Range Of Clinicians Research Articles

Psychiatry as a vocation: Moral injury, COVID-19, and the phenomenology of clinical practice.

In this article, we focus on a particular kind of emotional impact of the pandemic, namely the phenomenology of the experience of moral injury in healthcare professionals. Drawing on Weber's reflections in his lecture Politics as a Vocation and data from the Experiences of Social Distancing during the COVID-19 Pandemic Survey, we analyse responses from healthcare professionals which show the experiences of burnout, sense of frustration and impotence, and how these affect clinicians' emotional state. We argue that this may relate to the ethical conflicts they experience when they are forced to make clinical decisions where there are no optimal outcomes, and how in turn that impacts on their own emotional state. We then further examine the notion of 'burnout' and the phenomenology of 'moral injury'. Our argument is that these experiences of moral injury across a range of clinicians during the pandemic may be more prevalent and long-standing in psychiatry and mental health than in other areas of healthcare, where ethically difficult decisions and resource constraints are common outside times of crisis. Hence, in these clinical arenas, moral injury and the phenomenology of emotional changes may be independent of the pandemic. The insights gained during the pandemic may provide wider insights into the challenges of developing services and training the workforce to provide appropriate mental health care.

Evaluation of learning transfer after a perinatal/neonatal palliative care virtual training course.

The success of a training can be determined by the degree of learning transfer. To address a gap in educational offerings during the pandemic, an interdisciplinary team developed and offered a 3-day virtual course, called Next Level Perinatal Palliative Care Training. This study aimed to evaluate the transfer of learning and practice from a virtual training course on perinatal/neonatal palliative care (PNPC) by a range of clinicians. A descriptive prospective survey design was used to collect data at two time points, immediately following the training course and 6 months later. Frequency and descriptive statistics were used to measure the implementation of PNPC quality indicators, self-reported competence, and clinical facilitators and barriers. A t-test was used to compare participants' anticipated learning transfer to actual learning transfer. Two open-ended items assessed benefits and drawbacks of virtual training. At course completion, participants anticipated opportunities to implement PNPC strategies with means of 84-87, and at the 6-month mark, the reported implementation had means ranging from 71 to 77. At 6 months post training, participants reported feeling competent/highly competent in each variable with frequency scores of 89%-98%. The opportunity to learn key concepts of PNPC and refresh skill sets ranked as the top facilitators, while the top barriers were the lack of opportunity to use PNPC principles and the lack of funding. Learning transfer after a virtual training course of PNPC proved to be successful, with a high rate of self-reported actual implementation and competence at 6 months after the training.

Prioritising child health and maternity evidence-based interventions or service models: a stakeholder-driven process

AimA UK programme, led by the National Institute for Health Research (NIHR) (https://www.nihr.ac.uk) and coordinated by Applied Research Collaborations (ARC), (https://www.nihr.ac.uk/explore-nihr/support/collaborating-in-applied-health-research.htm) aimed to identify and select evidence-based, implementation-ready service innovations for evaluation. The programme focused on seven areas of health provision. We report on a prioritisation process designed to identify and assess innovations in one of these areas: child and maternal health (CH&M).MethodsWe developed a three-stage, online, stakeholder driven process to 1) identify, 2) assess and prioritise and 3) select evidence-based interventions or service models, using crowdsourcing to identify projects and the APEASE criteria to assess and select projects. A brief evidence review was conducted for all initial suggestions to identify those with the largest evidence-base to take forward for ranking by stakeholders. Stakeholder workshops considered and ranked these suggestions using the APEASE criteria. We then conducted in-depth evidence reviews for the highest ranked suggestions. The Project Management Group and Advisory Board used these reviews and the APEASE criteria to select the final projects.ResultsWe received 32 initial suggestions from a range of clinicians, practitioners and researchers. Fourteen of the most evidence-based suggestions were considered and ranked at four themed stakeholder workshops. Nine suggestions were ranked for further in-depth evidence review and a final four projects were selected for implementation evaluation using the APEASE criteria. These were: 1. Maternal Mental Health Services Multidisciplinary Teams 2. Early years tooth brushing programme 3. Trauma-focused CBT for young people in care and 4. Independent Domestic Violence Advisors in maternity settings. Feedback from participants suggested that having public representatives participating in all stakeholder meetings, rather than being consulted separately, focused discussions clearly on patient benefit rather than research aims.ConclusionsThe stakeholder-driven process achieved its aim of identifying, prioritising and assessing and selecting, evidence-based projects for wider implementation and evaluation. The concurrent process could be adapted by other researchers or policy makers.

Identifying ways to improve diabetes management during cancer treatments (INDICATE): protocol for a qualitative interview study with patients and clinicians

IntroductionA large and growing number of patients with cancer have comorbid diabetes. Cancer and its treatment can adversely impact glycaemic management and control, and there is accumulating evidence that suboptimal...

COGConnect: A new visual resource for teaching and learning effective consulting

ObjectiveConsultation skills are essential to clinical practice and, when effective, can facilitate diagnoses and improve patient satisfaction. Various models exist to facilitate consultation teaching. These can be prescriptive, a challenge to apply in clinical settings and are often designed for primary care. In redesigning our entire curriculum, we sought to create a new visual, digital, resource for consultation teaching, aligned with statements from the UK Council for Clinical Communication (UKCCC), and suitable for the evolving expectations of patients, clinicians and the UK NHS, in 21st century medicine. MethodsWe conducted a literature review encompassing teaching methods, NHS Priorities, patients’ priorities, lifestyle interventions and practitioner resilience. COGConnect was designed iteratively through consultation with a graphic designer, health psychologists, a range of clinicians, and a consultation expert, and has evolved through extensive use in our new “effective consulting” course in primary and secondary care. ResultsCOGConnect is deliberately visual, iterative, bi-directional and multi-phasic. The central image of COGConnect is two persons in connection; the floating cogs suggesting an encounter of different agents who must adapt their cog-connection in terms of speed, direction and dimension. Around this image we place five core values. The consultation phases are represented by ten colourful cogs, with important additions including ‘formulating’, ‘activating’ and ‘integrating’. ConclusionCOGConnect builds on the strengths of existing frameworks and provides a strong visual resource suitable for digital learning. It offers greater emphasis on explicit clinical reasoning, activation of patient self-care and learning from the interaction. Having become the de facto resource for consultation skills training across primary and secondary care in our institution, the next phase is to develop the COGConnect.info website and a programme of formal evaluation.

Exploring the intersection of human rights, health, disability and refugee status: an arts-based approach

ABSTRACT Refugees often come from countries with histories of human rights violations and can face multiple challenges in building a new life in Australia. Little is known about the specific experiences of those who also live with a disability, and how this may impact their rights to health. We present an intersectional approach to using arts-based research to bring to light the embodied experiences of these people, who live at the intersection of multiple axes of marginalisation. Bringing together lived experience of displacement and disability, with interdisciplinary researchers and a range of clinicians and service providers, we present an overview of the issues faced by refugees with disabilities in Australia. We then discuss how arts-based research could help to generate academic and policy discourses which are more attentive to the needs, priorities and identities of refugees with disabilities.

Abstract 374: Trans-radial Access Angiography Learning Curve

Introduction: Radial artery access has been adopted widely around the world as standard best practice for coronary angiography with or without percutaneous coronary intervention. Radial artery access offers benefits in regard to reduced major bleeding, reduced hospital stay, fewer vascular complications, similar procedural times, patient preference and a mortality benefit in acute coronary syndrome/STEMI management. Despite transradial access being best practice, there has been a slow uptake of this technique amongst some cardiologists/interventionalists, particularly in the USA. This may partially be attributed to uncertainties regarding the learning curve and concerns regarding delaying treatment in STEMI if radial access fails. Methods: Using the data from the Coronary Angiography Database Of South Australia registry (CADOSA), we sought to determine the radial access failure rates for acute cases during transition from routine femoral access to routine radial access from 2012 to 2016, a period when the greatest transition in practice occurred. Data regarding initial vascular access, success or failure, and subsequent vascular access was prospectively recorded for all cases. Operators with at least a 70% rate of initial radial access were deemed to be established radial operators and acted as controls for operators transitioning from femoral access (at least 70% of cases) to radial access during the study period. Cases were further classified as elective, urgent (eg inpatient ACS) or emergency (eg STEMI). Results: There were 23 operators with sufficient volumes, responsible for 20,073 cath lab visits during the 5 year period studied. The overall radial access rate increased from 57% in 2012 to 78% in 2016. For operators transitioning from a default femoral access (76% of case) to a default radial access (75% of cases), the radial access failure rate for urgent and emergency cases was 3.7%, compared to 3.5% for experienced radial operators over the same period. Conclusion: Despite strong evidence of benefit for radial access angiography and intervention, compared to femoral access, some operators remain reluctant to transition. Utilising the CADOSA database, we observed a safe transition from femoral to radial access without an increased risk of access site failure for acute cases. Transition from femoral to radial access can be made safely by a range of clinicians managing acute cases.

Asthma: An overview of management and education

Asthma is the most common chronic disorder in schoolchildren and the school nurse plays an important role in supporting children with asthma ( Borgmeyer et al, 2005 ; Huss et al, 2001 ). School nurse have an important role in educating children about self-management and early management of exacerbations ( Ahmad and Grimes, 2011 ). This can lead to a reduction in absenteeism, and support their general wellbeing ( Ahmad and Grimes, 2011 ; Moonie et al, 2008 ; Rodriguez et al, 2013 ). Part of this role includes educating children and young adults about inhaler technique, and this is one area which nurses require further education and training ( Lalani et al, 2012 ; De Tratto et al, 2014 ). There is also a call for school nurses to work with a range of clinicians to support their students ( Hollenbach and Cloutier, 2014 ; Wilson et al, 2009 ).

The Impact of an Electronic Patient Bedside Observation and Handover System on Clinical Practice: Mixed-Methods Evaluation.

BackgroundPatient safety literature has long reported the need for early recognition of deteriorating patients. Early warning scores (EWSs) are commonly implemented as “track and trigger,” or rapid response systems for monitoring and early recognition of acute patient deterioration. This study presents a human factors evaluation of a hospital-wide transformation in practice, engendered by the deployment of an innovative electronic observations (eObs) and handover system. This technology enables real-time information processing at the patient’s bedside, improves visibility of patient data, and streamlines communication within clinical teams.ObjectiveThe aim of this study was to identify improvement and deterioration in workplace efficiency and quality of care resulting from the large-scale imposition of new technology.MethodsA total of 85 hours of direct structured observations of clinical staff were carried out before and after deployment. We conducted 40 interviews with a range of clinicians. A longitudinal analysis of critical care audit and electronically recorded patient safety incident reports was conducted. The study was undertaken in a large secondary-care facility in the United Kingdom.ResultsRoll-out of eObs was associated with approximately 10% reduction in total unplanned admissions to critical care units from eObs-equipped wards. Over time, staff appropriated the technology as a tool for communication, workload management, and improving awareness of team capacity. A negative factor was perceived as lack of engagement with the system by senior clinicians. Doctors spent less time in the office (68.7% to 25.6%). More time was spent at the nurses’ station (6.6% to 41.7%). Patient contact time was more than doubled (2.9% to 7.3%).ConclusionsSince deployment, clinicians have more time for patient care because of reduced time spent inputting and accessing data. The formation of a specialist clinical team to lead the roll-out was universally lauded as the reason for success. Staff valued the technology as a tool for managing workload and identified improved situational awareness as a key benefit. For future technology deployments, the staff requested more training preroll-out, in addition to engagement and support from senior clinicians.

Round up of the 2nd Commercial Law Clinics Round Table - 9th March 2018

The second annual Commercial Law Clinics Roundtable took place at the University of Sheffield on 9th March. The event was well attended by a range of clinicians and clinic students as well as start-up and enterprise advisers. Louise Glover, who organised the event, started the day by welcoming delegates before briefly talking about the successful growth experienced by the University of Sheffield’s legal clinic.

Co-designed outpatient clinic with consumerns for a patient and familiy centred approach

The Super Saturday Clinic provided patients and families with the opportunity to access a range of services on the same day. Family feedback demonstrated the importance of integrated care as families were appreciative to access services all in one day and in the same clinic. Working closely with consumers, the co-designed clinic was structured around patient centred care, and proved to be a great success. The Super Saturday Clinic concept emerged from consumer’s feedback that told us how many families travel to attend multiple appointments at Lady Cilento Children’s Hospital. These appointments are often scheduled across different days, resulting in travel costs, plus time away from work, school and family. They also noted that appointments scheduled across several days result in service gaps and missed opportunities for education. The co-designed outpatient clinic with consumers saw a range of clinicians come together to pilot a clinic outside of business hours on a Saturday. Current clinics are not always integrated with Allied Health who can be contacted on an ad-hoc basis. Alternative clinical practices were explored with interdisciplinary team work aligning with the super clinic which supported multiple disciplinary coordination and integration of services to meet the needs of patients and families in one clinic. [i] Two clinics were piloted for patients with juvenile idiopathic arthritic and inflammatory bowel disease. The clinic took three months of planning and coordination by the Innovation Change and Redesign Excellence (iCARE) unit. This team provides structure to enable transformation of health services within Children's Health Queensland (CHQ). Their involvement in the super clinic allowed seamless coordination as they were unrelated to a clinical team. The clinic was held in February 2017, with consultations being provided by the medical teams, clinical nurses, physiotherapy, occupational therapy, dietetics, social work, welfare, pharmacy and immunisation services. Overall, 119 consultations were delivered within 6 hours. There were 20 patients who attended, 18 of which had 4 or more consults and 5 of these patients had 7 or 8 consults. Families also had access with Non-Government Organisations to learn about community support. Since the pilot clinic, the primary driver has been to incorporate Allied Health permanently into existing clinics which is a sustainable approach compared to the current ad-hoc arrangement. The patient cohorts for the clinic were ideal as they had high proportion of Allied Health involvement which would be criteria for transferability between specialties. The lessons learnt focused on the need for a single coordinator and to allow sufficient time for clinic closure activities. A barrier to delivering Saturday clinics is dependent on the funding arrangements to support additional clinics which are reviewed yearly with Queensland Health. Families noted that they appreciated having access to services that they previously may not have seen. They also valued the availability of Saturday appointments reducing time off school and work while allowing other family members to attend. References : 1- Sandall S, McLean ME, Smith BJ. Recommended Practices in Early Intervention/Early Childhood Special Education. Longmont and Denver: Sopris West and DEC; 2000.

Clinician Attitudes Regarding ICD Deactivation in DNR/DNI Patients.

Implantable cardioverter-defibrillators (ICDs) offer lifesaving therapies but can become burdensome at the end of life. Many ICD patients choose to implement a do-not-resuscitate/do-not-intubate (DNR/DNI) order. When hospitalized, patients are seen by a range of clinicians whose beliefs about ICD management in DNR/DNI patients may vary. To assess clinician opinions on managing ICDs in DNR/DNI patients and stratify it by specialty and training level. An online survey was sent to attending physicians, fellows, advanced practice providers (physician assistants and nurse practitioners), and residents in general internal medicine, cardiology, electrophysiology, and geriatrics at an academic medical center. Residents were compared to attending physicians, and attending physicians were additionally stratified by specialty. The response rate was 32%, yielding 161 complete responses. Among residents (n = 73), 49.3% were comfortable with discussing ICD deactivation and 16.4% asked about it routinely. By contrast, among attending physicians (n = 66), 78.8% were comfortable with discussing deactivation and 34.8% routinely asked. Fewer general internists (19.2% of inpatient internists, 10.5% of outpatient internists) routinely asked about ICD deactivation as compared with 83.3% of geriatricians and 73.3% of cardiologists/electrophysiologists. Twenty-one percent of all respondents felt a DNR/DNI order equated to requesting ICD deactivation; Heart Rhythm Society (HRS) guidelines favor a more nuanced approach. Residents are less comfortable discussing ICD deactivation than attending physicians and do so less frequently. General internists discuss deactivation less routinely than cardiologists and geriatricians. Many providers hold opinions about ICD deactivation that differ from HRS guidelines. Additional didactic education could help close these gaps in clinician practice.

Comparison of Births by Provider, Place, and Payer in New Hampshire.

This study examines maternity care in a rural state by birth attendant, place of birth, and payer of birth. It is a secondary analysis of birth certificate data in New Hampshire between the years 2005 and 2012. Results revealed that in New Hampshire, the majority of births occurred in the hospital setting (98.6%). Physicians attended 75.8% of births, certified nurse midwives attended 17%, and certified professional midwives attended 1%. Medicaid coverage was the payer source for 28% of all births, compared with 44.9% nationally. Women with a private payer source were more likely than women with Medicaid or other payer sources to have a cesarean section. The findings demonstrate quality of care outcomes among a range of clinicians and settings, providing a policy argument for expanding maternity care options.

Selection by a panel of clinicians and family representatives of important early morbidities associated with paediatric cardiac surgery suitable for routine monitoring using the nominal group technique and a robust voting process

ObjectiveWith survival following paediatric cardiac surgery improving, the attention of quality assurance and improvement initiatives is shifting to long-term outcomes and early surgical morbidities. We wanted to involve family representatives...

Commentary on “Reflections on culture, structure and function of an intensive support service centred on positive behavioural support”

Purpose The purpose of this paper is to provide a commentary on Patterson and Berry’s paper “Reflections on culture, structure and function of an intensive support service centred on positive behavioural support”. Design/methodology/approach This paper reviews key ideas presented in Patterson and Berry’s article relative to the recent history of service delivery in the UK and the growing interest being shown in positive behaviour support. Findings Patterson and Berry’s article adds to a modest literature on specialist support services and should stimulate further descriptions of service models and the concepts underpinning them. Originality/value The literature on specialist support service models is limited and this addition should be relevant to a wide range of clinicians, consumers and commissioners.

Inter-observer agreement of thoracolumbar fascia morphology: An exploratory analysis of ultrasound images

BACKGROUND: Ultrasound imaging (USI) has been shown to be a valid method to investigate the morphology of the thoracolumbar fascia (TLF) [1]. A USI-based study has demonstrated that the TLF of subjects with chronic lower back pain (LBP) is on average 25% thicker and more disorganised compared to a control group [1]. The aim of this study is to explore inter-observer agreement between a range of clinicians on (dis)organisation of TLF in ultrasound images. There are currently no validated methods for the evaluation of USI of TLF. METHODS: Design: an exploratory analysis using a fully crossed design of inter-observer agreement. This study was approved by the University of Kent’s School of Sport and Exercise Sciences Research and Ethics Committee (Prop. 163 – 2013). Participants: Thirty observers consisting of 21 (70%) Medical Doctors, 7 (23%) physiotherapists and 2 (6%) radiologists, with a combined total average of 13 years of clinical experience (± SD 9.4). 57% had no experience in USI, 36% had experience ranging from monthly to daily evaluations of USI, no observers had experience in evaluating USI of TLF. Protocol: A sub-set of thirty ultrasound scans of TLF were randomly selected from a data set of 308 scans of subjects with and without LBP (from a larger study conducted by the first author). All scans were anonymised and displayed on a desktop computer, or projected on a screen. All observers viewed and rated each of the 30 scans independently on a Likert-type scale from 1(very disorganised) to 10 (very organised). Inter-observer agreement was assessed using a two-way mixed, consistency, average measures intra-class correlation (ICC), the Cronbach’s Alpha, to assess consistency among observers. The Krippendorff’s Alpha (Kalpha) [2] reliability estimate was used to assess agreement. RESULTS: The resulting ICC was in the excellent range, ICC = 0.98, indicating that observers had a high degree of consistency, suggesting that (dis)organisation was rated similarly across observers. Observers without USI experience scored an ICC = 0.96, observers with USI experience scored an ICC = 0.95, again both in the excellent range. In this small cohort, experience in USI does not appear to impact on consistency. The Krippendorff’s ordinal alpha ? was .621, indicating a modest degree of agreement. CONCLUSIONS: The high ICC and modest Kalpha suggest that a minimal amount of measurement error was introduced by the independent observers, and therefore statistical power for subsequent analyses is not substantially reduced. This will allow for further analysis of USI images of TLF in terms of morphology and classification. This could ultimately, lead to a meaningful evaluation of treatments of TLF.

A systematic review of motivational interviewing for weight loss among adults in primary care.

Motivational interviewing (MI) is a client-centred method of intervention focused on enhancing intrinsic motivation and behaviour change. A previous review of the literature and meta-analyses support the effectiveness of MI for weight loss. None of these studies, however, focused on the bourgeoning literature examining MI for weight loss among adults within primary care settings, which confers unique barriers to providing weight loss treatment. Further, the current review includes 19 studies not included in previous reviews or meta-analyses. We conducted a comprehensive review of PubMed, MI review papers, and citations from relevant papers. A total of 24 adult randomized controlled trials were identified. MI interventions typically were provided individually by a range of clinicians and compared with usual care. Few studies provided adequate information regarding MI treatment fidelity. Nine studies (37.5%) reported significant weight loss at post-treatment assessment for the MI condition compared with control groups. Thirteen studies (54.2%) reported MI patients achieving at least 5% loss of initial body weight. There is potential for MI to help primary care patients lose weight. Conclusions, however, must be drawn cautiously as more than half of the reviewed studies showed no significant weight loss compared with usual care and few reported MI treatment fidelity.

Mitigating clinician and community concerns about children's flatfeet, intoed gait, or knock‐knees

Background Foot and lower limb postures are a common parental concern, and present frequently to a range of clinicians. Referral of children with flatfeet, intoed gait, or knockknees that is within normal developmental limits has been reported as approximating 40%. This represents a substantial and unnecessary cost to any health care system. The dilemma for caring clinicians is that each of these common presentations can be frankly pathological, so erring on the side of caution is understandable.

Implementing thrombosis guidelines in cancer patients: a review.

Venous thromboembolism is a frequent and serious complication in patients with cancer. It is an independent prognostic factor of death in cancer patients and the second leading cause of death, but physicians often underestimate its importance, as well as the need for adequate prevention and treatment. Management of venous thromboembolism in patients with cancer requires the coordinated efforts of a wide range of clinicians, highlighting the importance of a multidisciplinary approach. However, a lack of consensus among various national and international clinical practice guidelines has contributed to knowledge and practice gaps among practitioners, and inconsistent approaches to venous thromboembolism. The 2013 international guidelines for thrombosis in cancer have sought to address these gaps by critically re-evaluating the evidence coming from clinical trials and synthesizing a number of guidelines documents. An individualized approach to prophylaxis is recommended for all patients.

Trauma-Informed Care With Childhood Maltreatment Survivors: What Do Maternity Professionals Want to Learn?

BACKGROUND: Posttraumatic stress disorder (PTSD) affects 8% of pregnant women, and the biggest risk factor for pregnancy PTSD is childhood maltreatment. The care they receive can lead to positive outcomes or to retraumatization and increased morbidity. The purpose of this study is to gather information from a range of clinicians about their continuing education needs to provide perinatal care to women with a maltreatment history and PTSD.METHOD: Maternity health care professionals were interviewed by telephone. Network sampling and purposive sampling were used to include physicians, nurse practitioners, midwives, nurses, and doulas (n = 20), and results were derived from content analysis.RESULTS: Most providers received little or no training on the issue of caring for women with a history of childhood maltreatment or PTSD during their original education but find working with this type of patient rewarding and wish to learn how to provide better care. Providers identified a range of educational needs and recommend offering a range of formats and time options for learning.CONCLUSIONS: Maternity health care providers desire to work effectively with survivor moms and want to learn best practices for doing so. Thus, educational programming addressing provider needs and preferences should be developed and tested to improve care experiences and pregnancy outcomes for women with a history of trauma or PTSD.