Day In Clinical Practice Research Articles

The Effect of the Orientation Program Performed for First Year Nursing and Midwifery Students on Their Clinical Stress

Objective: This study was conducted to determine the effect of an orientation program performed for first year nursing and midwifery students on their clinical stress and to identify their experiences.
 Methods: The mixed method was used in this study, quasi-experimental and phenomenological type. The population of the study consisted of first-year students (n=117) in the nursing and midwifery department of a university in the 2018-2019 Spring Semester, and the sample consisted of first year students in the nursing and midwifery departments who agreed to participate in the research (n=94). The data were collected using student information form, Clinical Stress Questionnaire and a semi-structured form in which students could write their experiences.
 Results: It was determined that there was a significant difference between the sociodemographic and academic characteristics of the students and their clinical stress levels, the stress level was highest on the last day of clinical practice (28.39±6.97), and the difference was significant (p

Clinical-practice stress levels and factors affecting these on first-year nursing students.

This study aimed to determine the stress levels of first-year nursing students end of the first day of clinical practice and the factors affecting these. This was a descriptive and cross-sectional study. A student information form and the clinical stress questionnaire (CSQ) were used to collect the research data. The average CSQ score of the students was 23.57 ± 8.35 and it was determined that the students experienced below-average stress. In line with the results obtained from the study, it was observed that the student's CSQ scores at the end of the first day of clinical practice were below average, and their biggest fear about clinical practice was that they would harm the patient.

Non-Alcoholic Fatty Liver Disease and Risk of Macro- and Microvascular Complications in Patients with Type 2 Diabetes.

Non-alcoholic fatty liver disease (NAFLD) is considered the hepatic manifestation of metabolic syndrome. To date, NAFLD is the most frequent chronic liver disease seen day by day in clinical practice across most high-income countries, affecting nearly 25–30% of adults in the general population and up to 70% of patients with T2DM. Over the last few decades, it clearly emerged that NAFLD is a “multisystemic disease” and that the leading cause of death among patients with NAFLD is cardiovascular disease (CVD). Indeed, several observational studies and some meta-analyses have documented that NAFLD, especially its advanced forms, is strongly associated with fatal and non-fatal cardiovascular events, as well as with specific cardiac complications, including sub-clinical myocardial alteration and dysfunction, heart valve diseases and cardiac arrhythmias. Importantly, across various studies, these associations remained significant after adjustment for established cardiovascular risk factors and other confounders. Additionally, several observational studies and some meta-analyses have also reported that NAFLD is independently associated with specific microvascular conditions, such as chronic kidney disease and distal or autonomic neuropathy. Conversely, data regarding a potential association between NAFLD and retinopathy are scarce and often conflicting. This narrative review will describe the current evidence about the association between NAFLD and the risk of macro- and microvascular manifestations of CVD, especially in patients with T2DM. We will also briefly discuss the biological mechanisms underpinning the association between NAFLD and its advanced forms and macro- and microvascular CVD.

Real-Life Analysis with Erenumab: First Target Therapy in the Episodic and Chronic Migraine's Prophylaxis.

Background: to research retrospectively the efficacy of Erenumab’s treatment, thus allowing to describe a summary more in line with the reality observed every day in clinical practice, relative to a sample of patients widely heterogeneous. The study aims to confirm the efficacy of Erenumab, in terms of reduction of migraine days per month, from baseline to month 12 of treatment. Additional objectives included a reduction in the number of days of symptomatic drug use and change from baseline in the Migraine Disability Assessment Score Questionnaire (MIDAS); Methods: the analysis included all patients treated for 12 months with Erenumab during the year 2019–2020. The population analyzed consists of twenty-six patients from the Neurology outpatient clinic in Fossombrone. Several quantitative and qualitative variables were recorded by reading the medical records of the patients. The MIDAS was administered to patients to assess the disability related to migraine; Results: at the end of treatment, a statistically significant reduction in the mean number of monthly migraine days, acute medication use per month, and MIDAS questionnaire score was observed; Conclusions: as a preventive treatment of episodic and chronic migraine, our analysis data confirm the efficacy of Erenumab for the prevention of the migraine. The success is achieved in 96% of cases.

Risk of True Allergy to Local Anesthetics: 10-Year Experience from an Anesthesia Allergy Clinic in China.

BackgroundLocal anesthetics (LAs) have been widely used throughout the healthcare settings, especially in local anesthesia and pain management. The incidence of allergic reactions to LAs remains uncertain. The danger of allergic reactions to the use of LAs in every day of clinical practice is a matter of great concern. Therefore, it is necessary to investigate the risk of true allergy to LAs.MethodsThis study retrospectively evaluated the medical records of patients who were referred to an anesthesia allergy clinic in China and underwent allergy tests with LAs over a 10-year period from 2009 to 2019. The following information was collected from medical records: demographics of the patients, reasons for referral, clinical features of drug hypersensitivity reaction (DHR), and test results with LAs. Skin tests combined with an in vitro method, basophil activation test (BAT), were used to investigate allergic reactions to LAs.ResultsA group of 109 patients were included in the analysis. The main reason for referral was the presence of a suspected DHR after procedures with LAs (n=68, 62%), the second most common reason for referral was a history of DHR to other drugs and the need to use LAs for upcoming procedures (n=41, 38%). Of the 68 patients with a suspected DHR to LAs, only six cases presented true allergy and showed positive results in skin tests and/or BAT. And all 41 patients who had a history of DHR to other drugs presented negative in all tests.ConclusionRisk of true allergy to LAs may be very low. However, patients with a suspected history of DHR to LAs should be considered for allergy tests. Skin tests and BAT may be useful in the investigation and diagnosis of true allergy to LAs in clinical practice.

Nurses confronting the coronavirus: Challenges met and lessons learned to date

Registered nurses are an essential workforce group across the globe. They use their expertise and skill sets every day in clinical practice to protect, promote, and advocate on behalf of patients and families under their care. In this article we discuss the physical, emotional, and moral stresses that nurses are experiencing in their day-to-day practice settings created by the novel coronavirus. We consider the demands placed on nurses by unexpected patient surges within hospital environments and inadequate personal protective equipment and other critical resources, challenging nurses’ ability to meet their professional and ethical obligations. We also share our thoughts on supporting nurses and others now, and ideas for needed healing for both individuals and organizations as we move forward. Finally, we argue for the need for substantive reform of institutional processes and systems that can deliver quality care in the future when faced with another devastating humanitarian and public health crises.

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Does writing patient care daily effects on critical thinking? A pilot study with 1st year nursing students

Writing is a powerful way of learning. Writing may provide students with opportunities to think by discussion and use higher-level thinking skills to answer complicated problems. The purpose of this study is to understand whether keeping written patient care logs has an effect on improving the critical thinking skills of nursing students. This study used a quasi-experimental, pretest-posttest design. The sample of the study consisted of 69 students who were registered for the course Fundamentals of Nursing, agreed to participate in the study and filled out the California Critical Thinking Disposition Inventory (CCTDI) completely. The study was conducted with students who were participating in clinical practice of the 1st-year course Fundamentals of Nursing in the spring semester of the academic year of 2016-2017. The pretest was carried out on the first day of clinical practice by applying a questionnaire form and the CCTDI with the students. Throughout the clinical practice, the students kept written logs at the end of each day of practice. The posttest was carried out on the last day of clinical practice by applying the CCTDI with the students. Wilcoxon signed-rank test was used to compare the results of the pretest and the posttest. The mean pretest critical thinking disposition score of the students was found as 214.71 ± 20.17, while their mean score in the posttest was found as 219.13 ± 23.96. The difference between the mean pretest and posttest critical thinking disposition scores was statistically significant. As a result of this study, it was found that the mean critical thinking scores of the students were not on a desired level but keeping written patient care logs affected the improvement of their critical thinking skills positively.

What does a good prescribing induction for the newly qualified doctor look like?

Foundation year 1 doctors (F1s) are expected to prescribe from their first day in clinical practice. Prescribing involves a complex series of steps involving integration of theoretical and experiential knowledge, patient information, communication skills, mathematics and awareness of human factors that undermine safe prescribing. It has been suggested that prescribing should routinely be viewed and treated as a high-risk procedural skill. The majority of prescriptions within secondary care are written by foundation doctors (FDs).1,2 FDs also make the most prescribing errors.2,3 An important part of the transition to prescriber is F1 induction. Since 2012, trusts and health boards must provide an induction and at least …

Moral Distress: A Lens to Focus on Moral Strength and Clinician Well-Being

Every day in clinical practice, health care clinicians make difficult decisions about appropriate treatment and care for their patients. Years of training prepare them for this responsibility, to choose the best course of action for a patient based on their clinical knowledge, the patient’s needs and wants, and the clinician’s professional and human values. […]

PTH-117 Appraising and Improving Junior Doctors Management of Acute Variceal Bleeds: A Quality Improvement Project

Introduction Acute gastrointestinal bleeding is a medical emergency. Some 44% of bleeds are caused by peptic ulcer disease but the most severe haemorrhage and highest mortality is seen amongst those with bleeding oesophageal or gastric varices. 1 Competent triage and assessment are cornerstones of its initial management, with emphasis on identifying sick patients with life threatening haemodynamic compromise, and then initiating appropriate and timely resuscitation being of paramount importance in the patient’s outcome. In a national audit, variceal bleeding accounted for just over 10% of all UK admissions, with just fewer than 50% presenting outside normal working hours. 2 The average mortality for a variceal bleed is reported to be up to 20%, with studies confirming a 2–3 fold increase in mortality amongst inpatients. 2 Therefore it is paramount that all junior are able to recognise and manage suspected variceal bleeds appropriately. Methods An initial questionnaire was distributed and completed by 67 junior doctors (FY1-FY2) at the University Hospitals of Leicester in November 2015, all with jobs involving the acute medical take and providing ward cover. Junior doctors perceived confidence and knowledge was sampled in a range of key areas i.e. management pre and post endoscopy, senior support and escalation, blood transfusion targets and use of risk stratification tools such as the Blatchford score. Following evaluation of the initial questionnaire a dedicated teaching programme was delivered to 65 junior doctors, whom were subsequently re-surveyed. Results Following introduction of the teaching session all junior doctors expressed improved confidence in managing variceal UGIB’s- improved from 8% to 41% of junior doctors feeling confident. Additionally there were significant improvements identified in all areas. Notably; correct pre-endoscopic management improved to 94% (from 36%), appropriate transfusion targets improved from 45% to 76%, knowledge and use of risk stratification scores improved to 88% (from 3%). With inappropriate pre-endoscopic use of proton pump inhibitors falling from 25% to 0%. Conclusion Adopting a focused teaching programme for junior doctors on the management of acute variceal bleeds designed around pre-identified areas of weakness has proven to increase both knowledge and confidence in its specific management. Junior doctor teaching on core medical emergencies such as UGIB’s should perhaps be incorporated into trust induction programmes to ensure junior doctors are as prepared as possible on their first day in clinical practice. References 1 Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. SIGN. September 2009. 2 UK comparartive audit of upper gastrointestinal bleeding and the use of blood. British. Disclosure of Interest None Declared

Consent and capacity: What GPs need to know

Consent and capacity are ethical issues that doctors encounter every day in clinical practice. Informed consent, when taken correctly, can help empower patients and improve adherence and understanding of their treatment. Despite this, these areas seem to be poorly understood by clinicians, and are a major cause of calls to medico-legal defence organisations. This article is a concise amalgamation of General Medical Council (GMC) and British Medical Association (BMA) guidance, with justification for the importance of consent in practice. It covers the definitions of consent and capacity, how they are to be taken, lack of capacity, consent in minors, and parental responsibility. This is in order to provide clinicians with a base knowledge of these issues, which they can apply to their everyday practice.

Using Gagne’s theory to teach procedural skills

Many key medical procedures are performed every day in clinical practice to yield important diagnostic information and to help determine the disease response to intensive treatments. Training clinicians to perform procedures competently and confidently thus carries considerable weight, helping to assure patient safety, the obtainment of adequate samples and minimising patient discomfort. This article considers how Robert Gagne's instructional design model may be effectively used to design lesson plans and teach procedural skills in small group settings. Gagne's model is based upon the information-processing model of mental events that occur when adults are presented with various stimuli. It highlights nine specific instructional events, which correlate with crucial conditions of learning, and are arranged to maximally enhance the learning process, improve session flow and, ultimately, ensure lesson objectives are comprehensively addressed. This article uses the nine points described by Gagne to outline a comprehensive lesson guide for teaching psychomotor skills, using a bone-marrow aspirate procedure as an example. Each of Gagne's instructional events is considered with specific activities for each, and with the variety of activities delineated to meet diverse learning styles. Gagne's instructional events can produce an effective and comprehensive lesson plan for teaching procedural skills, preparing learners with various preferred learning styles to perform psychomotor skills competently in clinical practice. This lesson plan can be of use for both teachers and students across clinical specialties, encouragingly outlining how Gagne's systematic and widely referenced theory can be creatively and practically used.

Atrial fibrillation: a spectrum of risk with a uniform treatment effect of novel anticoagulants?

This editorial refers to ‘Outcomes of apixaban vs. warfarin by type and duration of atrial fibrillation: results from the ARISTOTLE trial,’ by S. Al-Khatib et al. , doi:10.1093/eurheartj/eht135 The last several years have seen the completion of five pivotal outcomes trials evaluating three novel oral anticoagulants (NOACs) in > 55 000 patients with atrial fibrillation (AF) from around the world.1–5 Each of these studies has shown that the respective new agent is at least as efficacious as, if not superior to, warfarin in reducing stroke or non-central nervous system embolism; all three NOACs were shown to be superior to warfarin in reducing intracranial haemorrhage. The large, diverse populations enrolled across broad geographic regions and practice settings provide an opportunity to explore questions about the specific cohorts of patients with AF of clinical interest, the natural history of the disease, and the pragmatic challenges physicians confront each day in clinical practice. The analyses from the ARISTOTLE study database by Al-Khatib and colleagues6 provide important information about outcomes in groups with different subtypes of AF and about treatment effects with apixaban compared with placebo in the same subtypes. We agree with the authors' two primary conclusions: (i) patients with persistent or permanent AF have higher event rates (including rates of systemic embolus and bleeding complications) compared with patients with paroxysmal AF events after adjusting for baseline differences; and (ii) the effects of apixaban compared with warfarin in patients defined by AF subtype are consistent …

Extended-release niacin and laropiprant in the management of dyslipidemias

Despite the use of statins for prevention of cardiovascular events, a residual risk remains in part due to persisting abnormalities on lipids. For decades, niacin has been used for the management of dyslipidemia, it improves multiple lipid parameters and is the most potent drug available to increase HDL-C. Niacin, either in monotherapy or in combination with other lipid-lowering agents, decreases the risk of cardiovascular events. However, its use is limited by the high incidence of flushing, even with the extensed-release formulation. Laropiprant, a selective antagonist of prostaglandin D2 receptor 1, is effective in reducing niacin-induced flushing, without affecting thelipid effects of niacin. The available data on a single-tablet combination of niacin and laropiprant are promising to allow more patients to achieve the therapeutic niacin dose of 2 g per day in clinical practice. However, the niacin/ laropiprant combination does not completely eliminate niacin-flushing side effects and this treatment requires careful instructions to the patient. The ongoing clinical trial, HPS2-THRIVE, will provide important information on the efficacy of extended-release niacin/laropiprant for reducing cardiovascular events, as well as on the long-term safety of this drug.

Current corneal femtosecond laser techniques

The technological advances in ophthalmology, and especially those concerning the field of refractive surgery, have led the scientific community to the introduction of lasers with ultra fast pulses. Femtosecond laser function is based on the fact that ultra short infrared laser pulses are precisely focused inside the corneal tissue. At the focal point, tissue is disrupted and a small bubble is created. By placing these bubbles next to each other in a specific pattern, it is possible to create a cut that can have virtually any shape and position. Femtosecond lasers have been developed to decrease the energy necessary to incise tissues and minimize the thermal damage of the surrounding structures. The accuracy, safety and predictability of this new technology is proven every day in clinical practice, and a continuous line of new applications in corneal surgery confirm its efficacy and value.

Learning in Practice and Maintaining Certification in Pediatrics

1. Terry Kind, MD, MPH* 2. John T. Benjamin, MD† 3. John Parboosingh, MD‡ 4. Edward Rothstein, MD§ 5. Robert Perelman, MD** 6. Mary Carol Badat, MAdEd** 7. Henry Bernstein, DO†† 1. *Children's National Medical Center, Division of General Pediatrics & Community Health, Washington, DC 2. †Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC 3. ‡Office of Professional Development, Royal College of Physicians & Surgeons of Canada, Ottawa, Ontario, Canada 4. §Pennridge Pediatric Associates, Sellersville, Pa 5. **American Academy of Pediatrics, Elk Grove Village, Ill 6. ††Dartmouth Medical School, Children's Hospital at Dartmouth, Hanover, NH As the 21st century unfolds, a broader, more comprehensive program for maintaining certification has been created for pediatricians that includes the concept of lifelong learning with dynamic self-assessments in a clinical context. (1) It is called the Program for Maintenance of Certification in Pediatrics (PMCP®), and pediatricians will be asked by the American Board of Pediatrics (ABP) to comply with all of the specific requirements of this program starting in 2010. (2) Pediatricians can work toward meeting the requirements for maintaining certification through their learning in practice. Questions arise every day in clinical practice that should stimulate learning and foster professional development. (3) These questions establish a basis for personal learning, which benefits the practitioner while ultimately improving patient care. Adult learners each bring different experiences and motivations to their professional development needs and create their own blend of lifelong learning opportunities and preferences. The purpose of this article is to explore the evolution and importance of the concept of self-directed continuous professional development (CPD) and the link to maintenance of certification (MOC) as it fits within the context of real-time clinical pediatric practice. Although physicians enter and complete medical school during a finite time period, they continue as students of medicine throughout their careers. (4) In a study of medical oaths from the first century to present day, fewer than half of those analyzed included a commitment to lifelong learning, and most that did incorporate this commitment were not emphasized in medical schools. (5) The recent calls for reform in the certification process and the shift from continuing medical education (CME) to CPD are driven by a need for lifelong learning as well as the importance of factors such as patient safety, clinician professionalism, and ensuring clinical competence. (6) The changing health-care environment, new demands of clinical practice, …

The Peace of Mind Prescription: An Authoritative Guide to Finding the Most Effective Treatment for Anxiety and Depression

Back to table of contents Previous article Next article Book ReviewsFull AccessThe Peace of Mind Prescription: An Authoritative Guide to Finding the Most Effective Treatment for Anxiety and DepressionPryor Baird, Ph.D., M.D.Pryor BairdSearch for more papers by this author, Ph.D., M.D.Published Online:1 Aug 2005https://doi.org/10.1176/appi.ps.56.8.1033AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Hope is an antidote for depressive disorder; sound knowledge is a balm for anxiety disorders. This readable volume by experts Dennis S. Charney, M.D., and Charles B. Nemeroff, M.D., Ph.D., abounds with both hope and knowledge. As such, it is a readable text that is suitable for persons who suffer from these disorders as well as for those who care for them.The authors, whose credentials are impeccable, suffuse their mission with several premises. First, anxiety and depressive disorders are epidemic in their proportions and are both destructive and corrosive in their impact. Second, treatment can be improved by appropriate, accurate diagnosis; by overcoming stigma; and through the pursuit of evidence-based therapies. Third, all patients can expect to improve or recover. This is a powerful beacon for sufferers and their loved ones.The book includes a vital distinction between "adaptive" states of each disorder, which can promote and enhance survival and provide "temporarily valuable clarity of mind," and the formal disorders of depression and anxiety, which cause unnecessary suffering—physical, mental, and behavioral—in patients' lives. The authors give intelligent, thoughtful attention to a spectrum of pertinent topics: brain chemistry, impact on physical health, divorce guidance, psychotherapy, dysthymia (a surreptitious, less dramatic form of depression), pharmacologic treatments, and the ineffable issues related to human resilience. Many more related topics are addressed in this concise yet comprehensive volume.It is difficult to identify shortcomings of this text. I perhaps would have liked to see the authors elaborate on a matter observed every day in clinical practice—namely, the ubiquitous self-medication attempts of anxious and depressed persons with food, alcohol, nicotine, marijuana, and perhaps compulsive shopping. Helping patients observe and manage these understandable but misguided attempts to seek relief from their pain would be eminently worthwhile.Furthermore, the authors may be minimizing the probably pervasive anxiety and depression of our forbearer hunter-gatherers: "the pace of life was, literally, at a walk … contrast with the demands of the twenty-first century is so stark." In fact, the reader will finish this text with confidence that the authors—had they operated a clinic in the Stone Age—would have been as competent in the diagnosis and treatment of these painful conditions at that time as they are now.Dr. Baird is a licensed clinical psychologist and board-certified psychiatrist at Central State Hospital in Petersburg, Virginia.by Dennis S. Charney, M.D., and Charles B. Nemeroff, M.D., Ph.D.; Boston, Houghton Mifflin Company, 2004, 288 pages, $25 FiguresReferencesCited byDetailsCited ByNone Volume 56Issue 8 August 2005Pages 1033-1033 Metrics History Published online 1 August 2005 Published in print 1 August 2005

Features of the metabolic syndrome and the risk of cardiovascular disease

The metabolic syndrome is being increasingly recognized as an important risk factor for cardiovascular disease (CVD). While several clinical definitions have been proposed to identify patients with this syndrome, additional metabolic markers may be considered to improve one's ability to assess and predict the risk of CVD in this population. The objective of this short review is to provide an overview of the risk of CVD associated with specific features of the metabolic syndrome. The extent to which these markers may be used one day in clinical practice in primary prevention is also briefly discussed.

Complications and local anaesthetic toxicity in regional anaesthesia

Local anaesthetic agents are administered every day in clinical practice. These agents are relatively safe when administered in proper dosages at appropiate anatomical sites. However, when excessive dosages are administered or the incorrect site of administration is used there is a potential for toxic reactions. Ropivacaine, a pure S-enantiomer, and levobupivacaine, a single isomer of bupivacaine, have been introduced as new long-acting local anaesthetic agents with a potentially reduced toxicity compared with bupivacaine. The present review deals with recent knowledge about systemically induced local anaesthetic toxicity and localized toxicity. Studies have compared cardiotoxicity directly between ropivacaine and levobupivacaine in intracoronary injection in sheep and pigs, in small mammals, and arrhythmias and resuscitation in dogs. Direct left coronary arterial infusions of local anaesthetics in a conscious sheep model precludes central nervous system actions. Intracoronary studies showed similar toxicity for levobupivacaine and ropivacaine. When comparing and interpreting in-vivo animal studies of local anaesthetic toxicity, species variations, differences in the mode and site of local anaesthetic administration, and whether the animal is under the influence of anaesthesia must all be considered. Stereoselectivity may play a role in the lengthening of the atrioventricular conduction time for bupivacaine. In-vitro studies have revealed that intracellular calcium concentrations may contribute to myotoxicity. Current evidence suggests that ropivacaine is slightly less toxic than levobupivacaine; however, the difference in potency between the two agents is greater. The new local anaesthetic agents can be regarded as 'safer', but must not be regarded as safe.