Independent Practice Research Articles

Introduction: Emergency department thoracotomy (EDT) in children is a rare, high-stakes procedure performed primarily during traumatic cardiac arrest [1]. Training opportunities are limited, and current reliance on porcine models raises ethical concerns and lacks paediatric anatomical fidelity. This project aimed to develop and evaluate a low-cost, Aqueous Dietary fibre Antifreeze Mix gel (ADAMgel) based, synthetic model tailored to paediatric EDT, improving training accessibility, anatomical realism, and trainee confidence [2]. Methods: A novel thoracotomy model replicating the thoracic cavity of a 9-year-old child was constructed using synthetic materials, including ADAMgel-laminated soft tissues and a skeletal framework, Figure 1. The model underwent iterative development informed by expert focus groups. Final evaluation included two simulation sessions with doctors (n=11), who completed pre- and post-simulation Likert scale questionnaires assessing confidence and understanding. Data were collected between January and March 2025. Results were analysed using Wilcoxon signed-rank tests. Qualitative feedback was gathered from participants and faculty at the Royal College of Surgeons (RCS) Pre-hospital emergency resuscitative thoracotomy course. All procedures were conducted with appropriate institutional approval for educational simulation-based research. Results: Statistically significant improvements were observed across several domains: confidence in performing EDT increased from median 1 to 4 (p=0.027), understanding of the procedure (p=0.016) and anatomy (p=0.019) also improved. All participants unanimously agreed the model improved their confidence and was a useful training aid. Surface tissues were rated realistic by 91%, and bony structures by 82%. Feedback from RCS faculty highlighted the model’s advantages over porcine equivalents, including reusability, independent practice opportunities, and superior anatomical accuracy. Suggested improvements included stronger tissue fixation and simulated aortic control. Discussion: This ADAMgel-based model demonstrates a feasible, ethical, and effective alternative to animal models in paediatric EDT simulation. Improvements in learner confidence and anatomical understanding support its utility in early procedural training. Planned enhancements, including aortic occlusion simulation, will increase fidelity. Broader validation across experience levels will determine its future role in standardised trauma education. Ethics Statement: As the submitting author, I can confirm that all relevant ethical standards of research and dissemination have been met. Additionally, I can confirm that the necessary ethical approval has been obtained, where applicable.

Background: There is a well-established relationship between volume and outcomes among TAVR operators. However, there is little data about the association of years of experience of a TAVR operator and outcomes. Methods: Using data from the TVT Registry between 2011-2024, we examined the career stage of TAVR operators (including interventional cardiologists and cardiothoracic surgeons) using TVT NPI data and the American Board of Internal Medicine (ABIM) database to determine date of independent practice. We examined the association between years in practice and 30-day outcomes (mortality and composite outcome of death, stroke, major bleeding, stage III AKI and PVL). We excluded operators with missing NPI numbers, and operators who had performed <10 TAVRs. An early career TAVR operator was defined as an operator within the first 5 years of independent practice. We performed a sensitivity analysis where the early career operator cut-off wasa 10 years in practice. Results: During the study period, there were 3,126 TAVR operators at 847 sites treating 634,723 patients undergoing TAVR. Depending on year of the study, between 12-24% of TAVR patients were treated by early career operators. The median age of patients treated by early vs. non-early career were both 80 years, and patients cared for by early career were more likely on home oxygen and less likely elective (all p<0.001). The median operator annual volume by years in practice rose from years 1-4 in practice, and then remained nearly constant at 18 TAVRs/year ( Figure 1a ). The median STS risk score did not change by years of independent practice (constant at 4%), Figure 1b . The rates of 30-day death for early career were 2.4% and for non-early career were 2.5% (risk ratio 0.95, 95% CI 0.90-0.99, p=0.018). The rates of the 30-day composite outcome were 11.1% for early career and 11.9% for non-early career (risk ratio 0.93, 95% 0.91-0.95, p<0.001. The same trends occurred when the early career cut-off occurred at 10 years. Conclusions: Median annual number of TAVRs performed by U.S. operators remains low overall. Early career TAVR operators were more likely to perform non-elective cases and to care for patients with more comorbidities. Despite this, early career operators had lower rates of 30-day mortality and composite outcomes.

Background:Graduate-level licensed addiction counselors are a critical component of the substance use disorder workforce, yet their scope of practice, education and training requirements, and credentialing varies in the U.S.Objectives:To better understand the roles and functions of the graduate-level addiction counselor workforce across the U.S., this state-by state analysis sought to identify the titles, minimum education and training requirements, scope of practice, and supervisory opportunities for graduate-level addiction counselors.Design:This project conducted systematic abstraction and descriptive analysis of U.S. state Practice Acts, certification board rules, materials from behavioral health professional organizations, and state Medicaid plans, fee schedules, and provider manuals.Methods:Descriptive summaries were produced to describe trends across states. Tables synthesized aggregated data across the workforce domains of education and training, regulation and credentialing, supervision, and payment for graduate-level addiction counselors only.Results:Forty-one states offer a graduate-level addiction counselor credential, 18 of which offer multiple credentials for a total of 69 credentials. States varied in services permissible by scope of practice definition, including assessments (41 states), psychotherapy (28 states), telehealth (28 states), and diagnosis (16 states). Only 26 states allow for independent practice. States required an average of 2,887 practice hours and 143 post-graduate supervision hours. Sixteen states permitted all tiers of graduate-level addiction counselors to supervise others, and 10 states specifically offer a graduate-level supervisory credential.Conclusion:State graduate-level addiction counselor credentials widely vary, suggesting that states utilize this workforce differently based on differing training criteria, required competencies, scope of practice, and supervision. Strategies to support growth of this workforce include alignment of training competencies, additional substance use disorder training in behavioral health graduate programs, and expansion of supervisory pathways and credentials.

Modern conditions require improving the quality of services in the field of physical culture and health improvement, in particular aqua fitness as a promising area of health-improving activities. The aim of the study was to identify and analyze the main problems faced by higher education students in the process of mastering the discipline of “Aqua Fitness,” as well as to determine ways to overcome them, taking into account the individual characteristics of students and the specifics of the educational process. It has been established that at the present stage, the professional training of future aqua fitness specialists in higher education institutions is focused on developing special professional competencies in students in accordance with the current requirements of the fitness services market. In the process of analyzing the problems faced by students while studying the discipline “Aqua Fitness,” several key difficulties were identified: insufficient level of initial physical fitness, low motivation for systematic aqua fitness classes, limited awareness of the specifics of teaching methods in an aquatic environment, and difficulties in organizing independent practice. Based on the survey results, the following recommendations were formulated and presented: Strengthen theoretical training through additional classes, interactive formats, and independent study of the material; deepen knowledge of the physiology of water activities using multimedia tools and real-life examples; Conduct special training sessions on safety techniques in the form of practical classes; Provide students with more practice, both in and outside the classroom; Develop optional modules or training sessions at the request of students: teaching methods, working with special groups. The implementation of these measures will improve the quality of training for future aqua fitness specialists and make the training more in-depth, practical, and modern.

To inform initiatives to improve the interoperability of healthcare data, we described the experience of distinct phenotypes of physicians when obtaining information from outside sources. A total of 6175 family physicians across the United States responded to information technology questions on the 2022 and 2023 American Board of Family Medicine Continuous Certification Questionnaire (100% response rate). Latent class analysis grouped physicians by individual and practice characteristics and then compared reported experience with interoperability. A 4-class model ("Safety Net," "Health System," "Independent Practice," and "Large Practice") best fit. Health system and large practice physicians (predominately Epic users) were more likely to report information was integrated in their Electronic Health Record (EHR) than independent practice physicians (38% and 40%, respectively, compared to 24%), and to report that information from organizations using the same EHR was usable (52% and 51%, respectively, compared to 25%). Safety net physicians were least likely to report that information from outside organizations was usable (17% compared to 23% of independent physicians). Between 42% and 50% of each phenotype reported commonly encountering external records with a large volume of low-value information. Independent practice and safety net physicians reported worse experience in some dimensions of interoperability, likely driven by differences in access to information from organizations using the same EHR. Many other challenges were consistent across physician phenotypes. Initiatives to improve interoperability among physicians may be most effective if targeted at independent practices and safety net practices; however, broad improvements will be necessary to address similar challenges across phenotypes.

This study adopts the trade-off hypothesis as its theoretical framework, focusing on three key dimensions: complexity, accuracy, and fluency. It examines the differences in EFL learners speaking performance between independent practice and real-time communication. The findings show that learners tend to use more complex and accurate sentences during independent practice, as the absence of time pressure and interactive feedback allows greater cognitive resources for planning and self-monitoring. By contrast, in real-time communication, learners prioritise fluency to ensure smooth interaction, often simplifying sentence structures and sacrificing accuracy. This difference does not indicate insufficient ability but reflects strategic trade-offs under limited cognitive resources. The study argues that oral performance is context-dependent and should be understood as the speakers adaptation to the context, instead of a single-dimensional deficiency. Complexity and accuracy in independent practice reveal learners potential, while simplifications in real-time communication reveal their strategic choices in authentic interaction. These dynamics underscore the close link between language output and cognitive resource allocation, offering new insights into learner strengths and limitations. The implications of this study lie in two aspects. Firstly, it helps learners understand their performance across contexts, thereby enhancing their confidence and developing more effective learning strategies. Secondly, it provides insights for oral pedagogy, suggesting that teachers can balance complexity, accuracy, and fluency in task design.

The American Psychiatric Association (APA) on Oct. 22 announced that Justin Singh, M.B.A. , has joined as its new senior vice president of operations, finance and transformation, an APA news release stated. As part of a leadership restructuring, Singh will report to the CEO and medical director, overseeing many of the daily operations of the association and establishing its technology and innovation agenda. He will also facilitate the roll‐out of the APA's newly approved strategic plan, Psychiatry 2030: A Vision For Our Future, which emphasizes three key areas for the APA: medical leadership, member success and organizational strength. Singh comes to the APA with close to 20 years of experience in business and health care innovation. Most recently, he was a senior principal at Roivant Sciences, where he developed new artificial intelligence health technology products and business ventures. His extensive background in health care innovation ranges from clinical research and care delivery, large academic medical centers and independent private practices and across therapeutic areas.

South Africa’s private healthcare sector is experiencing rapid transformation, driven by regulatory reform, digitalisation, and changing patient expectations. Independent medical practitioners must now balance clinical autonomy with financial sustainability amid growing systemic and market pressures. This study investigates how private practices in Cape Town adapt to these challenges through strategic and entrepreneurial innovation. Using a qualitative, interpretivist approach, the research applied the STOF (service, technology, organisation, and finance) business model framework to analyse practitioner experiences and adaptive responses. Seven interrelated domains emerged, highlighting financial fragility, operational inefficiency, and inconsistent technological integration. In response, two context-specific business models, Strategic Alliance Practitioner (SAP) and Consolidated Business Administration Services (CBAS), were conceptualised to strengthen value creation, operational efficiency, and long-term resilience. The findings demonstrate that practitioner-driven business model innovations can transform independent practices into sustainable, patient-centered enterprises. Moreover, the study emphasises the value of integrating policy, education, and professional development to build adaptable, resilient healthcare ecosystems suited to emerging market realities.

Urologist Participation in Medicare Are Impacted by Subspecialty, Tenure, and Practice Type: A Retrospective Analysis of Opt-out Affidavits.

During the last 30 years inflammatory bowel disease specialist nurses have become commonplace throughout the United Kingdom. These days they play a very significant role in the day-to-day management of patients with Crohn's disease and ulcerative colitis. They provide advice on the telephone, run out-patient clinics, administer biologic therapies and provide support to inpatients. However, there are no mandatory training programmes or required accreditation to specifically support these activities. As a result of these clinical roles, IBD nurses are now commonly involved in cases of alleged clinical negligence and questions arise to their independent practice and to whom they are directly responsible. This paper reviews these issues in some detail.

This study aims to investigate students’ perceptions of YouTube as a learning tool for enhancing their speaking ability. This research employed a descriptive quantitative method with a survey design. Data were collected from 127 students of the English Education Study Program at Sriwijaya University using a Likert-scale questionnaire distributed both online and offline. The validity and reliability of the instrument were tested through expert judgment and statistical analysis, resulting in a Cronbach’s Alpha score of 0.766, indicating good reliability. The data were analyzed using descriptive statistics through SPSS to identify trends in students’ perceptions. The findings revealed that most students strongly agreed that YouTube supports improvements in pronunciation, fluency, vocabulary enrichment, intonation, and natural expression. Furthermore, students perceived YouTube as enjoyable, motivating, flexible, and easily accessible for independent practice beyond the classroom. These results demonstrate that YouTube plays a significant role in fostering confidence, engagement, and continuous improvement in English-speaking skills. In conclusion, YouTube is perceived as an effective and valuable supplementary tool for learning English speaking, providing both accessibility and flexibility. The study suggests that integrating YouTube into formal language instruction can enhance student motivation and support more effective speaking practice.

This study examines the multidimensionality of Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), tests the relationship of climates with quality of care, and determines if distinct climates arise based on organizationally defined groups. The 29-item NP-PCOCQ applicability to assessing advanced practice nurse prescriber (APNP) climates in rural settings is unknown. A cross-sectional, correlational survey design and mixed-mode data collection were used with 942 APNPs from rural areas in 1 state. A total of 179 questionnaires (19% response rate) were analyzed with confirmatory factor analysis, multivariate analysis of variance/analysis of variance tests, and hierarchical regression analysis. A 12-item NP-PCOCQ's 3-factor structure was confirmed: NP-administration relations, NP-physician relations, and independent practice and support. The NP-physician climate had the strongest association with quality of care. Statistically significant differences were found between organizational climate types by work roles, facility types, and tenure. The abridged survey will empower nurse leaders to track and improve APNPs' climates.

This study analyzes the influence of digitalization, green accounting, and sustainability awareness on sustainability environmental practice among MSMEs in East Java, with socioeconomic conditions as a moderating variable. Using a mixed-method approach, data were collected through surveys of 207 respondents and semi-structured interviews with 15 informants. The findings reveal that green accounting significantly enhances environmentally friendly practices, while digitalization and sustainability awareness show no direct effect. Furthermore, socioeconomic conditions do not moderate the relationships between the independent variables and environmental practices. These results highlight the persistence of the intention–behaviour gap, as MSMEs often recognize environmental issues but fail to implement systematic green practices due to limited literacy, resources, and external support. The study provides theoretical contributions to the application of the Theory of Planned Behaviour in the MSME context and practical implications for policymakers to strengthen incentives, regulations, and green literacy programs for sustainable MSME development.

Clinical perfusionists manage and optimize extracorporeal circulation as well as physiological and metabolic stability, to support positive patient outcomes under artificial physiological conditions, such as cardiopulmonary bypass, extracorporeal membrane oxygenation, and other extracorporeal circulation systems. Despite the central role of the profession in patient safety and surgical outcomes, clinical perfusion remains inconsistently defined, regulated, and recognized across Europe. In response to these challenges, the European Board of Cardiovascular Perfusion, together with the European Association for Cardio-Thoracic Surgery and the European Association of Cardiothoracic Anaesthesiology and Intensive Care, convened a multidisciplinary task force to develop a unified expert consensus on the minimum academic education, supervised clinical training, and continuing professional development for safe and independent practice. It defines essential technical competencies, such as the operation of heart-lung machines and mechanical circulatory support devices, alongside critical non-technical skills in decision-making, communication, and interdisciplinary collaboration. The document also introduces a tiered framework to classify perfusionists by experience level and proposes mechanisms for certification and recertification through the European Certificate in Cardiovascular Perfusion. Furthermore, the statement highlights the importance of structured quality assurance programs, simulation-based education, and incident reporting systems in advancing perfusion safety and clinical effectiveness. A harmonized European approach is urgently needed to ensure consistent training standards, enhance workforce mobility, and support formal recognition of clinical perfusion as a regulated healthcare profession. This consensus aims to serve as a benchmark for national regulatory efforts and future professional development across Europe.

The stochastic nature of next-token generation and resulting response variability in Large Language Models (LLMs) outputs pose challenges in ensuring consistency and accuracy on knowledge assessments. This study introduces a novel multi-agent framework, referred to as a “Council of AIs”, to enhance LLM performance through collaborative decision-making. The Council consists of multiple GPT-4 instances that iteratively discuss and reach consensus on answers facilitated by a designated “Facilitator AI.” This methodology was applied to 325 United States Medical Licensing Exam (USMLE) questions across all three exam stages: Step 1, focusing on biomedical sciences; Step 2 evaluating clinical knowledge (CK)\\; and Step 3, evaluating readiness for independent medical practice. The Council achieved consensus that were correct 97%, 93%, and 94% of the time for Step 1, Step 2 CK, and Step 3, respectively, outperforming single-instance GPT-4 models. In cases where there wasn’t an initial unanimous response, the Council deliberations achieved a consensus that was the correct answer 83% of the time, with the Council correcting over half (53%) of the responses that majority vote had gotten incorrect. The odds of a majority voting response changing from incorrect to correct were 5 (95% CI: 1.1, 22.8) times higher than the odds of changing from correct to incorrect after discussion. This study provides the first evidence that the semantic entropy of the response space can consistently be reduced to zero—demonstrated here through Council deliberation, and suggesting the possibility of other mechanisms to achieve the same outcome.. This study revealed that in a Council model, response variability, often considered a limitation, can be transformed into a strength that supports adaptive reasoning and collaborative refinement of answers. These findings suggest new paradigms for AI implementation and reveal the heightened strength that emerges when AIs begin to collaborate as a collective rather than operate alone.

This community service activity aims to improve the competence of students in the Indonesian Language and Literature Education Study Program at the Faculty of Teacher Training and Education, Pattimura University, in designing infographics as a learning medium. The background to this activity is the low level of understanding and skills among students in utilizing creative and communicative digital learning media. The training was conducted in three stages, namely socialization and provision of basic material on infographics, technical assistance in using the Canva application, and independent practice to produce infographic products. A total of 33 students participated in this training, with 91% of participants successfully creating infographics independently. The evaluation showed that the majority of participants considered the material easy to understand, relevant to the needs of prospective educators, the media and delivery methods interesting, and the presenters knowledgeable about the material. This training not only produced ready-to-use infographics for learning, but also training modules as additional outputs. The results of the activity showed a significant increase in students' digital literacy, visual creativity, and pedagogical skills, which supported the achievement of the university's Key Performance Indicators. In the future, this activity is expected to be integrated into the curriculum and replicated in other study programs to expand its benefits in producing educators who are adaptive to developments in learning technology.

IntroductionFluoroscopically guided spine procedures are a common and integral treatment option for a comprehensive spine care plan. Unfortunately, interventional spine education and training can vary greatly between residency programs.MethodsA two-session comprehensive workshop was developed to educate residents on interventional spine procedures using a mix of interactive lectures and hands-on education. This course includes an overview of (1) national guidelines, (2) case discussions, (3) systematic chart review, (4) procedural kit preparation, (5) fluoroscopic spine procedure simulation, and (6) management of postprocedure complications. Residents were asked to complete a pre- and postcourse evaluation to report their self-perceived confidence in several domains of interventional spine care, as well as their perceived benefits of the course content.ResultsSince 2018, 26 different residents have participated in the course. Participants reported a significant increase in confidence across several interventional spine care domains, particularly in addressing procedure complications and understanding procedure selection. Resident feedback provided high praise for how this course offered didactics, case discussion, and hands-on learning opportunities in a low-stress environment different from traditional lectures or clinical rotations.DiscussionThis interventional spine course provides resident-level education and active experiences essential to better understand interventional spine care. This course can serve as a framework for other residency programs to develop their own interventional spine course and raise the standards for interventional spine education across all residency programs. Future efforts include the development of a competency-based tool to assess resident skill acquisition longitudinally across their training and once in independent practice.

Abstract: As the demand for psychological services increases, particularly in Western societies, it is essential to understand how countries regulate and train psychologists to deliver effective psychotherapy. By focusing on countries in the WHO’s European, Americas, and Western Pacific regions, the paper compares national regulations, minimal training pathways, and the role of psychologists in providing psychotherapy. Through an analysis of legislative documents, training guidelines, and resources from international organizations, the paper identifies variations in certification, academic training, clinical experience, and continuing education across regions . The analysis identified five training pathways for psychologists seeking independent psychotherapy practice, with durations ranging from 0 to 12 years. Legal protections for professional titles play a crucial role in shaping these pathways. In Models A, B, C, and D, psychologists are granted the right to practice psychotherapy based on their educational qualifications, with additional requirements like supervised training or separate accreditation. In Model E, where titles are unregulated, anyone can claim the title of psychologist or psychotherapist, relying on voluntary associations for oversight. The practice of psychotherapy is a key aspect of the psychology profession. This study reveals a variety of training models across nations, highlighting a diversity of approaches to achieving the right to practice psychotherapy independently. Future discussions should carefully consider the impact of these training pathways on mental health outcomes. Ultimately, ensuring that psychologist practicing psychotherapy receive high-quality training will contribute to improved mental health services and better outcomes for individuals seeking psychological support.

Self-efficacy for independent practice business skills among current health service psychology graduate students and recent graduates.

An Untapped Solution to the Mental Health Crisis: Independent Practice for NPs