some challenges. While the wiki platform proved to be of limited benefit in advancing the project goals, the interactive format and collaborative nature of the one-day workshop were described as rewarding and effective in bringing together occupational therapy and physical therapy educators to meet, network, and share knowledge.     

Shared moral work of nurses and physicians

Physicians and nurses need to sustain their unique strengths and work in true collaboration, recognizing their interdependence and the complementarity of their knowledge, skills and perspectives, as well as their common moral commitments. In this article, challenges often faced by both nurses and physicians in working collaboratively are explored with a focus on the ways in which each profession's preparation for practice has differed over time, including shifts in knowledge development and codes of ethics guiding their practice. A call for envisioning their practice as shared moral work as well as practical strategies to begin that work are offered as a basis for reflection towards enhanced nurse-physician relationships.     

Emergency Physicians' Attitudes Toward the Emergency Nurse Practitioner Role: Validation Versus Rejection

A qualitative grounded theory approach was used in this study, which examined the attitudes of a group of emergency physicians toward collaborative practice with emergency nurse practitioners. Interviews were conducted with five physicians who were not currently working with nurse practitioners. Responses were coded, and a substantive theory model of dependent collaboration emerged. The physicians supported the emergency nurse practitioner role on the grounds that it be supervised in the traditional fashion by the physician. Concerns regarding education, trust, liability, and capability were identified. Deficits in knowledge regarding training and the role/function of nurse practitioners were also identified.     

Transesophageal Echocardiography Training of Emergency Physicians Through an E-Learning System

BackgroundTransesophageal echocardiography (TEE) has been shown to be a powerful tool that emergency physicians can use to guide resuscitation efforts during cardiac arrest. Currently, there is no standardized curriculum to teach TEE to emergency physicians.ObjectiveWe hypothesized that the use of a pilot training course combining interactive e-learning and hands-on simulation would increase the percentage of students achieving a score of ≥80% on a multiple-choice test of knowledge and increase self-reported comfort using TEE.MethodsWe designed a 2.5-h TEE course for emergency physicians and medical intensive care unit fellows. Participants took a test of knowledge and a survey of comfort—both online—before, just after, and 4 weeks after taking the course. Survey responses measured participants self-reported comfort with using TEE in clinical practice. A normal binomial approximation was used to calculate the 95% confidence interval.ResultsOf the 3 tests of knowledge, 15 participants completed all tests. Of the surveys of comfort, 31 participants completed the precourse survey, 32 completed the postcourse survey, and 19 completed the 4-week follow-up survey. The proportion of students scoring ≥80% improved from 40% on the precourse test to 80% on the postcourse test (95% confidence interval 1–79). The proportion of students indicating comfort with using TEE improved from 3% precourse to 53% postcourse (95% confidence interval 28–71).ConclusionsA TEE training course resulted in a 50% increase in surveyed participants feeling comfortable using TEE in cardiac arrest and a 40% increase in participants scoring ≥80% on a test of knowledge.     

Survey on breastfeeding among Chinese female physicians and nurses

The present study investigated knowledge of and beliefs about breastfeeding among Chinese female physicians and nurses and their breastfeeding practices. This study documented knowledge, attitudes and practices of breastfeeding among Chinese medical staff. A total of 367 female physicians and nurses completed a self‐administered, anonymous questionnaire; 96.2% indicated that breastfeeding was natural, but 29.2% thought it difficult. Only 18.5% of the participants questioned breastfeeding women on feeding status, and 12.8% gave breastfeeding advice when asked. After graduation from school, 79.3% of the participants stated that they did not receive training in breastfeeding. In personal practice, 69.2% initiated breastfeeding; 19.1% were still breastfeeding at 4 months, and only three nurses continued breastfeeding for more than 1 year. In conclusion, breastfeeding‐related knowledge is surprisingly poor, and attitudes are less positive. The exclusive breastfeeding rate was found to be low among Chinese female physicians and nurses. The findings highlight the need to re‐educate medical staff on breastfeeding, and imply the need for Baby‐Friendly Hospital Initiative implementation/training.     

Aortic disasters

TAD and AAA are two of the highest risk disease entities in emergency medicine. Emergency physicians should be vigilant in their approach to patients who have symptoms compatible with acute aortic disease. In chest and abdominal pain presentations, the chart must look like there was a search for the TAD and AAA. By having a sound knowledge of atypical cases;, having an appreciation for how subtle TAD and AAA can be; and recording and documenting a thorough history, physical examination, and risk factor profile, the emergency physician may reduce substantially the risk of missing a diagnosis and subsequently being sued. Emergency physicians cannot diagnose every case of acute aortic disease; what they can do is practice with a sound understanding of risk management principles and consider these diagnoses in all patients with chest, back, or abdominal pain.Ultimately, this strategy would provide protection for the patient and the physician.     

Hepatitis B exposure and the emergency physician: risk assessment and hepatitis vaccine update

Since the hepatitis B vaccine was licensed in 1981, emergency physicians have had the opportunity to be immunized against the hepatitis B virus (HBV). The factors that affect the decision to undergo vaccination include the risk of acquiring an HBV infection in emergency practice, the prevaccination immune status of emergency physicians who have knowledge of their hepatitis serum marker profile, and the efficacy and safety of the vaccine. Emergency physicians have a significant risk of acquiring an HBV infection and are recommended by the Centers for Disease Control to receive vaccination. However, emergency physicians are often incidentally tested for HBV serum markers before immunization. Recent investigations have shown that seropositivity for hepatitis surface antibody (anti-HBs) does not necessarily preclude the need for immunization. Finally, experience with 750,000 doses has shown that it is a highly effective and extremely safe vaccine.     

Supporting parents of children with autism spectrum disorders to become informed consumers of evidence on speech pathology practice

The aim of this pilot study was to evaluate the effectiveness of an intervention program designed to help parents of children with autism spectrum disorders (ASD) to become informed consumers of evidence for speech pathology services. The program comprised an interactive workshop and the provision of written materials aimed at increasing the participants’ knowledge of evidence-based practice (EBP) principles and confidence discussing EBP with their children's speech pathologists. Using a repeated measures within-group design (pre/post) and mixed methods of analysis, the results indicate that the participants’ knowledge and confidence increased following their participation in the program. Qualitative analysis revealed that parents differed with regard to which component (workshop or written information) was most helpful. The results provide preliminary evidence to support the further development and testing of intervention programs aimed at supporting parents of children with ASD to become informed consumers of evidence-based speech pathology services.     

The effect of a geriatric education program on emergency nurses.

OBJECTIVE: In a previous study, emergency nurses gave a high priority to the educational topics of geriatric depression, physical assessment of the elderly, and mental status testing. Our objective was to measure the impact of a 1-day workshop for emergency nurses that addressed these educational needs. METHODS: The workshop consisted of case-based didactic sessions addressing (1) physical assessment of the elderly, (2) delirium, depression, and dementia, and (3) a practical approach to mental status testing in the elderly. The educational program was evaluated using 2 methods: (1) before, and 1 month after, the workshop, participants rated their own practice patterns; and (2) during the course of 2 years, changes in the number of referrals for geriatric assessment and home care from a large emergency department in the study area were monitored. RESULTS: Of 101 ED nurses who attended the 1-day workshop, 51 completed both preworkshop and postworkshop questionnaires (response rate, 50.5%). the most significant self-reported changes in practice 1 month after the workshop were improved screening for depression and altered mental status in older adults (P <.0001 and P <.01, respectively). Other positive changes were noted for inquiring about unplanned weight loss and assistance received at home. A steady increase in the number of referrals for geriatric assessment and home care was noted from the emergency department being monitored. DISCUSSION: Targeted geriatric educational programs can make an impact on the practice of emergency nurses when they are part of an overall, coordinated approach to improving assessment and discharge planning for elderly patients in emergency departments. Mechanisms for reinforcing learning several months after educational events may prove critical to the long-term success of such initiatives.     

The Impact of a Stroke Screening Program

Stroke is a leading cause of serious disability and is the third leading cause of death in the United States. Prevention and early intervention are key to reducing death and disability from stroke. This study investigated the impact of a community-based stroke-screening program on the knowledge of participants regarding signs and symptoms of stroke, related emergency action, and personal risk factors for stroke. Self-reported behavioral changes were also recorded. Initial data were collected at the screening site as part of the program, and follow-up data were collected by telephone interview at 1, 3, and 6-month intervals after the screening. Of the 107 people who participated in the screening, 85 (79%) participated in all three follow-up interviews. Findings indicate that participants in this community-based stroke-screening program showed increases in their knowledge about stroke, including what a stroke is, signs and symptoms, related emergency action, personal risk factors, and ways to reduce risk. Furthermore, the findings demonstrate that the knowledge was retained throughout the study period. Approximately half of the participants also reported having made at least one behavioral change to reduce their stroke risk.     

Evidence-based migraine therapy: learning needs and knowledge assessment

One of the primary goals of continuing medical education (CME) is to enhance the learners' performance, and a major goal of evidence-based medicine (EBM) is to improve knowledge of current best care. This paper overviews the use of a Learning Needs and Knowledge Assessment tool to highlight the potential learning needs and knowledge of neurologists and to focus the issues, interest and interactions of neurologists in a workshop on EBM migraine therapy. Virtually all neurologists felt they used evidence-based medicine in their daily practice. Surprisingly, 50% of neurologists agreed that they were uncertain which triptan to use. The great majority of neurologists felt that the triptans were not all equally efficacious. Our survey identified significant knowledge gaps among neurologists regarding how to appraise the validity of evidence from a randomized clinical trial, and with regard to what are the most clinically useful measures of benefit in clinical trials.