Real-life Clinical Experiences Research Articles

Dancing with the Demons – Making sense of schizophrenia

ABSTRACT This paper explores the empathic nuances of the therapeutic process with a person experiencing ongoing psychosis associated with a diagnosis of schizophrenia, and with a history of severe relational trauma. Incorporating the self psychological principles of working with the therapist’s and client’s forward edge, utilizing experience-near empathic attunement, and the somatic psychotherapy essential for kinaesthetic conversation were essential elements for the ongoing integration of the client’s self. This work demonstrates the development of a nuanced understanding of pathological accommodation with its internal self-organizing dynamics as well as offering examples of forward edge movement. Interweaving vignettes from a two-year period with the subjective and intersubjective somatically animated experiencing of the therapist, the puzzle of how to work with all parts of the client unfolds gently and carefully. This paper outlines how connections were made between the two participants, in a clinical sense and within the client, creating a sense-making structure within the nuclear self experience of the client. Real life clinical experiences of what somatic psychotherapy, undertaken within a relational, intersubjective psychodynamic process, looks and feels like are in short supply. The presentation of this case hopes to remedy that by demonstrating the body mind integration required to work this way.

Shedding Light on the Hidden Curriculum: A Systematic Review of Ethics Education during General Surgery and Subspecialty Training

Ethics education in surgical residencies is often delivered in an informal and nonstructured manner as part of a "hidden curriculum", leading to few residencies routinely including it in their core curriculum. This systematic review aimed to summarize the delivery modes, curriculum, structure, and effectiveness of ethics educational interventions for surgical trainees. We performed a comprehensive database search including MEDLINE, Embase, Scopus and CENTRAL to search for articles describing the implementation of ethics educational interventions for general surgery or subspecialty trainees. A total of 14 studies were included. Only 2 centers performed targeted needs assessment. Curricula covered included informed consent, the doctor-patient relationship, breaking bad news, decision-making, end-of-life care, conflicts of interest, considering patients' personal contexts, and surgical research ethics. Modes of delivery varied across studies, including case-based learning, group discussions, didactic lectures, reading material, role-playing, simulated patients, and ethics morbidity and mortality (M&M) meetings. Evaluations were most commonly via surveys exploring knowledge and self-reported confidence, with only 3 studies measuring actual trainee performance using objective structured clinical examinations. In general, the educational interventions increased trainees' confidence/preparedness in handling ethical dilemmas. We recommend comprehensive local needs assessment to guide curricular development and designing specific learning objectives and measurable milestones to ensure evaluation. Educational interventions are best delivered in a graduated manner with the complexity of the topic mirroring residents' real-life clinical responsibilities and experiences. Teaching modalities should be tailored according to the nature of the curricular content being taught to make the learning experience more interactive and effective.

Effects of a Complex Case Study and High-Fidelity Simulation on Mechanical Ventilation on Knowledge and Clinical Judgment of Undergraduate Nursing Students.

Improving nursing students' knowledge and clinical judgment related to mechanical ventilation (MV) is paramount, considering the heightened need for MV due to the current COVID-19 (coronavirus disease 2019) pandemic. High-fidelity simulation (HFS) provides students with real-life clinical experiences that they would rarely confront in clinical training, especially complex case scenarios (such as a patient needing MV). This study assessed students' clinical knowledge and judgment after including HFS involving MV in an undergraduate nursing program. This was a quasi-experimental design with a convenience sample of 151 nursing students using the Lasater Clinical Judgment Rubric. There were significant differences between the intervention and control groups in knowledge (t = 20.42; P = .001) and total clinical judgment scores (t = 19.55; P < .001) post-HFS. Including a complex case study using MV and HFS significantly improved students' clinical decision-making, clinical knowledge, and self-confidence and enhanced their critical thinking, noticing, interpreting, reflecting, and responding capabilities.

Clinical Experiences of Intravenous Hydralazine and Labetalol for Acute Treatment of Severe Hypertension in Pregnant Thai Women.

Response to acute treatment of severe hypertension during pregnancy in Asian women was not known. Labor and delivery checklists of Thai women treated with intravenous hydralazine or labetalol for systolic blood pressure (SBP) ≥ 160 or diastolic blood pressure (DBP) ≥ 110 mmHg from January 2011 to December 2013 were reviewed as parts of an audit. Primary outcome was prompt achievement of SBP 140-150 and DBP 90-100 mmHg after the first bolus. Secondary outcomes were medication-related undesired effects. The mean ± standard deviation age and prevalence of chronic hypertension in hydralazine (n = 62) versus labetalol (n = 64) groups were 32.5 ± 6 versus 29.9 ± 6.8 years and 50% versus 21.9%, respectively (P < .05). Magnesium sulfate was promptly administered on admission to every woman to prevent seizure. Targeted blood pressure was timely achieved in 41.9% and 67.2% of the hydralazine and labetalol groups, respectively (P < .05). Nonreassuring fetal heart rate occurred in 51.6% and 32.8% of the hydralazine and labetalol groups, respectively (P = .05). The prevalence of cesarean section and Apgar score < 7 were not significantly different (P > .05). Real-life clinical experiences suggested significant advantages of intravenous labetalol over hydralazine in pregnant women with severe hypertension.

Into the black-box of learning in simulation debriefing: A qualitative research study

BackgroundSimulated learning activities are on the rise worldwide. Debriefing is viewed as a central element in simulated learning to enhance learning. Still, the question of how students learn in debriefing is underexplored. Aim, design and methodThe paper offers a contribution to the academy to better understand debriefing by presenting an in-depth, qualitative analysis of the practice of debriefing, carried out with 40 first-year nursing students (n = 40) in relation to roleplay simulation, training in clinical decision-making and patient involvement. The simulation sessions were carried out at a university hospital in Copenhagen, Denmark during clinical practice periods. FindingsUsing theoretical conceptualizations from learning theorist Knud Illeris as sensitizing concepts, the paper points to the emergence of intended as well as unintended learning processes. In addition, it highlights the importance of focusing on facilitators' empowering as well as disempowering impact on students' motivation to engage in debriefing learning processes. An important finding is that the curricular overload leads to a prioritization of learning outcome related to natural science at the expense of “softer” competencies, e.g. patient involvement. The analysis also finds that students' motivation to process their real-life clinical experiences tends to be neglected. The conclusion thus points to a profound dilemma, unidentified in the literature, of learning ambitions in debriefing: the tension between attaining the formal learning objective and thus facilitating a tightly structured and focused debriefing on the one side, and the wish to develop critical and independent thinking on the other.

Use of biosimilars in inflammatory bowel disease: a position update of the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD)

The first infliximab biosimilar for the treatment of inflammatory bowel disease (IBD) was introduced in 2013, and today eight anti-TNF alpha biosimilars (three for infliximab and five for adalimumab) have been approved and licensed by the European Medicines Agency. Biosimilars present great potential in terms of cost saving and possible consequential reinvestment in the health care system. The increasing knowledge about the process of biosimilar development and use in IBD and the publication of many prospective clinical studies and real-life clinical experiences have progressively changed the point of view of IBD physicians. In the present position paper, the Italian Group for the Study of Inflammatory Bowel Disease present and discuss their updated statements and positions on this topic, with emphasis on the concepts of biosimilarity and extrapolation across indications, safety and immunogenicity, interchangeability and switching, automatic substitution, and, finally, patient education about biosimilars.

Even better than the real thing? Using video assisted structured reflection in Simulated Clinical Scenarios and Real-Life Clinical Experiences in the Flipped Classroom.

&lt;p&gt;&lt;strong&gt;Background&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;This paper explores the attitudes of practitioners to the use of video assisted structured reflection in simulated clinical scenarios and real-life clinical experiences in the context of a Flipped Classroomto encourage and support reflection and reflective practice among pre-hospital emergency care practitioners in Ireland. It also examines the experiences of practitioners who participated in this process.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methodologies&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;This paper is part of a larger project which consisted of tree cycles of action research. Data was collected via an online survey questionnaire, and by conducting a series of semi-structured interviews with various stake-holders. These included all three clinical levels of pre-hospital emergency care practitioners and educators from emergency service providers, private ambulance services, and voluntary organisations.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Findings&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;When combined, a simulation experience with audio-visual recording and a structured model of reflection in the context of a Flipped Classroom has become a powerful learning experience. The process of a simulation experience with audio-visual recording, and a structured model of reflection appears to dovetail very nicely with the concept of the Flipped Classroom. The review of footage from audio-visual recording in the real-life clinical context provides a reliable and accurate means of evaluating clinical performance. Concerns were raised about the potential for abuse and misuse of audio-visual recordings. There are perceptions that audio-visual footage of real-life clinical experiences could potentially be used for unintended purposes such as, disciplinary procedures.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Recommendations&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;Since the process of combining a simulation experience with audio-visual recording and a structured model of reflection in the context of a Flipped Classroom has shown great promise as a learning experience, a larger scale pilot study is proposed. Develop a pilot programme with student practitioners during their undergraduate internship, and evaluate its findings. Develop a policy which clearly defines the use of audio-visual recording footage prior to the commencement of the pilot programme. A Learning Contract for all participants and faculty, including a confidentiality agreement, must be in place prior to the establishment of the process.&lt;/p&gt;

Applying Integrative Learning Strategies and Complexity Theory to Design Simulations for Care of Complex Patients.

Nurse educators use a variety of clinical simulation strategies to promote cognitive, psychomotor, and affective learning. Statistically significant increases in self-confidence levels were found among senior-level nursing students in the assessment and management of medical and psychiatric symptoms after participating in strategically designed, complex, student-led clinical simulations. Having students role play simulation scenarios that are developed from real-life clinical experiences is a cost-effective interactive strategy that enhances their communication and technical skills.

Starting aripiprazole long-acting-once-a-month early in treatment: why, how and for whom? Expert consensus and practical recommendations by a panel of Italian clinicians

ABSTRACTIntroduction: Aripiprazole long acting once-monthly (AOM) is approved for the treatment of schizophrenia in adults. Despite recent evidence of AOM efficacy in the acute treatment of schizophrenia, it is recommended that AOM should be started once the acute symptoms are controlled and patients are stabilized. However, there currently are no definitive guidelines exactly describing when a patient is to be considered stabilized enough to start AOM and which the patients are for whom an early AOM start is to be preferred.Areas covered: A panel of Italian clinicians experienced with real world use of AOM met to discuss the scenarios where an early (i.e., immediately after controlling the acute symptoms) start of AOM may be suggested. Real life clinical experiences were shared and a consensus was reached.Expert opinion: There are cases when the risks/benefits ratio suggests to start AOM early, i.e. immediately after the acute symptoms have been stabilized, as opposed to starting it several days/weeks after the stabilization of acute symptoms. Clinical pearls, guidelines and opinions are provided.

On-treatment and off-treatment efficacy of entecavir in a real-life cohort of chronic hepatitis B patients.

Entecavir (ETV) is a potent nucleoside analogue with high genetic barrier to resistance. In this study, real-life clinical experiences in the long-term use of ETV and the durability of its off-treatment effectiveness were analyzed. This study was based on a large real-life cohort of 2240 chronic hepatitis B patients treated with ETV between January 2006 and December 2012 using a centralized electronic data repository. Among 2240 patients, 804 patients were treatment naive and underwent ETV monotherapy. Their mean treatment duration was 712±493 days, with a cumulative proportion of patients achieving HBV DNA less than 300 copies/ml in 85.8, 95.7, and 97.6% at years 1, 2, and 3, respectively. Predictors for earlier virologic response were female sex, lower HBV DNA, higher alanine transaminase, lower platelet count, and HBeAg negativity at baseline. In patients who achieved virologic response and HBeAg loss, the cumulative relapse rate was 91.3% in 2 years after the cessation of treatment. During the treatment, 34 patients developed hepatocellular carcinoma, among whom 30 patients had cirrhosis before treatment initiation. ETV treatment showed efficient virologic response as the treatment duration was extended, but off-treatment efficacy was not durable, and the antiviral treatment showed some limitation in preventing hepatocellular carcinoma among liver cirrhosis patients, implying that treatment cessation should be taken into consideration more carefully. This study from a real-life cohort may provide data on treating chronic hepatitis B patients more close to everyday clinical practice.

Switching long acting antipsychotic medications to aripiprazole long acting once-a-month: expert consensus by a panel of Italian and Spanish psychiatrists

ABSTRACTIntroduction: Aripiprazole long acting once-monthly (AOM) is a long acting atypical antipsychotic with proven efficacy in schizophrenia and with a pharmacological and a side effect profile that is different from other antipsychotics. These and other characteristics make AOM a possible alternative in patients requiring a change in long acting antipsychotic treatment due to issues such as lack of efficacy or persistent side effects. Both clinical and pharmacological factors should be considered when switching antipsychotics, and specific guidelines for long acting antipsychotic switching that address all these factors are needed.Areas covered: A panel of Italian and Spanish experts in psychiatry met to discuss the strategies for the switch to AOM in patients with schizophrenia. Real life clinical experiences were shared and the clinical strategies to improve the likelihood of success were discussed.Expert Opinion: Due to its specific pharmacological and tolerability profile, AOM represents a suitable alternative for patients with schizophrenia requiring a switch to a new LAI treatment because of lack of efficacy or persistent side effects from another LAI. Possible strategies for the switch to AOM are presented in this expert consensus paper in an attempt to provide guidance throughout the entire switching process

Bespoke video vignettes - an approach to enhancing reflective learning developed by dental undergraduates and their clinical teachers.

This study explores the selective use of video as a medium to support reflective processes as related to dental undergraduate learning. With the objective of developing and enhancing high-quality adult dental care, the use of compiled video materials created in an undergraduate clinical setting was investigated. Video cameras were used to capture elements of reflection-in-action and reflection-on-action typically found during everyday clinical practice. 'Gold standard' or 'textbook outcomes' are rarely, if ever, fully achieved in dental practice. Real-life clinical experiences offer challenges and opportunities for both teachers and students to engage with reflective learning processes. The materials generated allowed for an experience of individual reflective learning and the creation of a data bank or archive with potential use for the benefit of a wider student cohort. Various aspects of the students' views and comments on the process of reflection were reported and explored by means of a semi-structured focus group moderated by a linked educational advisor.

Letter to the Editor: “High-Fidelity Meets Athletic Training Education: An Innovative Collaborative Teaching Project”

Letter to the Editor: “High-Fidelity Meets Athletic Training Education: An Innovative Collaborative Teaching Project”

The status of evidence-based medicine education in urology residency

Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of the current best evidence in decision-making for the care of patients. Teaching best evidence practice in residency should include both formal or freestanding content, as well as integration into clinical scenarios and patient care. We sought to assess the attitudes, experience and knowledge of EBM in urology residency training across Canada. An anonymous, cross-sectional, self-report questionnaire was completed by a convenience sample of 29 residents, including all chief urology residents in English-speaking programs across Canada. The survey included both open-ended and closed-ended questions designed to assess familiarity and attitudes towards EBM and potential barriers to developing EBM skills in a surgical training program. Questions were formatted to determine the understanding of statistical and analytical concepts, as well as familiarity of available EBM resources. Descriptive and correlative statistics were used to analyze the responses. The response rate was 100%. An overwhelming majority of residents felt that EBM is an important component of the urology residency and journal club was the most common vehicle for discussing best evidence concepts. However, there was significant variation in the presence of freestanding, formal curricula across programs, with only 28% of residents signifying that they received any formal training in their program. The apparent level of understanding of important EBM terminology and resources appears to be limited. The most frequently stated barriers to incorporating EBM curricula into urology training were time constraints and a perceived lack of expert educators. This self-report survey of urology chief residents identified the overwhelming acceptance of the importance of EBM in their training. Although best evidence practices appears to be addressed in journal clubs and in real-life clinical experiences, the obvious lack of familiarity and understanding of EBM content and resources would suggest a need for redoubling efforts to ensure appropriate exposure and instruction in our training programs.

On the MUVE or in decline: Reflecting on the sustainability of the Virtual Birth Centre developed in Second Life

&lt;span&gt;Pressures in terms of the availability of quality, real-life clinical experiences for students have resulted in increased interest in the use of simulation in a variety of healthcare disciplines. &lt;/span&gt;&lt;em&gt;Te wahi whanau: The birth place&lt;/em&gt;&lt;span&gt; is a Virtual Birth Centre (VBC) that was created in &lt;/span&gt;&lt;em&gt;Second Life&lt;/em&gt;&lt;span&gt; in 2009 as part of the Second Life Education in New Zealand (SLENZ) initiative. It was introduced to midwifery students at two New Zealand polytechnics, with the aim of exposing the students to a birth centre environment and providing them with an opportunity to practise midwifery through immersion and engagement in a number of clinical scenarios. It has been just over two years since the development of the VBC, yet it is no longer used in the midwifery programs in which it was introduced. Using the VBC as a case study, we recount its development and critically reflect on the factors impacting on its ongoing utilisation. We believe our reflections offer useful insight into issues relating more broadly to the sustainability of MUVE-based teaching and learning projects and initiatives.&lt;/span&gt;

Recognizing, responding to and reporting patient deterioration: Transferring simulation learning to patient care settings

BackgroundA simulation program was implemented in a pre-registration nursing curriculum for developing nursing students’ performances in assessing, managing and reporting in relation to patients with physiological deterioration. AimTo explore nursing students’ experiences of how a simulation programme has prepared them to transfer their performance to clinical practice, in their encounters with deteriorating patients in ward. MethodA qualitative study using a critical incident technique was conducted. After they had undertaken a simulation program, fifteen undergraduate nursing students, who had encountered deteriorating patients in their clinical practicum in wards were interviewed using semi-structured questionnaires. Content analysis was used to analyse the data. ResultsFour main themes emerged describing key factors influencing the transfer of simulation learning to clinical practice; memory, involving simulation learning enhanced storage and retrieval of knowledge; mnemonics as transfer tools for performing systematic physical assessment and reporting a patient's deterioration to a doctor; recognizing similar situations, where students used experiences from similar simulation situation to identify problems and initiate nursing interventions for their patients; and finally, emotional responses, that have both negative and positive impacts on transferring their simulation learning. Two other main themes emerged regarding strategies to facilitate transfer; self-directed learning for promoting the retention of simulation learning; and, realism, where simulated patients could be used to provide real-life clinical experiences. ConclusionThe findings provide an understanding of how a simulation program may impact on the nursing students’ performances in clinical practice, which is useful information for future improvement of programmes to optimize learning and transfer effective care to patient care settings.

The ASN In-Training Examination and the ABIM Certifying Examination

In 2009, a new computer-based in-training examination (ITE) was created by the American Society of Nephrology (ASN) in conjunction with the National Board of Medical Examiners to assess the medical knowledge of fellows training in nephrology. The ITE, patterned after the American Board of Internal Medicine certifying examination for nephrology (ABIM-CE), allowed fellows and training program directors (TPDs) to compare their performance with programs in the nation. However, despite using case vignettes to simulate real-life clinical experiences, the nation's graduating fellows answered a mean of only 69% of the questions correctly. Although unpublicized, the ABIM-CE passing grade can be estimated to be approximately 65%, resulting in the current passing rate of 94%. The ABIM states that they are testing 85% synthesis and clinical judgment, rather than recall memory. So are we to conclude from these two exams that the medical knowledge of our graduating nephrology fellows allows them to properly manage only about two-thirds of their patients? Rather, the construction of the test questions and their relevance to clinical practice should be reassessed. The time has come for a new testing paradigm, one that would require candidates passing the ABIM-CE to score 85% to 90% correct answers to more relevant "core" examination questions that assess the actual medical knowledge needed to practice competently in our subspecialty. If the ABIM-CE was revised, the ASN ITE, with no specific passing grade, could then test core and "factual" recall knowledge with feedback of questions to TPDs to assess and help fellows in training.