In-service Sessions Research Articles

Developing and Using Multiple-Choice Tests in Clinical Settings

Tests can be used to assess attitudes, knowledge, and comprehension of principles in clinical scenarios across a range of content areas. Multiple-choice tests, when well prepared, can be an efficient means of achieving these aims. They can also be used to introduce a topic or to assess prior knowledge for an in-service education session or workshop.

Parkinson's Disease Support Workers advise on symptom control

IntroductionThe symptoms of PD vary but with no cure, people with advanced disease experience distressing symptoms, such as motor complications, dementia, depression, pain and gastro intestinal symptoms which can be...

Moving from ‘gut feeling’ to ‘pure facts’: Launching the ASI interview as part of in-service training for social workers

Several standardized assessment instruments have been introduced in social work in the last 10 years. One such instrument, the Addiction Severity Index, is used today in the Swedish social services, as well as in the prison and probation services. Swedish state authorities have strongly declared their intention to implement the Addiction Severity Index interview, though critics are sceptical towards both its practical relevance and epistemological grounds. Given this background, the launch of the Addiction Severity Index interview is important as a case of how new instruments (flagged under the banner of evidence-based practice) are introduced into the field of social work. The aim of this article is to analyse how the Addiction Severity Index interview is presented and taught through in-service training for Swedish social workers. From observations of in-service training sessions, two professional styles seem to surface: ‘traditional’ and ‘new’. The trainer tends to use contrasting dichotomies as resources for constructing these professional styles. For example, ‘objectivity’ and ‘scientificity’ are presented as new professional ideals, rather than common sense or ‘gut feeling’, the latter of which is connected to traditional social work. The construction of a new professional style can be seen as an endeavour to achieve professional status in a more classical sense, partly by making the profession and its content more visible, but also by asserting its legitimacy as evidence-based work.

A Simple QI Project to Improve Practice Quality in Neuroradiological CT Angiography

ObjectiveThe purpose of this study was continuous quality improvement (CQI) of head and neck CT angiography (CTA) in the neuroradiology practice of a tertiary care medical center. Materials and MethodsWe conducted baseline quality audits of 50 consecutive head or neck CTAs, including referrals for a variety of indications from emergency department, ambulatory, and inpatient settings. Neuroradiologists as a group used Likert-type questionnaire items to assess scan quality. Based on identified opportunities for CQI, the group evaluated alternative scanning methods, proposed action items, and implemented changes in scanning methods. After implementing the changes, the group performed follow-up quality audits of 61 consecutive CTAs. Quality of scans was compared for baseline and postimplementation patients using chi-square or McNemar tests. ResultsSeveral key opportunities for CQI were identified, namely related to coverage levels and timing. These opportunities were translated into protocol changes, standardization of methods, and in-service sessions to implement specific process changes. Using a Likert-type scale with 1 anchored at “excellent” and 5 at “poor,” the overall quality of CTAs improved from 2.46 at baseline to 1.64 after implementation of QI measures (P < .01). There were significant improvements in timing and coverage, and fewer scans required quality disclaimers after CQI implementation. ConclusionUsing basic CQI techniques of assessment, analysis, change implementation, and reassessment, the quality of CTA scans in a busy neuroradiology clinical practice can be improved. These techniques are amenable to repeated use, so that CQI can be a routine practice to help optimize the quality of care in radiology.

Taking over as ‘pharmacist in charge’

Taking over as ‘pharmacist in charge’

Does supervision improve health worker productivity? Evidence from the Upper East Region of Ghana

To assess whether supervision of primary health care workers improves their productivity in four districts of Northern Ghana. We conducted a time-use study during which the activities of health workers were repeatedly observed and classified. Classification included four categories: direct patient care; documentation and reporting; staff development and facility operations; and personal time. These data were supplemented by a survey of health workers during which patterns of supervision were assessed. We used logistic regression models with health facility fixed effects to test the hypothesis that supervision increases the amount of time spent providing direct patient care (productivity). We further investigated whether these effects depend on whether or not supervision is supportive. Direct patient care accounted for <25% of observations. In bivariate analyses, productivity was higher among midwives and in facilities with a high volume of care. Supervisory visits were frequent in those four districts, but only a minority of health workers felt supported by their supervisors. Having been supervised within the last month was associated with a significantly higher proportion of time spent on direct patient care (OR = 1.57). The effects of supervision on productivity further depended on whether the health workers felt supported by their supervisors. Supportive supervision was associated with increased productivity. Investments in supervision could help maximize the output of scarce human resources in primary health care facilities. Time-use studies represent an objective approach in monitoring the productivity of health workers and evaluating the impact of health-system interventions on human resources.

Sleeping at Home: A New Model for a Hospital Teaching Service

The traditional marriage between teaching hospitals and residents pivots on a central prenuptial agreement: residents offer their hospitals round-the-clock patient care, and, in exchange, hospitals provide an experiential learning modality. This long-held covenant may require an update due to 3 significant changes: the increased spotlight on protecting resident education from excessive service demands; the development of hospital medicine as a specialty; and the need to provide more experiential learning in ambulatory care settings for primary care programs, including family medicine. The rapid growth of hospitalist care—84% of all teaching hospitals in the United States have at least 3 hospitalists1—has been sparked in part by pressure placed on primary care doctors to increase outpatient visits and on hospitals to reduce length of stay.2 The desire to have better work/life balance coupled with fewer inpatient admissions and increased financial demands have resulted in a decline in family medicine physicians who provide both inpatient and outpatient care. Many hospitals are moving to hospitalist care, citing improved care and decreased cost.,3,4 In 2006, the year before we implemented our new model of inpatient teaching, 62.5% of our program's new graduates entered into practice without an inpatient component. We describe a unique adult inpatient teaching service in a family medicine residency program that integrates resident teaching with hospitalist care. The novelty stems from the use of hospitalists, not residents, as the primary workforce in the hospital. By uncoupling the educational experience of teaching residents how to care for hospitalized patients from the service demands of the hospital, it is possible to achieve both of these goals and comply with duty hour limits. The added advantage of our system is that residents are able to spend more time in the outpatient setting. This gain in ambulatory training aligns with most of our residents' postgraduation plans to work as primary care physicians in the outpatient setting.

Implementation of a bowel care protocol within ICU

This 11 bedded level 3 ICU did not have a formal bowel care protocol in place. Bowel care was addressed by giving a variety of aperients and a general observation over a period of several months was that constipation was a problem. A small audit was carried out in June to July 2008 on 7 patients. All patients were intubated and ventilated, receiving enteral feeding and had not had bowel surgery. The objectives were to determine how long after admission were aperients given, what aperients were given and how long after admission were bowels opened. Patients were commenced on aperients on day 4 of admission on average. All patients received prune juice BD and then varients of Movicol, Lactulose, Microlax and senna. Bowels were opened on day 9 of admission on average. A need for a bowel care protocol was identified. A protocol was developed between June 2008 and February 2009. Inservice sessions for staff were carried out from Mar 2009 onwards and the protocol was implemented in June 2009. A repeat audit in May to June 2010 was carried out on 7 patients. Patients were commenced on the protocol on day 1.6 of admission on average. Bowels were opened on day 5.3 of admission on average. It was clear from the results that the implementation of a formal protocol has improved bowel care and decreased constipation.

Shifting Workplace Behavior to Inspire Learning: A Journey to Building a Learning Culture

This article discusses the process of building a learning culture. It began with establishing acceptance and connection with the nurse unit manager and the ward team. In the early phases of developing rapport, bullying became apparent. Because bullying undermines sharing and trust, the hallmarks of learning environments, the early intervention work assisted staff to recognize and counteract bullying behaviors. When predominantly positive relationships were restored, interactions that facilitated open communication, including asking questions and providing feedback-behaviors commensurate with learning in the workplace-were developed during regular in-service sessions. Staff participated in role-play and role modeling desired behaviors. Once staff became knowledgeable about positive learning interactions, reward and recognition strategies began to reinforce attitudes and behaviors that align with learning. Through rewards, all nurses had the opportunity to be recognized for their contribution. Nurses who excelled were invited to become champions to continue engaging the key stakeholders to further build the learning environment.

Using Audience Response Technology in Hospital Education Programs

An audience response system (ARS) is an interactive teaching tool that permits an instructor to poll an audience, either anonymously or in a tracked manner, in response to questions. The instructor can then display the responses to the audience. An ARS can be used in hospital-based education programs to assess group learning. The instructor receives immediate feedback that allows review of concepts that were not grasped by the majority of students. This article reviews systems currently on the market and offers tips for choosing an ARS for hospital-based use. Survey data of nurses attending in-service education sessions show that participants overwhelmingly favor the use of an ARS and the nonthreatening learning environment that these systems create. Instructor survey data show positive responses regarding the benefits of ARS use in hospital-based education programs.

Chasing Zero: Our Journey to Preventing Surgical Site Infection

After an increase in methicillin-resistant Staphylococcus aureus infections was discovered at a health care facility in Arizona, a multidisciplinary team convened to investigate the underlying problem and work toward eliminating surgical site infections. The team investigated environmental factors, held inservice sessions to reinforce sterile technique, and made important changes to the facility culture in efforts to eliminate surgical site infections. The team's efforts were put into practice on October 30, 2008, and only one surgical site infection was identified in the following seven months.

Nursing students’ knowledge and practice of infection control precautions: an educational intervention

This paper is a report of the effectiveness of a purpose-designed education program in improving undergraduate nursing students' understanding and practice of infection control precautions. The severe acute respiratory syndrome outbreak in 2003 highlighted that healthcare workers were under-prepared for such an epidemic. While many in-service education sessions were arranged by institutions in response to the outbreak, preservice nursing education has overlooked preparation for handling such infectious disease epidemics. A quasi-experimental design was used and a 16-hour, purpose-designed infection control education programme was implemented for preservice nursing students in southern Taiwan. Self-administered questionnaires were distributed at three time points during the period September 2005 to April 2006 to examine the sustainability and effectiveness of the intervention. A total of 175 preservice nursing students participated in the study. Following the education programme, students in the intervention group showed a statistically significant improvement across time in their knowledge of these precautions [F(2, 180) = 13.53, P < 0.001] and confidence in resolving infection-related issues [F(1.79, 168.95) = 3.24] when compared with those in the control group. To improve nursing students' capacity in responding to infectious epidemics, an educational programme that integrates the theme of infection precautions, learning theory and teaching strategies is recommended for all nursing institutes.

Fearful symmetry: Palestinian and Jewish teachers confront contested narratives in integrated bilingual education

The present paper deals with Jewish and Palestinian teachers who work in an integrated school in Israel, and shows the challenges and possibilities from examining these teachers' powerful historical narratives in the context of in-service training sessions. It is shown how these teachers essentially remain firmly rooted in the hegemonic historical narratives of their own community, even when their attitudes are challenged and clearer alternatives are considered to the reigning narratives. The findings highlight predominantly the failures in terms of the potential of educational efforts to help overcome situations of intractable conflict even within contexts specifically devised for this purpose; yet, also some openings become apparent in the process of negotiating competing narratives and inventing new dialogic possibilities. The implications of this work suggest that schools and their historical tradition are difficult places to reach change or produce it—even in integrated schools in which partial structural change takes place—and teacher training may not always be the answer for the need to bring changes. However, it is also indicated that an ongoing agonistics of raising critical issues regarding one's identifications with hegemonic narratives does offer openings to take responsibility for both the challenges and the dialogic possibilities that are created in the process.

Monitoring the Effectiveness of Hospital Cleaning Practices by Use of an Adenosine Triphosphate Bioluminescence Assay

To evaluate the usefulness of an adenosine triphosphate (ATP) bioluminescence assay for assessing the efficacy of daily hospital cleaning practices. A 2-phase prospective intervention study. A university-affiliated community teaching hospital. During phase I of our study, 5 high-touch surfaces in 20 patient rooms were sampled before and after daily cleaning. Moistened swabs were used to sample these surfaces and were then plated onto routine and selective media, and aerobic colony counts were determined after 48 hours of incubation. Specialized ATP swabs were used to sample the same high-touch surfaces in the 20 patient rooms and were then placed in luminometers, and the amount of ATP present was expressed as relative light units. During phase II of our study, after in-service housekeeper educational sessions were given, the housekeepers were told in advance when ATP readings would be taken before and after cleaning. During phase I, the colony counts revealed that the 5 high-touch surfaces were often not cleaned adequately. After cleaning, 24 (24%) of the 100 surface samples were still contaminated with methicillin-resistant Staphylococcus aureus, and 16 (16%) of the 100 surface samples still yielded vancomycin-resistant enterococci. ATP readings (expressed as relative light units) revealed that only bathroom grab bars and toilet seats were significantly cleaner after daily cleaning than before. During phase II, a total of 1,013 ATP readings were obtained before and after daily cleaning in 105 rooms. The median relative light unit was significantly lower (ie, surfaces were cleaner) after cleaning than before cleaning for all 5 high-touch surfaces. Suboptimal cleaning practices were documented by determining aerobic colony counts and by use of an ATP bioluminescence assay. ATP readings provided quantitative evidence of improved cleanliness of high-touch surfaces after the implementation of an intervention program.

Integrating Consumer Health Care With Supportive Housing Services

Integrating Consumer Health Care With Supportive Housing Services

Results of a Radiation Therapist Opinion Survey Identifying, Measuring and Addressing Radiation Therapy Patient Supportive Care Needs

Background: At Sunnybrook's Odette Cancer Centre, a multidisciplinary research team with expertise in radiation therapy and supportive care embarked on a comprehensive, evidence-based three-phase study, “Identifying, Measuring and Addressing Radiation Therapy Patient Supportive Care Needs at the Odette Cancer Centre.” The subject of this paper, a radiation therapist opinion survey, constitutes Phase I of that study. Purpose: The goal of Phase I was to provide an opportunity for radiation therapists (RTs) to express their views concerning a wide range of supportive care issues as they relate to patients and their families, and also to themselves as RTs. The aim was to use the findings to create in-service educational sessions for RTs at the Odette Cancer Centre. These sessions would then allow RTs to enact the protocol that will follow in Phase II and III of the larger study. Materials and Methods: An online RT opinion survey was created, which used opinion statement questions. Included in the survey were questions regarding RTs' perspectives on supportive care issues and RTs' comfort level in addressing patient supportive care needs. Participants were asked about the barriers to the provision of optimal supportive care, and for suggestions to overcome these barriers. A treatment record audit was conducted simultaneously to augment the survey findings and to establish a baseline for future improvement measurements. Results: Although there appears to be room for improvement in documentation practices, a high level of commitment to the provision of optimal supportive care has been demonstrated. Concerns regarding a range of relevant issues were expressed. RTs' comfort levels addressing specific supportive care needs of patients and their families, and the barriers that they believe hinder the provision of quality supportive care were identified. The following four themes were suggested in overcoming those barriers: staff education and training, system change, more time for the provision of supportive care, and role clarification. Conclusions: The survey provided information that can be used to promote quality supportive care that extends beyond the aim of the survey; namely, to create in-service education sessions for RTs at the Odette Cancer Centre.

Impact of Preoperative Briefings on Operating Room Delays

Preoperative briefings have the potential to reduce operating room (OR) delays through improved teamwork and communication. Pre-post study. Tertiary academic center. Surgeons, anesthesiologists, nurses, and other OR personnel. An OR briefings program was implemented after training all OR staff in how to conduct preoperative briefings through in-service training sessions. During the preoperative briefings, the attending surgeon led OR personnel in a 2-minute discussion using a standardized format designed to familiarize caregivers with each other and the operative plan before each surgical procedure. The OR Briefings Assessment Tool was distributed to OR personnel at the end of each operation. Survey items questioned OR personnel about unexpected delays during each procedure and the relationship between communication breakdowns and delays. Responses were compared before and after the initiation of the preoperative briefings program. The use of preoperative briefings was associated with a 31% reduction in unexpected delays; 36% of OR personnel reported delays in the preintervention period, and 25% reported delays in the postintervention period (P<.04). Among surgeons alone, an 82% reduction in unexpected delays was observed (P<.001). A 19% reduction in communication breakdowns leading to delays was also associated with the use of briefings (P<.006). Preoperative briefings reduced unexpected delays in the OR by 31% and decreased the frequency of communication breakdowns that lead to delays. Preoperative briefings have the potential to increase OR efficiency and thereby improve quality of care and reduce cost.

Treating Obesity:Interventions in an Inner-City Population

Back to table of contents Previous article Next article Frontline ReportFull AccessTreating Obesity:Interventions in an Inner-City PopulationJoanne Caring M.D.Joanne Caring M.D.Search for more papers by this authorPublished Online:13 Jan 2015AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The problems of obesity, metabolic syndrome, and diabetes in the inner-city Latino and African-American populations with severe and persistent mental illness are well documented and complex.In response to the New York City Department of Health and Mental Hygiene's mandate for quality assurance, our continuing day-treatment program chose treating obesity as the subject of an ongoing quality improvement study that began in 2005. At the Community Support Services Program of Metropolitan Hospital Center, we implemented a comprehensive protocol to improve body mass index (BMI) and increase exercise in these populations. All clients with a BMI higher than 30 (the index for obesity) qualified for this ongoing study, resulting in 33 participants.The interventions and our program are based on and informed by cognitive-behavioral therapy, dialectical behavior therapy, and adherence techniques. All staff members are trained in these therapies through workshops and in-service sessions that are ongoing. The daily treatment we offer includes teaching the clients to identify and anticipate personal obstacles to healthy eating and exercise and to develop their own interventions to change their behavior.Clients identify personal intervention strategies in therapy groups. Some examples of groups in which we promote these behavioral changes are nutritional coaching, coping skills, diabetes, healthy cooking, community meeting, and "waist watcher." In waist watcher, clients are weighed weekly, and we focus on motivation and goal setting. We reinforce interventions in medication and treatment plan sessions.The team encourages all clients to exercise for a half hour per day five days per week. Clients choose their exercise class: walking group, sit and stretch, yoga, or gym. We award certificates when walking, weight loss, and exercise milestones are achieved. Each time a client earns any three certificates, he or she is eligible to be in the Member of the Month poll. We enhance participation in the indoor walking group by adding music via stereo.In group sessions, clients identify personal obstacles to making healthy food choices and eating healthy portion sizes. They receive support and feedback from peers and staff. For example, clients may select one achievable step toward behavioral change to practice per week. These steps are chronicled in progress notes.In the initial 21 months, 67% of clients (N=22) lost weight, 64% (N= 21) lost five pounds or more, and 52% (N=17) lost from ten to 39 pounds. There was a fivefold increase in exercise session participation. No control group was used. We continue to monitor for weight loss, weight loss maintenance, and increased exercise to evaluate the longer-term effectiveness of our interventions.One major challenge has been to transform the clients' concepts of portion size. We instruct them in the use of measuring cups to learn and achieve healthy portion sizes.Another challenge is to teach clients to eat healthily on very limited budgets. We guide them in making healthy choices in how to budget money (oatmeal versus doughnuts, using food pantries for staples, shopping wisely for healthy food in grocery stores, and bypassing junk food in fast-food outlets). We also work with clients to help them integrate healthy eating patterns into their diverse cuisines and cultures. Many clients have been able to switch from fried foods to broiled or baked foods and to add more fruits and vegetables to their diets while maintaining their native cuisine's flavors. Many lost weight by incorporating these adjustments into their meals and by eating appropriate portion sizes of their cuisines.We emphasize enjoyment of food and broadening the range of pleasurable activities pursued by each client. The community's attitude to food has evolved from "eat all you can eat" to an appreciation of a more balanced, healthy diet in appropriate portions.Dr. Caring is unit chief of the Community Support Services Program, Metropolitan Hospital Center, 1901 First Ave., New York, NY 10029 (e-mail: joannecaring [email protected]). She is also assistant professor at the New York Medical College in Valhalla, New York. FiguresReferencesCited byDetailsCited ByNone Volume 59Issue 10 October, 2008Pages 1216-1217PSYCHIATRIC SERVICES October 2008 Volume 59 Number 10 Metrics PDF download History Published online 13 January 2015 Published in print 1 October 2008

The importance of context in malaria diagnosis and treatment decisions ‐ a quantitative analysis of observed clinical encounters in Tanzania

To gain a better understanding of the decision-making context in the diagnosis of malaria in order to inform behaviour change strategies, using quantitative methods. We observed hospital outpatient and inpatient consultations in northeast Tanzania where malaria testing was routinely available, recording potential influences on testing and prescribing decisions. We analysed the effects of variables at patient, clinical context and clinician levels on three key decisions in malaria diagnosis and treatment: decision to test for malaria, presumptive treatment and treatment of test-negative patients with antimalarials. Observation of 2082 consultations took place during 120 clinics (different shifts on different days and in different departments) with 34 clinicians. Malaria tests were requested for 16.9% of patients. This decision was driven primarily by clinical symptoms. Of patients not tested for malaria, 36.0% were prescribed antimalarials, this decision being associated with both clinical and non-clinical factors. In outpatients fever was a strong predictor of presumptive treatment [adjusted odds ratio (AOR): 45.9, 95% CI: 30-73], in inpatients this was less so (AOR: 2.7, 95% CI: 0.98-7.7). Outpatient clinicians who were working alone or who had attended <2 in-service training sessions in the past year were more likely to prescribe antimalarials presumptively. The decision to prescribe antimalarials without also prescribing antibiotic treatment to 22.8% patients who tested negative for malaria was not driven by clinical symptoms but was associated with age over 5 years, lower patient load and male sex of clinician. Non-clinical factors are important in the overdiagnosis of malaria. Strategies to target antimalarials and antibiotics better need to use methods that address the context of clinical decision making in addition to the dissemination of conventional clinical algorithms.

Medication Management in Primary and Secondary Schools: Evaluation of Mental Health Related In-Service Education in Local Schools

An increasing number of students are taking medications while they are in school or are under the influence of medication during school hours. In a novel effort, clinical pharmacists and mental health therapists worked together to provide "mini-in-service" educational programs on psychological disorders and medications used to treat these disorders. The purpose of this study was to implement and evaluate the effectiveness of these educational programs presented to school nurses, teachers, school administrators, and other personnel. The study compared participant responses before and after attending a medication in-service session on a psychological disorder and its related medications. Results indicated that in-service education on attention deficit/hyperactivity disorder (ADHD) and depression improved the knowledge and confidence levels of school personnel regarding medications and symptoms. Feedback indicated school personnel wanted longer educational sessions and more information on these disorders and treatments. School nurses working with health professionals can improve education for staff, families, and students about mental health disorders and their treatment.