Actual Practice Change Research Articles

Evaluating the UK's first national prescribing assessment for GPs in training using an online survey.

GP trainees may not have experienced a systematic and comprehensive education in safe prescribing. Therefore, a self-assessment prescribing review was developed. To determine whether the assessment was feasible, had face validity, and did not disadvantage particular groups of participants. An online survey that evaluates the opinions of GPs in training of a prescribing assessment in the UK. All full-time UK trainees who started their final year of GP training in August 2019 undertook the prescribing assessment along with their trainers, after which they completed an online anonymous feedback questionnaire. The questionnaire completed by trainees sought their opinions of the assessment, and collected ethnicity and disability data. The trainer questionnaire was similar but did not include any demographic information. The questionnaire was completed by 1741 trainees and 1576 trainers. There was no evidence that ethnic group and disability were related to aspects of the review. Most of the trainees (76.4%, n = 1330) and trainers (82.0%, n = 1293) agreed or strongly agreed that the prescribing review was helpful for assessing and learning about the trainee's prescribing. However, most participants (63.2%, n = 1092) took >4 hours to review their prescriptions. A majority of trainees (90.2%, n = 1571) reported that completing the assessment had resulted in a change in their prescribing practice. The majority of trainers and trainees reported that the prescribing assessment was helpful. The study was not able to assess whether there had been an actual change in practice that resulted in an error reduction.

1026-P: Impact of Online CME on Planned and Actual Practice Changes Related to CGM Use

Objective: Assess impact of online education to prompt changes in practice of diabetologists/endocrinologists (D/Es), PCPs and CDEs related to use of real-time continuous glucose monitoring (rtCGM) in practice. Method: Online summary of a symposium presented at the ADA 2021 Conference. Faculty presentation was reinforced with synchronized slides presenting supportive data. The impact of the education measured with a survey immediately post-education to assess planned changes in clinician practice as a result of participation in CME activity. Survey participants were contacted 8 weeks later to assess self-reported actual changes in practice. The activity launched August 3, 2021 and data were collected through June 29, 2022. Results: A total of 324 clinicians in the target audience completed the survey immediately post-education. • 74 D/Es, 141 PCPs, and 109 CDEs • 33% of D/Es, 10% of PCPs, and 17% of CDEs treat more than 30 patients per week with diabetes • 92% of respondents indicated an average of 3.1 planned practice changes each When re-engaged with the follow up survey, 15 completed the survey. • 6 D/Es and 9 PCPs • 67% of D/Es and 56% of PCPs treat more than 30 patients per week with diabetes • Of those, 93% reported making an average of 4.8 changes in practice as a result of this activity • Changes in practice include: o Recommending CGM in patients who want to improve time in range and minimize hypoglycemia (100% D/Es and 78% PCPs) o Recommending CGM in patients with diabetes on insulin (100% D/Es and 67% PCPs) o Increasing familiarity with clinical trial data related to CGM use (83% D/Es and 67% PCPs) o Target time in range with diabetes-related treatment goals (83% D/Es and 44% PCPs) Conclusion: The outcomes gathered in this assessment provide compelling evidence that participation in online CME prompts both planned and actual changes in practice related to CGM use. Future education is needed for PCPs regarding time in range goals as part of a diabetes treatment plan. Disclosure A.Larkin: None. J.Schrand: None. A.Le: None. Funding Dexcom, Inc.

Measuring the Impact of a Faculty Development Program on Clinical Educators.

IntroductionAn Academy of Clinical Educators (ACE) was established at the University of Newcastle, to support and build capacity among existing and prospective medical educators. ACE established a Certificate of Clinical Teaching and Supervision (CCTS) program, the final assessment of which was a reflective piece on how the course has affected participants’ practice as clinical teachers or supervisors and how changes are expected to impact learner achievement. We conducted a qualitative evaluation of these to explore the impact of the CCTS on participants’ teaching.MethodsThirty-one participants (of 90 completers to date) consented for their written reflections to undergo qualitative thematic analysis and completed a survey exploring their preparation for, and experience of the program, and application of skills learnt.ResultsMost participants reported applying the skills gained through the CCTS to their teaching practice to a large (n=23; 72%) or very large (n=5; 16%) extent. Four themes emerged from the qualitative data, aligned with the topics of the CCTS: teaching structure; feedback; orientation; and assessment. Participants described application of more structured approaches to orientation, teaching and feedback, positive student responses, and self-reported satisfaction with adopted changes.DiscussionThe CCTS has motivated change in the teaching practice of participants. Although evidence presented here is limited by the self-reported nature, descriptions of actual changes in practice were detailed and specific enough to suggest they could act as a proxy for objectively measured change in behaviour and outcome.ConclusionA faculty development program delivered to clinicians with a range of teaching and education-related roles, from varied clinical disciplines and professions, can promote improved, structured teaching and feedback.

Turning rules into practices: An inside-out approach to understanding the implementation of sustainability standards

While sustainability standards promise better labor and environmental conditions, changes in actual practice occur inconsistently. Existing literature has explained this mainly through focusing on structures and mechanisms that originate from outside producers' organizations. This paper instead examines the intraorganizational process by which rules turn into practices on the ground. It offers an inside-out approach that draws on data from an eight-month participant observation study of certified agricultural commodity producers in Brazil. The key finding of this paper is that rules get turned into practices through discovering and cultivating a practice ecosystem in which certified producers in the Global South learn to implement new practices through a self-guided, two-step discovery process. First, they must discover how to build and integrate the elements of a practice; second, they must discover how to support the internalization of this practice. Further, adjacent practices—those alongside the ones that need to be integrated—are pivotal in determing whether producers succeed in building new practices. This paper contributes to the literature on sustainable commodity governance and to organizational theories of practice adaptation. It shows that sustainable commodity governance depends not only on external structures and mechanisms, but also, equally importantly, on the internal organizational mechanisms for new practices to take hold.

Commitment to Change Statements and Actual Practice Change After a Continuing Medical Education Intervention.

Continuing medical education (CME) interventions often evaluate participant commitment to change (CTC) clinical practice. Evidence linking CTC to actual practice change is limited. In an intervention that combined live CME with changes to the electronic health record to promote judicious antibiotic use for children with urinary tract infections (UTIs), we evaluated CTC and subsequent prescribing behavior in Kaiser Permanente Colorado, an integrated health care system. CTC was assessed immediately after the session using closed-ended questions about session learning objectives and open-ended questions to elicit specific practice changes. Perceived barriers to implementing recommended changes were also assessed. Among 179 participants, 80 (45%) completed postsession evaluations and treated one or more child with a UTI in the subsequent 17 months (856 UTIs in total). In closed-ended responses about session learning objectives, 45 clinicians (56%) committed to changing practice for antibiotic choice and duration, whereas 37 (46%) committed to implementing new practice guidelines. When asked open-ended questions to identify specific practice changes, 32 (40%) committed to antibiotic choice change and 29 (36%) committed to treatment duration change. Participants who made specific CTC statements had greater improvement in antibiotic choice (relative rate ratio 1.56, 95% CI 1.16-2.09) and duration (relative rate ratio 1.59, 95% CI 1.05-2.41) than participants who did not make specific commitments. Few perceived barriers affected subsequent prescribing. Commitments to changing specific clinical behaviors were associated with sustained changes in prescribing for children with UTIs. Linking self-evaluations with clinical data in integrated health care systems is an important tool for CME evaluators.

Trend and Factors Associated with Repeat Computed Tomography Examinations in Tertiary Hospitals: Linked Health Administrative Data in Western Australia

IntroductionComputed tomography (CT) has become an essential part of clinical practice. However, repeat CT scans has raised a concern about unnecessary exposure to ionising radiation and waste of health care resource. While substantial effort is underway to reduce inappropriate use of diagnostic imaging tests including CT, little evidence of any change in repeat CT use and its associated factors. Objectives and ApproachThis study aimed to measure trend in repeat CT use and identify factors associated with repeat CT use in tertiary hospitals in Western Australia (WA). This study used WA linked administrative records from hospital morbidity, emergency department presentations, and picture archiving and communication system datasets to capture all tertiary hospitalisations and number of CT use during the admission from 2003 to 2015. Multivariate logistic regression was used to examine trend and determine characteristics associated with repeat CT, for admissions with and without major surgery during hospitalisation. ResultsAmong 303,439 admissions with CT scan 11.9% had repeat CT scan in the same anatomic areas. While the probability of repeat CT among admission with surgery remained unchanged over the study period, its counterpart significantly reduced about 4% per year. Regardless of surgical status, repeat CT scanning was significantly lower among females, Indigenous and older age groups but higher among people living in rural and remote areas. We found that admissions for circulatory conditions, injuries, cancer or multimorbidity had significantly higher probability of having repeat CT. Conclusion / ImplicationsThis study indicates that clinical factors such as cancer, injury and multimorbidity are factors contributing to repeat CT. A reduction of repeat CT over the study period among admissions without surgical procedure suggests a potential reduction of unnecessary CT scan, although further study is needed to fully capture whether this is an actual change in practice.

Neoadjuvant chemotherapy versus adjuvant chemotherapy in breast cancer patients: Analysis of breast conserving rate and de-escalation of axillary surgery in 5,141 Korean women.

e12531 Background: Neoadjuvant chemotherapy (NCT) in breast cancer has several advantages such as more breast conservation surgery (BCS) rate and de-escalation of extent of axillary surgery. Actual practice change in this area compared with adjuvant chemotherapy (ACT) is not well established. Methods: We retrospectively analyzed 5,141 women diagnosed with breast cancer from 2009 to 2013, treated with chemotherapy before or after definite surgery. BCS rate and axillary surgery categories (sentinel lymph node biopsy (SNB), axillary lymphnode dissection (ALND) or SNB followed by ALND) are compared between two groups. Results: Among 5,141 patients, 3930 (76.4%) women had ACT and 1211 (23.6%) had NCT. Median age at diagnosis was 48 (range 22-83). BCR rate was lower in T2 (57.1% vs 64.1%), T3 (12.6% vs 20.9%) group between ACT vs NCT ( p=0.03, 0.001), no difference was shown in T1 and T4 tumors. SNB try (SNB only or SNB followed by ALND) rate was still higher in ACT group with cN0 (98.4% vs 95.4%), cN1 (89.3% vs 73.5%), cN2 (77.9% vs 62.1%) tumors ( p=0.001, <0.001, 0.003, respectively). SNB only rate which means that patients spared ALND, was lower in ACT group with all cN stage (cN1; 17.5% vs 29.2%, cN2; 3.2% vs 5.9%, cN3; 5.1% vs 20.5%, all p=0.000) except cN0 (95.6% vs 81.4%, p<0.001). Axillary surgery rate analyzed with pathologic N stage showed more ALNDs attempted even after achieving pathologic complete nodal response or minimal residual N disease (ypN0: 4.4% vs 27.2%, ypN0(i) & ypN1mi; 26.2% vs 57.6%, p<0.001, =0.001 respectively). In contrast however, average of total axillary nodes retrieved by cN stage were statistically lower in NCT group in clinically positive tumors (N1; 15.3 vs 12.7, N2; 19.1 vs 14.6, N3; 25.1 vs 15.6, all p<0.001). Conclusions: NCT had shown advantage to perform more BCS than ACT in T2, T3 tumors. SNB attempts in NCT was comparable to ACT. Still, patients with NCT received more aggressive axillary surgery than ACT shown by axillary surgery category irrespective of negative SNB results.

Translating guidelines to practice: a training session about cancer-related fatigue.

Cancer-related fatigue (crf) is the highest unmet need in cancer survivors. The Canadian Association of Psychosocial Oncology (capo) has developed guidelines for screening, assessment, and intervention in crf; however, those guidelines are not consistently applied in practice because of patient, health care provider (hcp), and systemic barriers. Notably, previous studies have identified a lack of knowledge of crf guidelines as an impediment to implementation. In this pilot study, we tested the preliminary outcomes, acceptability, and feasibility of a training session and a knowledge translation (kt) tool designed to increase knowledge of the capo crf guidelines among hcps and community support providers (csps). A one-time in-person training session was offered to a diverse sample of hcps and csps (n = 18). Outcomes (that is, knowledge of the capo crf guidelines, and intentions and self-efficacy to apply guidelines in practice) were assessed before and after training. Acceptability and feasibility were also assessed after training to guide future testing and implementation of the training. After training, participants reported increased knowledge of the capo crf guidelines and greater self-efficacy and intent to apply guidelines in practice. Participant satisfaction with the training session and the kt tool was high, and recruitment time, participation, and retention rates indicated that the training was acceptable and feasible. The provided training is both acceptable to hcps and csps and feasible. It could increase knowledge of the capo crf guidelines and participant intentions and self-efficacy to implement evidence-based recommendations. Future studies should investigate actual changes in practice and how to optimize follow-up assessments. To promote practice uptake, kt strategies should be paired with guideline development.

‘InUTERO’: The effectiveness of an educational half day stillbirth awareness workshop for maternity care providers

BackgroundThere is a disconnect between what maternity care providers consider should be done and what they actually do with respect to talking with their pregnant clients about reducing their risk of stillbirth. This suggests that they would benefit from receiving up-to-date knowledge about stillbirth, alongside education that provides them with strategies for talking about stillbirth with pregnant women. ObjectivesTo gain an understanding of maternity care provider (obstetricians and midwives) knowledge of stillbirth and determine whether delivering a half day workshop improves knowledge and results in intention to change practice. DesignA pre-post intervention study. SettingMaternity care providers (Obstetricians, Midwives) working in the northern areas of Tasmania, Australia were asked, via questionnaire, about their knowledge of stillbirth both before and after attending a half-day workshop. ParticipantsMaternity care providers (n = 51) attended the workshop and 30 (59%) completed both the pre-workshop and post-workshop surveys. MethodsA four hour interactive workshop grounded in understanding the stillbirth experience. Participants were given up-to-date information about stillbirth risks and current prevention research as well as provided with an actionable step wise approach to talking about stillbirth prevention in pregnancy. ResultsStillbirth knowledge scores (total of 8-points) significantly increased following the workshop (pre: mean = 2.9 ± 1.5; post: mean = 4.7 ± 1.4 points, t 29 = 7.9, <0.001). Before the workshop, only 20% of participants responded that they “always” or usually” discussed the possibility stillbirth occurring with pregnant women in their care whereas, after the workshop, nearly all (88%) indicated that they planned to “always” discuss stillbirth with their pregnant clients. ConclusionsAttending a stillbirth awareness for prevention education workshop resulted in significant knowledge improvement and self-reported intention to change practice in a group of Australian maternity care providers. While these results are promising, further study is needed to determine the presence and extent of actual practice change following such education.

Deimplementation in Clinical Practice: What Are We Waiting For?

Deimplementation in Clinical Practice: What Are We Waiting For?

Evaluating Transfer of Continuing Education to Nursing Practice.

The nursing profession needs solid evidence of the important contributions that continuing education (CE) makes to nursing practice change. We analyzed nurses' intent to change practice, actual practice change, and examples of practice change after completing CE courses of differing types, topics, and geographic locations. A retrospective, mixed-methods study design was used to assess quantitative and qualitative survey data gathered upon completion and within 1 year following completion of 16 different CE courses. A large majority of nurses reported positive intent to change practice (88.6%) and actual practice change (89.1%) following participation in the CE courses. Qualitative analysis revealed four themes related to types of practice change, including Becoming Certified, Improved Leadership, Enhanced Role Performance, and Educating or Mentoring Others. CE can positively influence nursing practice change and lead to broader organizational improvements. [J Contin Educ Nurs. 2019;50(8):375-380.].

What motivates general practitioners to change practice behaviour? A qualitative study of audit and feedback group sessions in Dutch general practice

ObjectivesAdopting an attributional perspective, the current article investigates how audit and feedback group sessions contribute to general practitioners’ (GPs) motivation to change their practice behaviour to improve care. We focus...

SAT-131 Success of CME/CE in Promoting Practice Improvements in the Use of New Technologies for Glucose Monitoring

Introduction: Glucose monitoring is a critical component in effective diabetes management. With the evolution of continuous glucose monitoring (CGM), we studied the effect of online education designed to improve the knowledge and competence of primary care physicians (PCPs), nurse practitioners (NPs) and physician assistants (PAs), and nurses in diabetes management as well as to help develop new decision-making skills. Method: The CME activity was a 30-minute online video panel discussion with experts discussing key study findings and offering practical recommendations on the use of CGM in the management of diabetes. Faculty discussion was reinforced with synchronized slides presenting supportive data. The activity was targeted to primary care physicians (PCPs), diabetologists and endocrinologists, nurse practitioners (NPs) and physician assistants (PAs). The impact of the education on performance outcomes was measured with a follow-up Planned Change Assessment® (PCA) survey. The PCA survey was delivered immediately post-education to assess planned changes in clinician practice, and survey participants were contacted 8 weeks later to assess self-reported actual changes in practice. Results: A total of 859 clinicians in the target audience completed the survey immediately post-education, with 89% of respondents indicating an average of 2.7 planned practice changes each. When re-engaged with the follow up survey 58 targeted clinicians completed the survey. Of those, 90% reported making an average of 3.2 changes in practice as a result of this activity. Changes in practice were reported in the following areas: familiarizing self and other clinicians on how to read an ambulatory glucose profile (AGP) report (52% PCPs, 59% NPs/PAs, 42% nurses), recommending CGM in all appropriate patients (48% PCPs, 59% of NPs/PAs, 50% nurses), and using the AGP report to help patients understand how diet and exercise impact their glucose levels (31% PCPs, 47% NPs/PAs, 58% of nurses). The most commonly reported barriers to practice change included financial constraints such as formulary, reimbursement issues, or patient affordability, and time required to teach patients to use CGM. Conclusion: The outcomes gathered in this assessment provide compelling evidence that participation in a a 30-minute online video panel discussion with synchronized slides prompted changes in practice and prompted physicians, NPs/PAs, and nurses to recommend CGM in appropriate patients.

A Dynamic Model of Rescuer Parameters for Optimizing Blood Gas Delivery during Cardiopulmonary Resuscitation.

Introduction The quality of cardiopulmonary resuscitation (CPR) has been shown to impact patient outcomes. However, post-CPR morbidity and mortality remain high, and CPR optimization is an area of active research. One approach to optimizing CPR involves establishing reliable CPR performance measures and then modifying CPR parameters, such as compressions and ventilator breaths, to enhance these measures. We aimed to define a reliable CPR performance measure, optimize the CPR performance based on the defined measure and design a dynamically optimized scheme that varies CPR parameters to optimize CPR performance. Materials and Methods We selected total blood gas delivery (systemic oxygen delivery and carbon dioxide delivery to the lungs) as an objective function for maximization. CPR parameters were divided into three categories: rescuer dependent, patient dependent, and constant parameters. Two optimization schemes were developed using simulated annealing method: a global optimization scheme and a sequential optimization scheme. Results and Discussion Variations of CPR parameters over CPR sequences (cycles) were analyzed. Across all patient groups, the sequential optimization scheme resulted in significant enhancement in the effectiveness of the CPR procedure when compared to the global optimization scheme. Conclusions Our study illustrates the potential benefit of considering dynamic changes in rescuer-dependent parameters during CPR in order to improve performance. The advantage of the sequential optimization technique stemmed from its dynamically adapting effect. Our CPR optimization findings suggest that as CPR progresses, the compression to ventilation ratio should decrease, and the sequential optimization technique can potentially improve CPR performance. Validation in vivo is needed before implementing these changes in actual practice.

Towards equity in global health partnerships: adoption of the Research Fairness Initiative (RFI) by Portuguese-speaking countries

Research partnerships between high-income countries (HICs) and low- and medium-income countries (LMICs) often display a set of asymmetries that hinder the development of science, technology and health systems in the...

Constitutional War Initiation and the Obama Presidency

In 2007, presidential candidate Barack Obama argued that the U.S. president did not have independent constitutional authority to use military force except in response to an actual or imminent attack on the United States. Since 2008, President Obama has directed the use of U.S. military force in at least seven countries (Iraq, Syria, Libya, Yemen, Afghanistan, Pakistan, and Somalia). Critics find inconsistency in these positions, contending that the Obama presidency will be remembered for expansion of the presidency's war powers. But when the administration's record is closely examined, these claims seem overstated. At least with regard to war initiation, the Obama presidency need not be regarded as materially enhancing the president's constitutional powers.This assessment begins by establishing two baselines. First, most war powers scholars agree that under the Constitution's original meaning, Congress’ power to “declare War” required the president to seek congressional approval prior to initiating war. This constitutional command had substantial grey areas, including responses to threats and attacks, relations with non-state actors, and low-level hostilities. Nonetheless, the basic proposition stated by candidate Obama appears well founded both in the Constitution's text itself and in early postratification practice. Second, in the modern (post-Vietnam War) era, most scholars agree that the practice has changed somewhat, with presidents asserting an expanded independent authority over uses of military force. This essay agrees with that description, although it contends that the change in actual practice is less dramatic than commentary sometimes claims.

Development and use of a research productivity assessment tool for clinicians in low-resource settings in the Pacific Islands: a Delphi study.

BackgroundResearch performance assessments have proliferated, but research indicators for use amongst clinicians in poorly resourced countries have been ill-defined. The aims of the present paper were to determine a set of indicators as determined by clinician participants from the Pacific Islands and a panel of research experts for use in the performance assessment of clinicians.MethodsTwo focus group discussions, one for nurses and one for doctors, were used to obtain the views of 28 Pacific Island clinicians of the BRRACAP Study about what the research indicators should be. A modified Delphi survey was used to obtain a consensus amongst 19 research experts, with Pacific Island research experience, as to what the indicators should be and then to rank these in terms of importance. A survey of the participants obtained data on the research tasks/actions performed 20 months after the initial research workshop. A resultant tool comprising of 21 indicators was used to assess the performance of 18 Pacific participants.ResultsThe Pacific Island clinicians determined that research was important and that performance should be measured. They identified research indicators that could be used in their settings and ranked their importance using a points system. The panel of experts identified implementation of research findings, collaborations and actual change in practice as more important, with bibliometric measurements low down in the scale. Although only 64 % of the 28 BRRACAP Study participants returned the questionnaire, 39 % of those performed more than half of the 21 indicators used. Of the 18 Pacific clinicians assessed, 7 (39 %) performed 10 or more tasks.ConclusionsA research performance assessment tool was developed using process and output indicators identified by Pacific clinicians and a panel of research experts. The tool, which placed emphasis on process and outputs that were not bibliometric based, proved useful in assessing the performance of Pacific clinicians working in a low-resource setting.Electronic supplementary materialThe online version of this article (doi:10.1186/s12961-016-0077-4) contains supplementary material, which is available to authorized users.

Do complexity-informed health interventions work? A scoping review.

BackgroundThe lens of complexity theory is widely advocated to improve health care delivery. However, empirical evidence that this lens has been useful in designing health care remains elusive. This review assesses whether it is possible to reliably capture evidence for efficacy in results or process within interventions that were informed by complexity science and closely related conceptual frameworks.MethodsSystematic searches of scientific and grey literature were undertaken in late 2015/early 2016. Titles and abstracts were screened for interventions (A) delivered by the health services, (B) that explicitly stated that complexity science provided theoretical underpinning, and (C) also reported specific outcomes. Outcomes had to relate to changes in actual practice, service delivery or patient clinical indicators. Data extraction and detailed analysis was undertaken for studies in three developed countries: Canada, UK and USA. Data were extracted for intervention format, barriers encountered and quality aspects (thoroughness or possible biases) of evaluation and reporting.ResultsFrom 5067 initial finds in scientific literature and 171 items in grey literature, 22 interventions described in 29 articles were selected. Most interventions relied on facilitating collaboration to find solutions to specific or general problems. Many outcomes were very positive. However, some outcomes were measured only subjectively, one intervention was designed with complexity theory in mind but did not reiterate this in subsequent evaluation and other interventions were credited as compatible with complexity science but reported no relevant theoretical underpinning. Articles often omitted discussion on implementation barriers or unintended consequences, which suggests that complexity theory was not widely used in evaluation.ConclusionsIt is hard to establish cause and effect when attempting to leverage complex adaptive systems and perhaps even harder to reliably find evidence that confirms whether complexity-informed interventions are usually effective. While it is possible to show that interventions that are compatible with complexity science seem efficacious, it remains difficult to show that explicit planning with complexity in mind was particularly valuable. Recommendations are made to improve future evaluation reports, to establish a better evidence base about whether this conceptual framework is useful in intervention design and implementation.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0492-5) contains supplementary material, which is available to authorized users.

The Iowa Model of Evidence-Based Practice to Promote Quality Care: An Illustrated Example in Oncology Nursing

Evidence-based practice (EBP) improves the quality of patient care and helps control healthcare costs. Numerous EBP models exist to assist nurses and other healthcare providers to integrate best evidence into clinical practice. The Iowa Model of Evidence-Based Practice to Promote Quality Care is one model that should be considered. Using an actual clinical example, this article describes how the Iowa Model can be used effectively to implement an actual practice change at the unit or organizational level.

Technological revolution, media existence and the role of journalism in search of a sustainable model

New technologies and new media certainly are one of the biggest challenges for the media and journalism in their original concept and tradition. The result is a number of innovations and problems in practice, as well as a variety of predictions as their theoretical reflection. Today, the media and journalists operate in conditions that have significantly changed the entire way of their functioning, as well as the media and journalistic culture in general, and have thus influenced the fact that this moment is often seen as an epochal turning point and a fundamental change in the traditional functions of journalism and media practice, as well as their role in contemporary culture. In order to understand the current circumstances, it is necessary to recognize not only the global importance of the role of the media and the original principles of journalism, but also the actual change in practice - as comprehensively as possible - and to present implications of the so-called new technological revolution. The ultimate goal is to find the most reliable lines of thinking when it comes to the future of the journalism, which is the essence of the media world, no matter which way we look. If we try, it is necessary to observe the situation from different aspects and thus analyze global challenges and changes that have already occurred. Of course, they should not be viewed as isolated incidents, and due to their complexity still need to be observed in as much detail as possible. It seems that one of the ways to study them could be the one that we shall try to offer in this paper - through observation of: 1 Altering of the public role and position of journalists and journalism; and 2. Changing of the media and journalism everyday organizations and work. The first means an external reflection of journalism and how it affects changes in other spheres of life, and conversely, how these changes affect the public role of journalism. The other one is an internal reflection of the changes in terms of everyday journalistic (and editorial) work - the tasks and how they are carried out. Their synthesis may perhaps mean the ability to reach a valid assessment of the direction in which we will be working and reporting further. It puts the focus on the dimension of the managerial and editorial features in the media, which is always crucial in terms of their orientation and ways of working (although often ignored), and therefore the ways in which journalism occurs. That also involves one of the key issues when it comes to the media and journalism today - the question of a sustainable model of journalism and the media (in terms of business, but also in terms of quality journalism) in the 21st century.