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Comprehensive Assessment of Critical Care Needs in a Community Hospital
Abstract
To design and implement a needs assessment process that identifies gaps in caring for critically ill patients in a community hospital.
This mixed-method study was conducted between June 2011 and February 2012. A conceptual framework, centered on the critically ill patient, guided the design and selection of the data collection instruments. Different perspectives sampled included regional leaders, healthcare professionals at the community hospital and its referral hospital, as well as family members of patients who had received care at the community ICU. Data sources included interviews (n = 22), walk-throughs (n = 5), focus groups (n = 31), database searches, context questionnaires (n = 8), family surveys (n = 16), and simulations (n = 13).
None.
Nine needs were identified. At the community hospital, needs identified included lack of access to human resources, gaps in expertise, poor patient flow and ICU bed use, communication, lack of educational opportunities, and gaps in end-of-life care and interprofessional teamwork. Needs were also identified in the interhospital interaction between the community and referral hospitals, which included an inadequate hospital network and gaps in transfer and repatriation of patients. The methodology uncovered the causes and widespread impact of each need and how they interacted with one another. Proposed solutions by the participants are presented including both organizational and educational/clinical solutions.
This study captured needs in a complex, interprofessional, interhospital context, which can be targeted with tailored interventions to improve patient outcomes in a community hospital. Furthermore, this study provides a preliminary framework and rigorous methodology to performing a needs assessment in this setting.
... In keeping with this mandate, a comprehensive NA was completed by members of the current research team, which identified gaps in caring for critically ill patients at a single community hospital. 15 These results provided insights into the needs of a community to optimise care of its critically ill patients, as well as suggestions for how a referral hospital may best support its community site. However, the cost and time required to complete this study was substantial, and the process requires streamlining in order to be feasible to implement across numerous sites. ...
... 19 The constant comparative method was used as data were analysed. 18 Full information regarding the original study can be found in Sarti et al. 15 ...
... To assess performance during simulation, custom task checklists and two validated global rating scales were completed. 22 23 Only quantitative data from the simulations was included in the original NA, 15 given that debriefs have not been described as NA tools. ...
Objective
To better understand the potential of a needs assessment approach using qualitative data from manikin-based and virtual patient simulation debriefing sessions compared with traditional data collection methods (ie, focus groups and interviews).
Design
Original data from simulation debrief sessions was compared and contrasted with data from an earlier assessment of critical care needs in a community setting (using focus groups and interviews), thus undertaking secondary analysis of data. Time and cost data were also examined. Debrief sessions were coded using deductive and inductive techniques. Matrices were used to explore the commonalities, differences and emergent findings across the methods.
Setting
Critical care unit in a community hospital setting.
Results
Interviews and focus groups yielded 684 and 647 min of audio-recordings, respectively. The manikin-based debrief recordings averaged 22 min (total=130 min) and virtual patient debrief recordings averaged 31 min (total=186 min). The approximate cost for the interviews and focus groups was $13 560, for manikin-based simulation debriefs was $4030 and for the virtual patient debriefs was $3475. Fifteen of 20 total themes were common across the simulation debriefs and interview/focus group data. Simulation-specific themes were identified, including fidelity (environment, equipment and psychological) and the multiple roles of the simulation instructor (educative, promoting reflection and assessing needs).
Conclusions
Given current fiscal realities, the dual benefit of being educative and identifying needs is appealing. While simulation is an innovative method to conduct needs assessments, it is important to recognise that there are trade-offs with the selection of methods.
... Yet, the different hospital contexts may influence the role of education and training, as well as protocols to support the provision of EOLC in ICUs. To address the community hospital context, a study was conducted by Sarti et al. (2014) in which they designed and implemented a needs assessment to identify gaps in caring for critically ill patients in a community hospital in Ontario, Canada. A mixed method design was employed to identify intra-hospital needs, as well as inter-hospital needs between the community hospital and a referral hospital where patients could be transferred. ...
... Many ICUs in community hospitals are limited in their ability to provide the full spectrum of critical care services, but are generally able to treat and manage patients post-operatively or with single organ failure using short-term mechanical ventilation (less than 48 hours) (MOHLTC, 2009). If the patient's condition demands further intervention they are then transferred to other facilities (Critical Care Services Ontario, 2015;Sarti et al., 2014). ...
Written from the perspective of a critical care nurse, this commentary examines how the author envisions knowledge translation becoming more effective in the year 2020. The coronavirus pandemic, social media dissemination, and digital innovations are contended as central to such improvements in knowledge translation. Future direction for knowledge translation within the nursing profession are also discussed.
... For seriously ill hospitalized patients, goals of care conversations include deliberation and decision-making about the use or non-use of lifesustaining treatments [12]. While many previous studies of EOL communication have focused on barriers [13,14], a solutions-oriented focus can also generate important insights [15,16]. Recognizing that effective initiatives to overcome perceived barriers can be found within a community itself, the objective of the current multicentre, cross-sectional survey was to elicit hospitalbased healthcare providers' strategies for effective goals of care discussions and decision-making. ...
Communication gaps impact the quality of patient care. Previous research has focused on communication barriers rather than seeking solutions. Our aim was to identify strategies for effective communication and decision-making about goals of care for medical interventions in serious illness, from the perspectives of hospital-based healthcare providers.
A cross-sectional survey composed of closed- and open-ended questions about goals of care communication and decision-making was administered to healthcare providers in 13 centres in six Canadian provinces. We analyzed a portion of the open-ended survey questions, specifically (1) suggestions for overcoming barriers encountered in discussing goals of care, and (2) currently effective practices. Thematic content analysis was used to analyze responses to the open-ended questions.
Of the 1,256 respondents to the larger survey, 468 responded to the open-ended questions (37 %), including 272 of 512 nurses (53 %), 153 of 484 internal medicine trainees (32 %), and 43 of 260 attending physicians (17 %). Responses to each of the two questions were similar, generating a common set of themes and subthemes. Effective strategies and ideas for improving communication and decision-making about goals of care clustered under five themes: patient and family factors, communication between healthcare providers and patients, interprofessional collaboration, education, and resources. Subthemes highlighted core elements of shared decision-making.
Translating our findings into multifaceted interventions that consider patient and family factors, address knowledge gaps, optimize resource utilization, and facilitate communication and collaboration between patients, families and healthcare providers may improve communication and decision-making about goals of care.
... 35 Many guidelines and resources exist to guide us in caring for these patients, but practices must be contextualized to the local environment with consid-eration to human, physical and social capital. 42 For example, at the time of this study, international and provincial guidelines made clear recommendations on requirements for patient placement, such as ensuring a single room with negative pressure, a dedicated toilet, and a space and layout that allow for clear separation between clean and potentially contaminated areas. However, at the local level, ensuring adequate separation was constrained by the physical layout of the rooms, because the facilities were not originally designed to meet this requirement. ...
Background: The current outbreak of Ebola has been declared a public health emergency of international concern. We performed a rigorous and rapid needs assessment to identify the desired results, the gaps in current practice, and the barriers and facilitators to the development of solutions in the provision of critical care to patients with suspected or confirmed Ebola.
Methods: We conducted a qualitative study with an emergent design at a tertiary hospital in Ontario, Canada, recently designated as an Ebola centre, from Oct. 21 to Nov. 7, 2014. Participants included physicians, nurses, respiratory therapists, and staff from infection control, housekeeping, waste management, administration, facilities, and occupational health and safety. Data collection included document analysis, focus groups, interviews and walk-throughs of critical care areas with key stakeholders.
Results: Fifteen themes and 73 desired results were identified, of which 55 had gaps. During the study period, solutions were implemented to fully address 8 gaps and partially address 18 gaps. Themes identified included the following: screening; response team activation; personal protective equipment; postexposure to virus; patient placement, room setup, logging and signage; intrahospital patient movement; interhospital patient movement; critical care management; Ebola-specific diagnosis and treatment; critical care staffing; visitation and contacts; waste management, environmental cleaning and management of linens; postmortem; conflict resolution; and communication.
Interpretation: This investigation identified widespread gaps across numerous themes; as such, we have been able to develop a set of credible and measureable results. All hospitals need to be prepared for contact with a patient with Ebola, and the preparedness plan will need to vary based on local context, resources and site designation.
Aim:
There is a paucity of data on the provision of palliative care in the critical care settings of smaller community hospitals. This study aimed to identify the gaps that affect the provision of palliative care in a community critical care setting.
Setting:
The study was set in a 10-bed, open intensive care unit and emergency department at a community hospital.
Methods:
Mixed methods were used. Quantitative data included those drawn from databases and surveys; qualitative data included those collected from interviews, focus groups, and onsite walk-throughs and were analyzed with inductive coding techniques.
Results:
Gaps were identified in palliative care, goals of care and end-of-life discussions, and resources. Community hospital healthcare professionals did not fully appreciate their essential contribution to the provision of palliative care in the intensive care unit. In addition, there was a lack of expertise, and a lack of interest in gaining expertise, in palliative/end-of-life care.
Conclusion:
Interrelated needs in a complex interprofessional, interhospital context were captured. Further studies are required to obtain data on palliative practice in the care of critically ill patients in various community hospital contexts.
Abstract Most physicians believe that to provide the best possible care to their patients, they must commit to continuous learning. For the most part, it appears the learning activities currently available to physicians do not provide opportunities for meaningful continuous ...
Although the concept of needs assessment in continuing medical education is well ac-cepted, there is limited information on needs assessment in postgraduate medical education. We discuss the learning needs of postgraduate trainees and review the various methods of needs as-sessment such as: questionnaire surveys, interviews, focus groups, chart audits, chart-stimulated recall, standardized patients, and environmental scans in the context of post graduate medical edu-cation.
Time delays in the treatment and transfer of trauma patients is a contributing factor responsible for many fatalities. Time delays are more characteristic of rural trauma systems due to factors such as greater distance, and delays in accident reporting. Efforts to reduce the trauma transfer process have resulted in many changes in protocol and use of technology, yet have resulted in little improvement in time reduction. The current investigation sought to test the effects of communication training on the trauma transfer process. Results indicate that personnel in trauma facilities that received both medical and communication training (effective and affirming communication) reported decreased patient transfer times.
Among practitioners, it is often said that there is much that is useful that takes place during the evaluation process. The literature on the utilization of evaluation, however, mostly refers to lessons learned and recommendations implemented after the evaluation. This article seeks to contribute to the debate by exploring further the process use of evaluations — the evaluation use that takes place before lessons learned are generated and feedback processes are initiated.
Five different types of process use are identified: learning to learn; developing networks; creating shared understanding; strengthening the project; and boosting morale.
Most resources in an evaluation process are spent in preparation and implementation. Very little is spent on feedback. A conventional way of improving evaluation use would be to shift resources from the preparation and implementation stages to the feedback stage. The article argues that in general, shifting resources from preparation and implementation to disseminating results would jeopardize the quality of the entire evaluation because it would ceteris paribus reduce the design, data collection and analytical quality. Instead it is argued that evaluation commissioners and evaluators should work explicitly to increase process use as the most cost-effective way of strengthening the overall utility of an evaluation.
Most physicians believe that to provide the best possible care to their patients, they must commit to continuous learning. For the most part, it appears the learning activities currently available to physicians do not provide opportunities for meaningful continuous learning. At the same time there have been increasing concerns about the quality of health care, and a variety of groups within organized medicine have proposed approaches to address issues of physician competence and performance. The authors question whether CME will be accepted as a full partner in these new approaches if providers continue to use current approaches to planning and assessing CME. A conceptual model is proposed for planning and assessing continuous learning for physicians that the authors believe will help CME planners address issues of physician competence, physician performance, and patient health status.
Although technology-enhanced simulation has widespread appeal, its effectiveness remains uncertain. A comprehensive synthesis of evidence may inform the use of simulation in health professions education.
To summarize the outcomes of technology-enhanced simulation training for health professions learners in comparison with no intervention.
Systematic search of MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011.
Original research in any language evaluating simulation compared with no intervention for training practicing and student physicians, nurses, dentists, and other health care professionals.
Reviewers working in duplicate evaluated quality and abstracted information on learners, instructional design (curricular integration, distributing training over multiple days, feedback, mastery learning, and repetitive practice), and outcomes. We coded skills (performance in a test setting) separately for time, process, and product measures, and similarly classified patient care behaviors.
From a pool of 10,903 articles, we identified 609 eligible studies enrolling 35,226 trainees. Of these, 137 were randomized studies, 67 were nonrandomized studies with 2 or more groups, and 405 used a single-group pretest-posttest design. We pooled effect sizes using random effects. Heterogeneity was large (I(2)>50%) in all main analyses. In comparison with no intervention, pooled effect sizes were 1.20 (95% CI, 1.04-1.35) for knowledge outcomes (n = 118 studies), 1.14 (95% CI, 1.03-1.25) for time skills (n = 210), 1.09 (95% CI, 1.03-1.16) for process skills (n = 426), 1.18 (95% CI, 0.98-1.37) for product skills (n = 54), 0.79 (95% CI, 0.47-1.10) for time behaviors (n = 20), 0.81 (95% CI, 0.66-0.96) for other behaviors (n = 50), and 0.50 (95% CI, 0.34-0.66) for direct effects on patients (n = 32). Subgroup analyses revealed no consistent statistically significant interactions between simulation training and instructional design features or study quality.
In comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviors and moderate effects for patient-related outcomes.
Despite increased calls for use of mixed-methods designs in mental health services research, how and why such methods are being used and whether there are any consistent patterns that might indicate a consensus about how such methods can and should be used are unclear.
Use of mixed methods was examined in 50 peer-reviewed journal articles found by searching PubMed Central and 60 National Institutes of Health (NIH)-funded projects found by searching the CRISP database over five years (2005-2009). Studies were coded for aims and the rationale, structure, function, and process for using mixed methods.
A notable increase was observed in articles published and grants funded over the study period. However, most did not provide an explicit rationale for using mixed methods, and 74% gave priority to use of quantitative methods. Mixed methods were used to accomplish five distinct types of study aims (assess needs for services, examine existing services, develop new or adapt existing services, evaluate services in randomized controlled trials, and examine service implementation), with three categories of rationale, seven structural arrangements based on timing and weighting of methods, five functions of mixed methods, and three ways of linking quantitative and qualitative data. Each study aim was associated with a specific pattern of use of mixed methods, and four common patterns were identified.
These studies offer guidance for continued progress in integrating qualitative and quantitative methods in mental health services research consistent with efforts by NIH and other funding agencies to promote their use.
Based on a proven six-step model and including examples and questions to guide application of those timeless principles, Curriculum Development for Medical Education is a practical guidebook for all faculty members and administrators responsible for the educational experiences of medical students, residents, fellows, and clinical practitioners. Incorporating revisions driven by calls for reform and innovations in medical education that challenge established teaching models, the third edition includes an awareness of new accreditation standards and regulatory guidelines. The authors have expanded their discussion of survey methodology for needs assessment and stress the importance of writing competency-based goals and objectives that incorporate milestones, entrustable professional activities, and observable practice activities. With updated examples focusing on interprofessional education, collaborative practice, and educational technology, they describe educational strategies that incorporate the new science of learning. A completely new chapter presents the unique challenges of curriculum development for large, long, and integrated curricula. © 1998, 2009, 2016 Johns Hopkins University Press. All rights reserved.
This case study details an evaluation of a sales program within a business services organization, here called XYZ Corporation. Logic models were employed to identify the processes, as well as the short- and long-term outcomes. Twenty-three sales people, 10 implementation specialists, and nine consultants from XYZ were interviewed, along with 40 XYZ clients. In addition, written surveys and archival data were gathered. Although timely evaluation reports were produced and presented, reorganization at XYZ Corporation limited direct instrumental use of the evaluation. The present article focuses on use and non-use of the evaluation results, with particular emphasis on process use, and it discusses factors contributing to use and non-use of this private sector evaluation.
The clear and practical writing of Educational Research: Planning, Conducting, and Evaluating Quantitative and Qualitative Researchhas made this book a favorite. In precise step-by-step language the book helps you learn how to conduct, read, and evaluate research studies. Key changes include: expanded coverage of ethics and new research articles.
Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifying the components or outcomes of care to be sampled, formulating the appropriate criteria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known.
(JAMA 1988;260:1743-1748)
This case study details an evaluation of a sales program within a business services organization, here called XYZ Corporation. Logic models were employed to identify the processes, as well as the short- and long-term outcomes. Twenty-three sales people, 10 implementation specialists, and nine consultants from XYZ were interviewed, along with 40 XYZ clients. In addition, written surveys and archival data were gathered. Although timely evaluation reports were produced and presented, reorganization at XYZ Corporation limited direct instrumental use of the evaluation. The present article focuses on use and non-use of the evaluation results, with particular emphasis on process use, and it discusses factors contributing to use and non-use of this private sector evaluation.
In recent years there has been increasing interest in the notion of process use, that is, in understanding the ways in which individuals learn about the evaluand, evaluation practice, and each other, from their involvement in an evaluation study. As a form of social constructivism, process use is most closely related to participatory and collaborative evaluation approaches. The purpose of this article is to report the results of an exploratory study of process use and to discuss a set of variables that may influence process use. In addition, we pose several future research questions.
In this article, I outline how, with the appropriate mix of external requirements and internal motivation, structure and capacity, a school can promote and maintain a culture of evaluative practices, specifically data use, for continuous improvement. I draw upon qualitative data conducted in a study of an Edison Project school. The findings from this paper are the result of a larger 4-year study examining Comprehensive School Reform in 12 Title 1 schools in three states. Interviews were conducted with principals, teachers, other staff, parents and students, as well as with state officials, the superintendent, assistant superintendent and other high level administrators in the district. Observations were undertaken at the classroom level. Key findings include the importance of obtaining a multidimensional view of educational change. That is, we need to obtain a picture of the school reform environment (i.e., interconnections between the state, district, and school levels), and simultaneously investigate the interplay among critical school levers that are required to promote and maintain a culture of data use for school improvement. From this multidimensional view, we are better positioned to investigate and evaluate school change efforts.
Quantitative research is designed to test well-specified hypotheses,
determine whether an intervention did more harm than good, and find out how
much a risk factor predisposes persons to disease. Equally important, qualitative
research offers insight into emotional and experiential phenomena in health
care to determine what, how, and why. There are 4 essential aspects of qualitative
analysis. First, the participant selection must be well reasoned and their
inclusion must be relevant to the research question. Second, the data collection
methods must be appropriate for the research objectives and setting. Third,
the data collection process, which includes field observation, interviews,
and document analysis, must be comprehensive enough to support rich and robust
descriptions of the observed events. Fourth, the data must be appropriately
analyzed and the findings adequately corroborated by using multiple sources
of information, more than 1 investigator to collect and analyze the raw data,
member checking to establish whether the participants' viewpoints were adequately
interpreted, or by comparison with existing social science theories. Qualitative
studies offer an alternative when insight into the research is not well established
or when conventional theories seem inadequate.
Major difficulties arise when introducing evidence and clinical guidelines into routine daily practice. Data show that many patients do not receive appropriate care, or receive unnecessary or harmful care. Many approaches claim to offer solutions to this problem; which ones are as yet the most effective and efficient is unclear. We aim to provide an overview of present knowledge about initiatives to changing medical practice. Substantial evidence suggests that to change behaviour is possible, but this change generally requires comprehensive approaches at different levels (doctor, team practice, hospital, wider environment), tailored to specific settings and target groups. Plans for change should be based on characteristics of the evidence or guideline itself and barriers and facilitators to change. In general, evidence shows that none of the approaches for transferring evidence to practice is superior to all changes in all situations.
We discuss the challenges confronting environmental governance caused by the increasing connectivity of resource-use systems and the growing functional interdependencies of ecological and social systems. We take as a point of departure the case of the Xingu Indigenous Park (PIX) in Brazil and its surrounding agro-industrial region. This case provides a basis for reviewing the literature on resource governance, including both points of consensus and contentious issues. We argue that no fixed spatial or temporal level is appropriate for governing ecosystems and their services sustainably, effectively, and equitably. We point to the need to recognize the multilevel nature of such problems and the role of institutions in facilitating cross-level environmental governance as an important form of social capital that is essential for the long-term protection of ecosystems and the well-being of different populations.
School-university partnerships with professional learning agendas provide appealing contexts for the introduction and application of systematic evaluative inquiry. The challenges faced by evaluators in moving from results-focused evaluation to learning-oriented evaluative inquiry are discussed, as are the influences of this transition on individual practitioners and their organizations.
Providing a complete portal to the world of case study research, the Fourth Edition of Robert K. Yin's bestselling text Case Study Research offers comprehensive coverage of the design and use of the case study method as a valid research tool. This thoroughly revised text now covers more than 50 case studies (approximately 25% new), gives fresh attention to quantitative analyses, discusses more fully the use of mixed methods research designs, and includes new methodological insights. The book's coverage of case study research and how it is applied in practice gives readers access to exemplary case studies drawn from a wide variety of academic and applied fields.Key Features of the Fourth Edition Highlights each specific research feature through 44 boxed vignettes that feature previously published case studies Provides methodological insights to show the similarities between case studies and other social science methods Suggests a three-stage approach to help readers define the initial questions they will consider in their own case study research Covers new material on human subjects protection, the role of Institutional Review Boards, and the interplay between obtaining IRB approval and the final development of the case study protocol and conduct of a pilot case Includes an overall graphic of the entire case study research process at the beginning of the book, then highlights the steps in the process through graphics that appear at the outset of all the chapters that follow Offers in-text learning aids including 'tips' that pose key questions and answers at the beginning of each chapter, practical exercises, endnotes, and a new cross-referencing tableCase Study Research, Fourth Edition is ideal for courses in departments of Education, Business and Management, Nursing and Public Health, Public Administration, Anthropology, Sociology, and Political Science.
A diverse array of factors may influence both earnings and consumption; however, this work primarily focuses on the impact of investments in human capital upon an individual's potential earnings and psychic income. For this study, investments in human capital include such factors as educational level, on-the-job skills training, health care, migration, and consideration of issues regarding regional prices and income. Taking into account varying cultures and political regimes, the research indicates that economic earnings tend to be positively correlated to education and skill level. Additionally, studies indicate an inverse correlation between education and unemployment. Presents a theoretical overview of the types of human capital and the impact of investment in human capital on earnings and rates of return. Then utilizes empirical data and research to analyze the theoretical issues related to investment in human capital, specifically formal education. Considered are such issues as costs and returns of investments, and social and private gains of individuals. The research compares and contrasts these factors based upon both education and skill level. Areas of future research are identified, including further analysis of issues regarding social gains and differing levels of success across different regions and countries. (AKP)
The abstract for this document is available on CSA Illumina.To view the Abstract, click the Abstract button above the document title.
Incl. index, bibliographical references pp. 387-413, biographical note on the author
To develop a valid, reliable and feasible teamwork assessment measure for emergency resuscitation team performance.
Generic and profession specific team performance assessment measures are available (e.g. anaesthetics) but there are no specific measures for the assessment of emergency resuscitation team performance.
(1) An extensive review of the literature for teamwork instruments, and (2) development of a draft instrument with an expert clinical team. (3) Review by an international team of seven independent experts for face and content validity. (4) Instrument testing on 56 video-recorded hospital and simulated resuscitation events for construct, consistency, concurrent validity and reliability and (5) a final set of ratings for feasibility on fifteen simulated 'real time' events.
Following expert review, selected items were found to have a high total content validity index of 0.96. A single 'teamwork' construct was identified with an internal consistency of 0.89. Correlation between the total item score and global rating (rho 0.95; p<0.01) indicated concurrent validity. Inter-rater (k 0.55) and retest reliability (k 0.53) were 'fair', with positive feasibility ratings following 'real time' testing. The final 12 item (11 specific and 1 global rating) are rated using a five-point scale and cover three categories leadership, teamwork and task management.
In this primary study TEAM was found to be a valid and reliable instrument and should be a useful addition to clinicians' tool set for the measurement of teamwork during medical emergencies. Further evaluation of the instrument is warranted to fully determine its psychometric properties.
The term “education” has many meanings, although its gestalt shows little effect on the performance of clinicians or the outcomes of health care. This lack of effect is especially true in continuing medical education (CME), where education often implies a large, group-based session held in a hotel or conference setting. The American Medical Association defines CME as “any and all ways by which physicians learn and maintain their competence” — clearly a more fulsome construct than attending a short course.1
In this paper, we describe educational interventions that are designed to promote the incorporation of best evidence into the practices of health professionals. We address a theoretic basis for the learning and education of physicians (making reference mainly to physicians because most studies in this area have involved physicians). We also provide an outline of effective large-group methods, describe innovations in formal education that use high-tech (and low-tech) strategies and discuss future trends in CME.
How are human capital investments allocated between women and men? What are the returns to investments in women's nutrition, health care, education, mobility, and training? In thirteen wide-ranging and innovative empirical analyses, Investment in Women's Human Capital explores the nature of human capital distributions to women and their effect on outcomes within the family. Section I considers the experiences of high-income countries, examining the limitations of industrialization for the advancement of women; returns to secondary education for women; and state control of women's education and labor market productivity through the design of tax systems and the public subsidy of children. The remaining four sections investigate health, education, household structure and labor markets, and measurement issues in low-income countries, including the effect of technological change on transfers of wealth to and from children in India; women's and men's responses to the costs of medical care in Kenya; the effects of birth order and sex on educational attainment in Taiwan; wage returns to schooling in Indonesia and in Cote d'Ivoire; and the increasing prevalence of female-headed households and the correlates of gender differences in wages in Brazil.
Human Capital is Becker's classic study of how investment in an individual's education and training is similar to business investments in equipment. Recipient of the 1992 Nobel Prize in Economic Science, Gary S. Becker is a pioneer of applying economic analysis to human behavior in such areas as discrimination, marriage, family relations, and education. Becker's research on human capital was considered by the Nobel committee to be his most noteworthy contribution to economics. This expanded edition includes four new chapters, covering recent ideas about human capital, fertility and economic growth, the division of labor, economic considerations within the family, and inequality in earnings. "Critics have charged that Mr. Becker's style of thinking reduces humans to economic entities. Nothing could be further from the truth. Mr. Becker gives people credit for having the power to reason and seek out their own best destiny."âWall Street Journal
Despite the manpower shortage to care for the critically ill, the number of ICU beds has been rising for the last 2 decades. The ICU intensivist physician staffing model is still in flux in this country. Despite a challenge by a recent single publication, numerous studies have shown that high-intensity intensivist staffing improves patient outcome in the ICU. However, 73% of the ICUs in this country provide low-intensity or no intensive care coverage. Although it may not be possible to implement 24 h/d intensivist coverage of all ICUs at this time, we believe it is the best model for achieving good patient outcome. The mere presence of intensivists in the ICU is unlikely to improve patient outcome unless it is associated with the creation of an organizational environment ideal for the implementation of evidence-based practice. In this commentary, we will discuss the available evidence behind the current models and express our opinions about current and future ICU intensivist staffing.
The opposing forces of increased training expectations and reduced training resources have greatly impacted health professions education. Virtual patients (VPs), which take the form of interactive computer-based clinical scenarios, may help to reconcile this paradox.
We summarise research on VPs, highlight the spectrum of potential variation and identify an agenda for future research. We also critically consider the role of VPs in the educational armamentarium.
We propose that VPs' most unique and cost-effective function is to facilitate and assess the development of clinical reasoning. Clinical reasoning in experts involves a non-analytical process that matures through deliberate practice with multiple and varied clinical cases. Virtual patients are ideally suited to this task. Virtual patients can also be used in learner assessment, but scoring rubrics should emphasise non-analytical clinical reasoning rather than completeness of information or algorithmic approaches. Potential variations in VP design are practically limitless, yet few studies have rigorously explored design issues. More research is needed to inform instructional design and curricular integration.
Virtual patients should be designed and used to promote clinical reasoning skills. More research is needed to inform how to effectively use VPs.
The objective of this study is to identify and appraise qualitative research evidence on the experience of making life-support decisions in critical care.
In six databases and supplementary sources, we sought original research published from January 1990 through June 2008 reporting qualitative empirical studies of the experience of life-support decision making in critical care settings.
Fifty-three journal articles and monographs were included. Of these, 25 reported prospective studies and 28 reported retrospective studies.
We abstracted methodologic characteristics relevant to the basic critical appraisal of qualitative research (prospective data collection, ethics approval, purposive sampling, iterative data collection and analysis, and any method to corroborate findings).
Qualitative research traditions represented include grounded theory (n = 15, 28%), ethnography or naturalistic methods (n = 15, 28%), phenomenology (n = 9, 17%), and other or unspecified approaches (n = 14, 26%). All 53 documents describe the research setting; 97% indicate purposive sampling of participants. Studies vary in their capture of multidisciplinary clinician and family perspectives. Thirty-one (58%) report research ethics board review. Only 49% report iterative data collection and analysis, and eight documents (15%) describe an analytically driven stopping point for data collection. Thirty-two documents (60%) indicated a method for corroborating findings.
Qualitative evidence often appears outside of clinical journals, with most research from the United States. Prospective, observation-based studies follow life-support decision making directly. These involve a variety of participants and yield important insights into interactions, communication, and dynamics. Retrospective, interview-based studies lack this direct engagement, but focus on the recollections of fewer types of participants (particularly patients and physicians), and typically address specific issues (communication and stress). Both designs can provide useful reflections for improving care. Given the diversity of qualitative research in critical care, room for improvement exists regarding both the quality and transparency of reported methodology.
Qualitative research and its methods stem from the social sciences and can be used to describe and interpret complex phenomena that involve individuals' views, beliefs, preferences, and subjective responses to places and people. Thus, qualitative research explores the many subjective factors that may influence patient outcomes, staff well-being, and healthcare quality, yet fail to lend themselves to the hypothesis-testing approach that characterizes quantitative research. Qualitative research is valuable in the intensive care unit to explore organizational and cultural issues and to gain insight into social interactions, healthcare delivery processes, and communication. Qualitative research generates explanatory models and theories, which can then serve to devise interventions, whose efficacy can be studied quantitatively. Thus, qualitative research works synergistically with quantitative research, providing new impetus to the research process and a new dimension to research findings. Qualitative research starts with conceptualizing the research question, choosing the appropriate qualitative strategy, and designing the study; rigorous methods specifically designed for qualitative research are then used to conduct the study, analyze the data, and verify the findings. The researcher is the data-collecting instrument, and the data are the participants' words and behaviors. Data coding methods are used to describe experiences, discover themes, and build theories. In this review, we outline the rationale and methods for conducting qualitative research to inform critical care issues. We provide an overview of available qualitative methods and explain how they can work in close synergy with quantitative methods. To illustrate the effectiveness of combining different research methods, we will refer to recent qualitative studies conducted in the intensive care unit.
Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifying the components or outcomes of care to be sampled, formulating the appropriate criteria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known.
Quantitative research is designed to test well-specified hypotheses, determine whether an intervention did more harm than good, and find out how much a risk factor predisposes persons to disease. Equally important, qualitative research offers insight into emotional and experiential phenomena in health care to determine what, how, and why. There are 4 essential aspects of qualitative analysis. First, the participant selection must be well reasoned and their inclusion must be relevant to the research question. Second, the data collection methods must be appropriate for the research objectives and setting. Third, the data collection process, which includes field observation, interviews, and document analysis, must be comprehensive enough to support rich and robust descriptions of the observed events. Fourth, the data must be appropriately analyzed and the findings adequately corroborated by using multiple sources of information, more than 1 investigator to collect and analyze the raw data, member checking to establish whether the participants' viewpoints were adequately interpreted, or by comparison with existing social science theories. Qualitative studies offer an alternative when insight into the research is not well established or when conventional theories seem inadequate. JAMA. 2000;284:357-362
To develop and test the feasibility of administering a questionnaire to measure family members' level of satisfaction with care provided to them and their critically ill relative.
To develop the questionnaire, existing conceptual frameworks of patient satisfaction, decision making, and quality of end-of-life care were used to identify important domains and items. We pretested the questionnaire for readability, clarity, and sensibility in 21 family members and 16 professionals. To assess validity, we measured the correlation between satisfaction with overall care and satisfaction with decision making. To assess the reliability of the questionnaire, we administered the questionnaire to next of kin of surviving patients on discharge and 7 to 10 days later.
Questionnaires were mailed out to 33 family members of nonsurvivors; 24 were returned completed but only 22 (66%) were usable.Twenty-five family members of eligible surviving critically ill patients participated in the test-retest part of this study. Of the 47 respondents, 84% were very satisfied with overall care and 77% were very satisfied with their role in the decision making. There was good correlation between satisfaction with overall care and satisfaction with decision making (correlation coefficient =.64). The assessment of overall satisfaction with care was shown to be reliable (correlation coefficient =.85).
This questionnaire has some measure of reliability and validity and is feasible to administer to next of kin of critically ill patients.
To determine the level of satisfaction of family members with the care that they and their critically ill relative received.
Prospective cohort study.
Six university-affiliated intensive care units across Canada.
We administered a validated questionnaire to family members who made at least one visit to intensive care unit patients who received mechanical ventilation for >48 hrs. We obtained self-rated levels of satisfaction with 25 key aspects of care related to the overall intensive care unit experience, communication, and decision making. For family members of survivors, the questionnaire was administered while the patient was still in the hospital. For family members of nonsurvivors, the questionnaire was mailed out to the family member 3-4 wks after the patient's death.
A total of 891 family members received questionnaires; 624 were returned (70% response rate). The majority of respondents were satisfied with overall care and with overall decision making (mean +/- sd item score, 84.3 +/- 15.7 and 75.9 +/- 26.4, respectively). Families reported the greatest satisfaction with nursing skill and competence (92.4 +/- 14.0), the compassion and respect given to the patient (91.8 +/- 15.4), and pain management (89.1 +/- 16.7). They were least satisfied with the waiting room atmosphere (65.0 +/- 30.6) and frequency of physician communication (70.7 +/- 29.0). The variables significantly associated with overall satisfaction in a regression analysis were completeness of information received, respect and compassion shown to the patient and family member, and the amount of health care received. Satisfaction varied significantly across sites.
Most family members were highly satisfied with the care provided to them and their critically ill relative in the intensive care unit. Efforts to improve the nature of interactions and communication with families are likely to lead to improvements in satisfaction.
Maintenance of professional competence is a critical component of professionalism. However, traditional methods, which rely on individual self assessment, are inadequate. Conversely, legislated recertification programmes are difficult to individualise and can be perceived as draconian. What is required are better methods of standardised individual needs assessment. We suggest some possible strategies.
Brigham and Women's Hospital (BWH), a major academic tertiary medical center, and Faulkner Hospital (Faulkner), a nearby community teaching hospital, both in the Boston, Massachusetts area, have established a close affiliation relationship under a common corporate parent that achieves a variety of synergistic benefits. Formed under the pressures of limited capacity at BWH and excess capacity at Faulkner, and the need for lower-cost clinical space in an era of provider risk-sharing, BWH and Faulkner entered into a comprehensive affiliation agreement. Over the past seven years, the relationship has enhanced overall volume, broadened training programs, lowered the cost of resources for secondary care, and improved financial performance for both institutions. The lessons of this relationship, both in terms of success factors and ongoing challenges for the hospitals, medical staffs, and a large multispecialty referring physician group, are reviewed. The key factors for success of the relationship have been integration of training programs and some clinical services, provision of complementary clinical capabilities, geographic proximity, clear role definition of each institution, commitment and flexibility of leadership and medical staff, active and responsive communication, and the support of a large referring physician group that embraced the affiliation concept. Principal challenges have been maintaining the community hospital's cost structure, addressing cultural differences, avoiding competition among professional staff, anticipating the pace of patient migration, choosing a name for the new affiliation, and adapting to a changing payer environment.