Expert Clinical Practice Research Articles

New Diabetes Nutrition Therapy Recommendations: What You Need to Know.

The American Diabetes Association (ADA) has long recognized the integral role of nutrition therapy in overall diabetes management and recommends that each person with diabetes receive an individualized eating plan that has been developed in collaboration with his or her health care provider (HCP).1 To ensure that members of the health care team are providing up-to-date, evidence-based clinical practice recommendations, the ADA issues official position statements on scientific or medical issues related to diabetes. Recently, the ADA published a position statement titled “Nutrition Therapy Recommendations for the Management of Adults With Diabetes.”2 These recommendations replace those in previous position statements. This article reviews the development process for the 2013 nutrition recommendations, shares highlights from those guidelines, and discusses priority topics in the publication. The 2013 ADA nutrition statement was written at the request of the ADA Professional Practice Committee. In August 2012, the ADA convened a committee of nutrition experts in clinical practice and research, as well as other members of the diabetes health care team (a registered nurse/advanced practice nurse practitioner, a physician, and a pharmacist) to review the scientific literature and develop recommendations. The multidisciplinary committee followed the Institute of Medicine (IOM) Standards for Trustworthy Clinical Practice Guidelines.3 Based on the IOM standards, conflict of interest disclosures were obtained before confirmation of appointment of the co-chairs and the members of the committee/writing group. Development of the position statement was funded from ADA general revenues and not with any corporate or industry financial support. The committee's work on the position statement began with an introductory conference call. The group reviewed an outline for the statement and assigned sections to specific members. Committee members were instructed to conduct thorough literature searches and create evidence tables for all of the topics included in the statement. Inclusion criteria for …

Driving Experts Address Expanding Access Through Pathways to Older Driver Rehabilitation Services: Expert Meeting Results and Implications

ABSTRACTAs one of the first papers in this special issue, this paper describes the expert meeting that established the goals of the Gaps and Pathways Project. Through a unique Audience response system (ARS), this expert panel established over 60 consensus statements grounded in evidence of either research literature or expert clinical practice. The paper describes the process and identifies the outcomes of the panel including gaps of need for occupational therapy service and potential ideas for future research.

Decision-making in operative vaginal delivery: when to intervene, where to deliver and which instrument to use? Qualitative analysis of expert clinical practice

ObjectiveTo identify the decision-making process involved in determining when to intervene, where to deliver and the optimal choice of instrument for operative vaginal deliveries in the second stage of labour. Study designA qualitative study using interviews and video recordings took place at two university teaching hospitals (St. Michael's Hospital Bristol and Ninewells Hospital, Dundee). Ten obstetricians and eight midwives were identified as experts in conducting or supporting operative vaginal deliveries. Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting low cavity vacuum and mid-cavity rotational forceps deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by three researchers and then compared for consistency of interpretation. The experts reviewed the coded interview and video data for respondent validation and clarification. The themes that emerged following the final coding were used to identify the decision-making process when planning and conducting an operative vaginal delivery. Key decision points were reported in selecting when and where to conduct an operative vaginal delivery and which instrument to use. ResultsThe final decision-making list highlights the various decision points to consider when performing an operative vaginal delivery. We identified clinical factors that experts take into consideration when selecting where the delivery should take place and the preferred choice of instrument. ConclusionThis detailed illustration of the decision-making process could aid trainees’ understanding of the approach to safe operative vaginal delivery, aiming to minimise morbidity.

Development of a Physical Therapy Patient-Interview Student Assessment Tool: A Pilot Study

Background and Purpose. While multiple medical school patient-interviewing tools exist for assessment of student competence in conducting histories, no validated or reliable physical therapy-specific tool has been found in the literature. Physical therapist education requires assessment and attainment of patient-interviewing competence before physical therapist students begin care. The purpose of this qualitative study was to develop and validate a physical therapy-specific tool to assess student patient-interviewing skill and to pilot its reliability.Method/Model Description and Evaluation. Literature review, qualitative assessment of existing medical tools for interviews, tool development, content validation, and pilot estimation of test-retest intrarater reliability were performed. Literature review results for history taking, expert clinical practice, and medical-based interviewing assessment instruments served as basis for the ECHOWS tool (E [Establishing Rapport], C [Chief Complaint], H [Health history], O [Obtain Psychosocial Perspective], W [Wrap-Up] , and S [Summary of Performance [).Content validity was established using 5 content experts, including entry-level and residency/fellowship faculty. These experts reviewed ECHOWS twice, leading to final revision and creation of a user guide. Five different reviewers assessed a convenience sample of 5 taped interviews for reliability. This pilot testing of ECHOWS allowed for the determination of necessary tool modifications, and an estimate of the variability of the inter and intrarater scores, which will be used to calculate a sample size for future reliability studies.Outcomes. ECHOWS and Guide to ECHOWS were developed and validated. Pilot testing revealed the need for additional alterations to ECHOWS. Statistical analysis revealed moderate to good instrument intrarater reliability.Discussion and Conclusion. The ECHOWS physical therapy student-assessment instrument for interviews also has the potential to provide PT faculty with additional strategies to teach interviewing skills. Future research will need to establish interrater reliability and construct validity.Key Words: Student evaluation, Patient interview, Competence.BACKGROUND AND PURPOSEConducting an interview, or what is commonly referred to as the patient history, is an important element of patient/client management by physical therapists.1 Accordingly, the American Physical Therapy Association (APTA) lists history-taking and communication competencies in the Minimum Required SkilL· of Physical Therapist Graduates at Entry Level.2 To conduct comprehensive and effective interviews, physical therapist (PT) students obtain information needed to: (1) determine whether physical therapy is appropriate for the patient, (2) proceed with appropriate tests and measures, (3) develop appropriate patient/client goals, (4) assist in making diagnoses, and (5) identify contextual factors that might influence the patient's/ client's prognosis and the nature of the practitioner-patient/client interaction. In addition, effective interviewing also requires skill in communication, including attentive listening, establishment of practitioner-client rapport, attention to cultural congruency in interactions, and the ability to convey information at appropriate medicalliteracy levels.3Patient interviewing, or history-taking, has long been recognized as critically important to the delivery of health care. Beattie et al4 investigated satisfaction with physical therapy services. The authors noted enhanced satisfaction when patients perceived that PTs spent adequate time with them, demonstrated good listening and communication skills, and offered clear treatment explanations. These findings were similar to Goldstein et al5 who reported that patients felt that being treated with respect and involvement in treatment decisions were the most important components of their physical therapy experience. …

Prophylaxis for Venous Thromboembolism: A Great Global Divide between Expert Guidelines and Clinical Practice?

Our understanding of development and prevention of venous thromboembolism (VTE) has improved dramatically since Virchow described the triad of stasis, hypercoagulability, and endothelial dysfunction during the mid-1800s. A full arsenal of effective pharmacological and mechanical methods can help prevent VTE and many professional organizations have provided extensive evidence-based statements for VTE prophylaxis. Disappointingly, however, VTE has remained the major preventable cause of hospital death. Adherence rate to clinical guidelines is undesirably low. Many real-world patients have also been excluded from VTE prevention trials and hence practice guidelines recommendations. The comprehensive and repetitious formats of many available guidelines also limit their readability and applicability by nonthrombosis specialists. Moreover, some patients suffer from VTE despite complying with the contemporary prophylaxis regimens. Besides, significant heterogeneity exists in thromboprophylaxis practice and pitfalls between different countries. Last but not the least; although many at-risk patients are underprophylaxed, there is evidence to suggest that overprophylaxis (i.e., prescription of thromboprophylaxis in low-risk patients) comprises another important problem. We review the thromboprophylaxis practice and pitfalls around the world and provide recommendations on how the major obstacles can be overcome.

Examining Pedagogical Practices in Family Systems Nursing

Teaching graduate family nursing students the important and delicate practice of entering into and mitigating families' illness suffering signifies an educational practice that is rigorous, intense, and contextual, yet not articulated as expounded knowledge. This study examined the pedagogical practices of the advanced practice of Family Systems Nursing (FSN) as taught to master's and doctoral nursing students at the Family Nursing Unit, University of Calgary, using observation of expert and novice clinical practice, live supervision, videotape review, presession hypothesizing, clinical documentation, and the writing of therapeutic letters to families. A triangulation of research methods and data collection strategies, interpretive ethnography, autoethnography, and hermeneutics, were used. Students reported an intensity of learning that had both useful and limiting consequences as they developed skills in therapeutic conversations with families experiencing illness. Faculty used an intentional pedagogical process to encourage growth in perceptual, conceptual, and executive knowledge and skills of working with families.

Evolution and Revision of the Perioperative Nursing Data Set

The Perioperative Nursing Data Set (PNDS) is a nursing language that provides standardized terminology to support perioperative nursing practice. The PNDS represents perioperative nursing knowledge and comprises data elements and definitions that demonstrate the nurse's influence on patient outcomes. Emerging issues and changes in practice associated with the PNDS standardized terminology require ongoing maintenance and periodic in-depth review of its content. Like each new edition of the Perioperative Nursing Data Set, the third edition, published in 2010, underwent content validation by numerous experts in clinical practice, vocabulary development, and informatics. The goal of this most recent edition is to enable the perioperative nurse to use the PNDS in a meaningful manner, as well as to promote standardization of PNDS implementation in practice, both in written documentation and the electronic health record.

Die Entwicklung von Qualitätsindikatoren – Hintergrund, Methoden und Probleme

Quality indicators (QIs) are used in many areas of health care in order to measure, compare, and improve quality. QIs are specific, measurable aspects of care that can be used to assess its quality. Assessing the quality of care contributes to quality improvement. Amongst other applications, QIs are used in quality management for comparisons between providers and in pay-for-performance systems. QIs can be developed on the basis of expert opinion, scientific evidence or clinical practice guidelines. For the efficient development of high quality QIs, rigorous, approved, and evidence-based development methods are needed. At present, there is no gold standard for the development of QIs.

The role of the consultant radiographer – Experience of appointees

Aim To explore the experience of the first consultant practitioners appointed; including the appointment process, nature of the role, their perceptions of success and challenges. Method This was a whole population study of the known consultant radiographers appointed up to March 2005. It consisted of 3 phases. The first compared appointees job descriptions with the Department of Health guidance, the second collected contextual information using a questionnaire, and the third explored postholders experiences using telephone interviews. Results Ten of the possible twelve appointees participated. All posts were established according to the guidelines, with largely similar job descriptions allowing for the different clinical specialist areas. All were very positive in their perceptions of their role, and faced similar challenges. They were strongest in their expert clinical practice working but had strong training and leadership roles. The number working at strategic level was low with limited research and few published papers, although there were notable exceptions. Conclusions The first appointees demonstrated notable successes, strongest in the expert clinical practice element of roles, with evidence of team leadership, and involvement in training and education. Strategic engagement was disappointing, with little research being undertaken. Their experience was that the nature of consultancy was poorly understood by peers and medical colleagues.

Medical Decision Making: What Do We Trust?

Medical Decision Making: What Do We Trust?

Clinical Nurse Specialist Practice Patterns

The study purpose was to describe clinical nurse specialist (CNS) practice patterns (activities, outcomes, and practice barriers). A cross-sectional survey design was used for this research study. California Board of Registered Nursing certified CNSs (N = 1,523). Surveys were mailed to CNSs and included the CNS Activity Questionnaire, the Clinical Nurse Specialist Outcomes and Barriers Analysis Survey, and a demographic survey. Descriptive (means, percentages) and inferential (t tests and one-way analyses of variance) statistics were used to analyze the data. Practicing CNSs (n = 947) demonstrated a role preference for expert clinical practice. Practice patterns (activities, outcomes, and barriers) differed in terms of CNS specialty, years of experience, number of units covered, and CNS reporting structure. Clinical nurse specialists are spending time in the 5 broad role components expert (clinical practice, consultation, education, clinical leadership, and research) utilized by the California Board of Registered Nursing as an organizing framework for practice; however, CNS practice patterns from this study reflect more discrete and functional activities that may be better encompassed under the CNS spheres of influence practice model. A number of barriers to practice exist, the most commonly reported being reporting structure. Years of experience in the role result in differences in both practice patterns and perceptions of barriers. Recommendations for CNSs and organizations include evaluating CNS reporting structures, developing advanced practice outcome-based job descriptions and competencies, and designing performance evaluations that recognize differences between inexperienced and experienced CNSs.

A Summary of the Endocrine Society Clinical Practice Guidelines on Congenital Adrenal Hyperplasia due to Steroid 21-Hydroxylase Deficiency

Steroid 21-hydroxylase deficiency accounts for about 95% of cases of congenital adrenal hyperplasia (CAH). Newborns are currently being screened for the classical forms of this disease throughout the United States and in 12 other countries. As such, it seems important to develop the best practice guidelines for treating not only infants and children, but affected adults as well. This report gives a brief overview of the most recent expert opinion and clinical practice guidelines for CAH as formulated by The Endocrine Society Task Force.

Psychiatric management of HIV/HCV-coinfected patients beginning treatment for hepatitis C virus infection: survey of provider practices

Objective To determine expert clinical practice in the management of psychiatric status of HIV/hepatitis C virus (HCV)-coinfected patients initiating pegylated interferon/ribavirin for the treatment of hepatitis C. Method Two hundred thirty-six expert providers were identified and invited by email to complete an online anonymous survey. Results Ninety-two providers (39%) completed the survey, 24 (26%) of whom are psychiatrists. More than one third of providers indicate that they use or offer the option of antidepressant use prophylactically in HIV-positive patients with no past or current depression beginning HCV treatment, and more than three quarters do so in patients with a history of depression but no current symptoms of depression. The most experienced nonpsychiatrist providers were more likely to use antidepressants prior to the start of treatment in HIV-coinfected patients as compared to in HCV monoinfected patients. There is consensus among providers to leave psychiatric medication unchanged in patients currently treated for unipolar depression. Conclusions Many expert providers prescribe antidepressants to HIV/HCV-coinfected patients initiating Hepatitis C treatment in the absence of symptoms of depression, despite the lack of data supporting this approach in this population. Research is needed to provide an evidence base to guide the optimal psychiatric management of HIV/HCV-coinfected patients beginning hepatitis C treatment.

The Role of the Clinical Laboratory in Teaching and Learning Family Nursing Skills

This exploratory case study of the role of the clinical laboratory in teaching and learning family nursing skills was undertaken at the Family Nursing Unit (FNU), University of Calgary. Qualitative data were gathered from current graduate students, graduates of the Master of Nursing program, faculty members, and clients of the FNU using participant observation, in-depth interviews, and review of documents. Content analysis was used to identify key themes. The study found that the family nursing clinical laboratory provided a safe, structured learning environment where students had the opportunity to observe expert clinical practice in family nursing and undertake closely supervised practice. Graduates felt well prepared and confident in their advanced nursing practice with families. Key to the success of the clinical laboratory was the teaching faculty who were skilled clinicians in family systems nursing and who used this same theoretical orientation to guide the relational, strengths-based, and collaborative learning with students.

Including the nonrational is sensible midwifery

Since the subordination of midwifery by medicine and nursing in the 19th and 20th centuries the standard approach to childbirth has been dominated by rationality. This approach proceeds by creating dichotomies and then prioritising one half of the dichotomy whilst rejecting the opposite term. Rationality itself is prioritised, for example, by contrasting it with the rejected opposite: irrationality. Expert clinical practice is, however, increasingly identified as being inclusive of more than merely rational ways of knowing and behaving. This paper is based on a post-structural study concerning changes to women's embodied sense of self during childbearing. We expose the limitations of pure rationality in the context of childbirth and use the concept of safety to exemplify the limitations that pure rationality imposes. The paper draws on philosophical and spiritual theory to present an analysis of ideas about mind, body, soul and spirit. The standard rational/irrational dichotomy is critiqued and contrasted with the embodied reality of nonrational experiences that are individual, contextual and 'in-the-moment'. Nonrational experiences are identified to be inclusive of power and knowledge that are both rational and nonrational. This revised conceptualisation provides a theoretical basis that allows for and promotes more possibilities and thus more holistic ways of knowing in midwifery. Our thesis is that midwives and women need to take conscious account of nonrational knowledge and power during the childbearing year. We argue that pure rational thinking limits possibilities by excluding the midwife's embodied ways of knowing along with the ways of knowing embodied by the woman. The inclusion of women's and midwives'nonrational ways of knowing in childbearing situations opens us up to knowledge and power that provides for a more complete, and therefore a more optimal, decision-making process.

APA AnnouncesDSM-VTask Force Members

APA Announces<i>DSM-V</i>Task Force Members

Nursing Programs Could Sharpen LTC Focus

Nursing Programs Could Sharpen LTC Focus

Practicing What We Preach: Balancing Teaching and Clinical Practice Competencies

Most nurse educators fulfill dual roles of clinical practitioner and teacher and thus have to achieve a balance between these two challenging sets of competencies. The authors discuss the obligation and expectation that nurse educators are concurrently experts in clinical practice and education. Is this dual competence a feasible and sustainable goal? To begin to explore this issue, the meanings of 'expert practice' and 'practice competence,' derived from the nursing education literature, are reviewed. Current professional practice competency requirements related to the nurse educator role are discussed. Questions are raised regarding support for and barriers to achieving these competencies. The potential challenges and rewards of this endeavour are presented and illustrated by two nurse educators who share their stories of achieving a balance in teaching and clinical practice competence. Finally, implications for nurse educators and directions for future research into this issue are proposed.

How to achieve consultant practitioner status: A discussion paper

Non-medical consultant posts are a relatively new addition to the National Health Service (NHS) workforce, the role first being announced for nurses in 1998 followed by the Allied Health Professions in 2000. They have been described as multidimensional positions that encompass the four core functions of consultant practice: expert clinical practice; professional leadership and consultancy; practice and service development, research and evaluation; education and professional development. Consequently, the purpose of non-medical consultants is to promote and develop practice at the clinical, strategic and policy level. Despite the professional drive to develop consultant radiographer roles, by the end of 2005 only 15 were in post. One of the reasons for this poor appointment rate is the deficiency in suitably qualified and experienced candidates, a finding acknowledged to be an issue across all the non-medical professions. Further, the development of potential consultant practitioners has been hampered by the lack of clearly defined clinical and educational pathways. This paper acknowledges the limited published material available to radiographers wishing to advance to consultant positions. Yet while recognising the need to establish a true consultant career pathway underpinned by an appropriate education and research strategy, it explores the requirements of consultant practice, identifying some opportunities available to radiographers to develop appropriate consultant level skills.

Ask the experts: person-centred care

My work covers four domains: Expert clinical practice Working within a critical companionship model has enabled me to challenge practice at the bedside. Reflective sessions within stroke care areas allow me to hear about difficulties staff face and, in turn, for me to challenge practice. Professional leadership and consultancy As a member of the professional executive committee and board of my primary care trust I have an insight into policy development and decision making. This knowledge has enabled me to forge ahead with service developments. Education, training and development Following years of holding formal training and education sessions, I have adopted a practice-based learning approach to education. Ascertaining what clinicians know, what they believe they need to know, and demonstrating how best to build on clinical skills is a very effective method of learning. I am also able to access older people across a range of settings. Primary and secondary prevention of stroke in residential care is vital and I have undertaken work in partnership with both statutory and non-statutory providers. Practice and service development My duty is to be flexible and adaptable, facilitating innovation and service redesign from the patient’s perspective. I have developed a community stroke rehabilitation team based on a study that gathered the views of older stroke survivors and their carers. Listening to and being able to represent their needs provided the stimulus to modernise local services. Research I have undertaken has affected clinical care by ensuring that ethical, sensitive decision making regarding feeding after stroke is person and family-centred. The use of audit and evaluative data ensures that stroke care remains a high priority on each local organisation’s agenda. The role of consultant nurse in stroke care is dynamic and innovative. Eighty per cent of strokes occur in people over the age of 65 and keeping abreast of the needs of older individuals is crucial. It is imperative to be politically aware at local and national levels, and to have the courage to speak out and be innovative. Retaining clinical credibility and having sound leadership skills will ensure that other clinicians learn by example and aspire to consultant practitioner roles. Jane Williams