Patient Care Skills Research Articles

Fecal microbiota transplantation: Safe, simple, and effective

Fecal microbiota transplantation (FMT) re-emerged over the last decade, primarily in response to the escalating problem of health-care-associated Clostridium difficile (CD) infection (CDI). Increasing virulence and antibiotic resistance of CD prompted intensified efforts to broaden therapeutic options for this emerging health threat. It is well established that homeostasis of intestinal flora (or microbiota) is critical to human well-being. Introduction and misuse of various health-care related interventions, including antibiotics and gastric acid-reducing agents, contributed to the current state of crisis. Common therapeutic options for CDI include antibiotics, probiotics, and surgery. More recently, there has been as shift toward the utilization of FMT as a second-line option for severe/complicated CDI. The aim of this review is to provide health-care professionals with a concise summary of management options for CDI, with special focus on FMT and its indications, contraindications, and implementation experiences. The following core competencies are addressed in this article: Medical knowledge, Patient care and procedural skills, Systems-based practice.

Endoscopic retrograde cholangiography: Complications, emergencies, and related topics

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure with both diagnostic and therapeutic indications. Following wider adoption of magnetic resonance cholangiopancreatography and endoscopic ultrasound, a shift emerged toward the interventional use of ERCP. Inherent to this shift was the evolution of procedural risk profile, resulting in a greater propensity for more severe periprocedural morbidity. Because ERCPs are so ubiquitous, it is imperative for medical and surgical practitioners to posses excellent knowledge of the risks, benefits, and therapeutic/diagnostic alternatives. The intent of the current manuscript is to provide an authoritative review on the topics of ERCP-related complications, emergencies, and related subject matter. The following core competencies are addressed in this article: Patient care and procedural skills, Medical knowledge, Practice-based learning and improvement.

Programmatic Assessment in Emergency Medicine: Implementation of Best Practices.

Programmatic assessment is the intentional collection of key data from multiple sources for both assessment of learning and assessment for learning. We developed a system of programmatic assessment (PA) to identify competency progression (summative) and assessment for learning to assist residents in their formative development. The programmatic assessment was designed iteratively from 2014 through 2016. All assessments were first categorized by competency domain and source of assessment. The number of assessment modalities for each competency domain was collected. These multisource assessments were then mapped by program leadership to the milestones to develop a master PA blueprint. A resident learning management system provided the platform for aggregating formative and summative data, allowing residents and faculty ongoing access to guide learning and assessment. A key component of programmatic assessment was to support resident integration of assessment information through feedback by faculty after shifts and during monthly formal assessments, semiannual resident reviews, and summative judgments by the Clinical Competency Committee. Through the PA, the 6 competency domains are assessed through multiple modalities: patient care (22 different assessments), professionalism (18), systems-based practice (17), interprofessional and communication skills (16), medical knowledge (11), and practice-based learning and improvement (6). Each assessment provides feedback to the resident in various formats. Our programmatic assessment has been utilized for more than 2 years with iterative improvements. The implementation of programmatic assessment allowed our program to organize diverse, multisourced feedback to drive both formative and summative assessments.

Using an Inflammatory Bowel Disease Objective Structured Clinical Examination to Assess ACGME Milestones in Gastroenterology Fellows

Introduction: The Accreditation Council for Graduate Medical Education (ACGME) has identified six core competencies in which trainees are expected to demonstrate proficiency. Milestones have been developed to provide a framework for evaluating trainee performance within these competencies. We used an objective structured clinical examination (OSCE) focused on inflammatory bowel disease (IBD) to assess the milestones in gastroenterology (GI) fellows. Methods: Ten second-year fellows from six GI fellowship programs participated in an OSCE. In the “Transition of Care” case the fellow was to assess a patient's readiness on the planned transition from child-centered to adult-centered care. In the “Shared Decision Making” case the fellow was to evaluate a patient with Crohn's disease who would benefit from combination therapy. In the “ER Flare” case the fellow was to triage and suggest management of a flaring ulcerative colitis patient. In the “IBS in IBD” case the fellow was asked to discuss irritable bowel syndrome in the context of quiescent IBD. Previously validated OSCE checklists were used to assess the GI fellows' performance using a 3- and 5-point behaviorally-anchored Likert Scale. Checklists were scored by the standardized patient. Checklist items were mapped to appropriate ACGME milestones by a GI medical educator. Scores within each milestone were normalized on a scale from 0-9 as utilized by the ACGME in the Next Accreditation System milestone initiative. Fellows were provided feedback on their performance. Results: The majority of fellows scored between 6 and 9 in the milestones assessing patient care (PC), medical knowledge (MK), interpersonal and communication skills (ICS), professionalism (Prof), and systems-based practice (SBP). Composite average scores for all participants were as follows: PC1 7.7, PC2 6.9, MK1 6.9, MK2 7.0, ICS1 7.4, Prof1 7.6, Prof3 6.9, and SBP4 6.4. Fellows scored highest in “Shared Decision Making” and scored lowest in “Transitions of Care”. Conclusion: In this OSCE GI fellows performed well in the majority of milestones evaluated, however areas of less optimal performance were identified, providing areas for future focus in fellow training. The OSCE is a well-validated standardized tool for evaluating trainees, and with appropriate mapping of checklists to ACGME milestones, it can serve as an objective method to assess GI fellows' progress in the core competencies.

Graduate medical education competencies for international health electives: A qualitative study

Background: Residency programs offer international health electives (IHEs), providing multiple educational benefits. This study aimed to identify how IHEs fulfill the Accreditation Council for Graduate Medical Education (ACGME) core competencies.Methods: We conducted a thematic analysis of post-rotation reflective reports from residents who participated in IHEs through the Mayo International Health Program. We coded reports using a codebook created from the ACGME competencies. Using a constant comparative method, we identified significant themes within each competency.Results: Residents from 40 specialties participated in 377 IHEs in 56 countries from 2001 to 2014. Multiple themes were identified within each of the six ACGME core competencies: Patient Care and Procedural Skills (4), Medical Knowledge (5), Practice-Based Learning and Improvement (3), Interpersonal and Communication Skills (5), Professionalism (4), and Systems-Based Practice and Improvement (3). Themes included improving physical exam and procedural skills, providing care in resource-limited setting, gaining knowledge of tropical and non-tropical diseases, identifying socioeconomic determinants of health, engaging in the education of others, and increasing communication across cultures and multidisciplinary teams.Conclusions: Through IHEs, residents advanced their knowledge, skills, and attitudes in each of the six ACGME competencies. These data can be used for development of IHE competencies and milestones for resident assessment.

Contextual Influences of Trainee Characteristics and Daily Workload on Trainee Learning Preferences.

We previously defined teaching domains necessary for successful inpatient medicine attending rounds from the trainees' perspective in Role Modeling, Learning Environment, Teaching Process and Team Management. We sought to understand whether trainee characteristics and daily fluctuations in workload influence the prioritization of these domains. We conducted a prospective observational study in general medicine inpatient wards at a university, Veterans Affairs, and a county hospital affiliated with one academic institution over the course of 6 months. All student and resident trainees on internal medicine inpatient wards were eligible to participate. We designed a daily assessment tool on which trainees were asked to identify the teaching domain most important to them, along with information on sex, training level, call-cycle day, patient census, and number of team members absent during rounds. We examined associations between training level and workload factors with the prioritized teaching domain using Pearson's chi-square analysis, adjusted for clustering effects. We collected 1,378 daily assessment cards evaluating 53 (91%) attending physicians. Students valued Teaching Process (𝑃 < 0.001), while senior residents sought Team Management (𝑃 < 0.001). On most days, Teaching Process was prioritized (𝑃 = 0.005). On post-call days and days with a high patient census, Team Management was prioritized (𝑃 < 0.001). Attending physicians may consider tailoring rounds in response to work-related pressures. Days with a high workload are better suited for demonstrating efficient and effective patient care skills.

Dedicated Research Time During Surgery Residency Leads to a Significant Decline In Self-Assessed Clinical Aptitude and Surgical Skills

The surgical community commonly perceives a decline in surgical and patient care skills among residents who take dedicated time away from clinical activity to engage in research. We hypothesize that residents perceive a decline in their skills because of dedicated research time. UC Davis Medical Center, Sacramento, CA, an institutional tertiary care center. General surgery residents and graduates from UC Davis general surgery residency training program, who had completed at least 1 year of research during their training. A total of 35 people were asked to complete the survey, and 19 people submitted a completed survey. Participants were invited to complete an online survey. Factors associated with the decline in skills following their research years were examined. All statistical analyses were performed with IBM SPSS Statistics software. A total of 19 current or former general surgery residents responded to the survey (54% response rate). Overall, 42% described their research as "basic science." Thirteen residents (68%) dedicated 1 year to research, while the remainder spent 2 or more years. Basic science researchers were significantly more likely to report a decrease in clinical judgment (75% vs. 22%, p = 0.013) as well as a decrease in patient care skills (63% vs. 0%, p = 0.002). Residents who dedicated at least 2 years to research were more likely to perceive a decline in overall aptitude and surgical skills (100% vs. 46%, p = 0.02), and a decline in patient care skills (67% vs. 8%, p = 0.007). Most residents who dedicate time for research perceive a decline in their overall clinical aptitude and surgical skills. This can have a dramatic effect on the confidence of these residents in caring for patients and leading a care team once they re-enter clinical training. Residents who engaged in 2 or more years of research were significantly more likely to perceive these problems. Further research should determine how to keep residents who are interested in academics from losing ground clinically while they are pursuing research training.

Feasibility, Acceptability, and Preliminary Effectiveness of a 4-week Mindfulness-Based Cognitive Therapy Protocol for Hospital Employees.

Hospital employees may experience occupational stress and burnout, which negatively impact quality of life and job performance. Evidence-based interventions implemented within the hospital setting are needed to promote employees' well-being. We offered a 4-week Mindfulness-Based Cognitive Therapy group program for hospital employees, and used a mixed-methods practice-based research approach to explore feasibility, acceptability, and effects on stress and burnout. Participants were 65 hospital employees (Mage = 44.06; 85% white) who participated between September 2015 and January 2016. Participants completed validated measures of stress and burnout before and after the program, and answered open-ended satisfaction questions after the program. Groups consistently enrolled at least 10 participants, but attendance rates declined across sessions (76% at session 2 vs. 54% at session 4) due primarily to work-related scheduling conflicts. The program content was acceptable as evidenced by high perceived value (M = 9.18 out of 10), homework compliance (51% practicing at least 3 times/week), and qualitative requests for program expansion. There were large, statistically significant decreases in stress (ΔM = 2.1, p < .001, d = .85) and medium decreases in burnout (ΔM = .46, p = .01, d = .57), which were supported by qualitative themes of improved self-regulation and mindfulness skills, stress reduction, emotional well-being, and improved work productivity and patient care skills. Findings suggest that 4-week MBCT is acceptable and useful for hospital employees, though research is needed to identify alternate delivery methods or strategies to enhance session attendance.

Creating objective and measurable postgraduate year 1 residency graduation requirements.

The process of developing objective and measurable postgraduate year 1 (PGY1) residency graduation requirements and a progress tracking system is described. The PGY1 residency accreditation standard requires that programs establish criteria that must be met by residents for successful completion of the program (i.e., graduation requirements), which should presumably be aligned with helping residents to achieve the purpose of residency training. In addition, programs must track a resident's progress toward fulfillment of residency goals and objectives. Defining graduation requirements and establishing the process for tracking residents' progress are left up to the discretion of the residency program. To help standardize resident performance assessments, leaders of an academic medical center-based PGY1 residency program developed graduation requirement criteria that are objective, measurable, and linked back to residency goals and objectives. A system for tracking resident progress relative to quarterly progress targets was instituted. Leaders also developed a focused, on-the-spot skills assessment termed "the Thunderdome," which was designed for objective evaluation of direct patient care skills. Quarterly data on residents' progress are used to update and customize each resident's training plan. Implementation of this system allowed seamless linkage of the training plan, the progress tracking system, and the specified graduation requirement criteria. PGY1 residency requirements that are objective, that are measurable, and that attempt to identify what skills the resident must demonstrate in order to graduate from the program were developed for use in our residency program. A system for tracking the residents' progress by comparing residents' performance to predetermined quarterly benchmarks was developed.

Content analysis of resident evaluations of faculty anesthesiologists: supervision encompasses some attributes of the professionalism core competency.

Anesthesiology departments need an instrument with which to assess practicing anesthesiologists' professionalism. The purpose of this retrospective analysis of the content of acohort of resident evaluations of faculty anesthesiologists was to investigate the relationship between a clinical supervision scale and the multiple attributes of professionalism. From July 1, 2013 to the present, our department has utilized the de Oliveira Filho unidimensional nine-item supervision scale to assess the quality of clinical supervision ofresidents provided by our anesthesiologists. The "cohort" weexamined included all 13,664 resident evaluations of all faculty anesthesiologists from July 1, 2013 through December 31, 2015, including 1,387 accompanying comments. Words and phrases associated with the core competency of professionalism were obtained from previous studies, and the supervision scale was analyzed for the presence of these words and phrases. The supervision scale assesses some attributes of anesthesiologists' professionalism as well as patient care and procedural skills and interpersonal and communication skills. The comments that residents provided with the below-average supervision scores included attributes of professionalism, although numerous words and phrases related to professionalism were not present in any of the residents' comments. The de Oliveira Filho clinical supervision scale includes some attributes of anesthesiologists' professionalism. The core competency of professionalism, however, is multidimensional, and the supervision scale and/or residents' comments did not address many of the other established attributes of professionalism.

Development and evaluation of an intermediate-level elective course on medical Spanish for pharmacy students

Background and Purpose: The Spanish-speaking population in the United States is increasing rapidly, and there is a need for additional educational efforts, beyond teaching basic medical Spanish terminology, to increase the number of Spanish-speaking pharmacists able to provide culturally appropriate care to this patient population. This article describes the development and evaluation of an intermediate-level elective course where students integrated pharmacy practice skills with Spanish-language skills and cultural competency.Educational Activity and Setting: Medical Spanish for Pharmacists was developed as a two-credit elective course for pharmacy students in their third-professional-year who possessed a certain level of Spanish language competence. The course was designed so that students would combine patient care skills such as obtaining a medication list and providing patient education, and pharmacotherapy knowledge previously learned in the curriculum, along with Spanish-language skills, and apply them to simulated Spanish-speaking patients. Elements to promote cultural competency were integrated throughout the course through a variety of methods, including a service learning activity.Findings: Successful attainment of course goals and objectives were demonstrated through quizzes, assignments, examinations, and an objective structured clinical examination (OSCE). Based on these course assessments, students performed well during both offerings of the course.Discussion: While the class cohort size was small in the two offerings of the course, the Medical Spanish for Pharmacists elective may still serve as an example for other pharmacy programs as an innovative approach in combining Spanish language, specific pharmacy skills, cultural competency, and service learning.

Scenario development strategies and process for simulation-based education in anesthesiology

Scenario creation is fundamental to simulation. An effective design is necessary to optimize training. This paper describes the process of creating and applying mannequin-based high-fidelity simulation case scenarios for a graduate program in anesthesiology. The objective of scenario building is to provide an opportunity for trainees to learn the management of both common and rare case scenarios to better prepare them for the written and applied board examinations and real-life situations. Scenario development for high-fidelity simulation requires assembling all the elements to recreate a realistic environment while considering the trainees' different learning styles. The goal is to create scenarios that help the learner build knowledge, skills, and confidence. The following core competencies area addressed in this article: Patient care, Interpersonal and communication skills, Systems-based practice.

The american college of academic international medicine 2017 consensus statement on international medical programs: Establishing a system of objective valuation and quantitative metrics to facilitate the recognition and incorporation of academic international medical efforts into existing promotion and tenure paradigms

The growth of academic international medicine (AIM) as a distinct field of expertise resulted in increasing participation by individual and institutional actors from both high-income and low-and-middle-income countries. This trend resulted in the gradual evolution of international medical programs (IMPs). With the growing number of students, residents, and educators who gravitate toward nontraditional forms of academic contribution, the need arose for a system of formalized metrics and quantitative assessment of AIM- and IMP-related efforts. Within this emerging paradigm, an institution's “return on investment” from faculty involvement in AIM and participation in IMPs can be measured by establishing equivalency between international work and various established academic activities that lead to greater institutional visibility and reputational impact. The goal of this consensus statement is to provide a basic framework for quantitative assessment and standardized metrics of professional effort attributable to active faculty engagement in AIM and participation in IMPs. Implicit to the current work is the understanding that the proposed system should be flexible and adaptable to the dynamically evolving landscape of AIM – an increasingly important subset of general academic medical activities. The following core competencies are addressed in this article: Patient care, Medical knowledge, Professionalism, Interpersonal and communication skills, Practice-based learning and improvement, and Systems-based practice

Putting the pieces together: The role of multidisciplinary simulation in medical education

Simulation is becoming an increasingly important tool in medical education. Specifically, multidisciplinary team-based simulation exercises are being used to promote teamwork and communication among various members of care teams. Similar to its use in the aviation industry, this type of team building simulation has shown promising results in improving teamwork and improving patient safety outcomes. Several key players in the health-care setting, including hospitals and malpractice insurance providers, have recognized these benefits and are promoting the use of multidisciplinary simulation for staff training. Despite several barriers to implementation, the use of multidisciplinary simulation will be an important part of a new emerging model of medical education. The following core competencies are addressed in this article: Patient care, Interpersonal and communication skills, Systems-based practice.

A comprehensive framework for international medical programs: A 2017 consensus statement from the American College of Academic International Medicine

The American College of Academic International Medicine (ACAIM) represents a group of clinicians who seek to promote clinical, educational, and scientific collaboration in the area of Academic International Medicine (AIM) to address health care disparities and improve patient care and outcomes globally. Significant health care delivery and quality gaps persist between high-income countries (HICs) and low-and-middle-income countries (LMICs). International Medical Programs (IMPs) are an important mechanism for addressing these inequalities. IMPs are international partnerships that primarily use education and training-based interventions to build sustainable clinical capacity. Within this overall context, a comprehensive framework for IMPs (CFIMPs) is needed to assist HICs and LMICs navigate the development of IMPs. The aim of this consensus statement is to highlight best practices and engage the global community in ACAIM's mission. Through this work, we highlight key aspects of IMPs including: (1) the structure; (2) core principles for successful and ethical development; (3) information technology; (4) medical education and training; (5) research and scientific investigation; and (6) program durability. The ultimate goal of current initiatives is to create a foundation upon which ACAIM and other organizations can begin to formalize a truly global network of clinical education/training and care delivery sites, with long-term sustainability as the primary pillar of international inter-institutional collaborations. The following core competencies are addressed in this article: Patient care, Medical knowledge, Professionalism, Interpersonal and communication skills, Practice-based learning and improvement, and Systems-based practice.

Medical student expectations from surgical education: A two-year institutional experience

BackgroundThe third-year surgical rotation is the first exposure medical students have to the fundamentals of surgical education. It is known that medical students come to the surgical clerkship with preconceived ideas, many of them negative and based on prior student feedback and hearsay. MethodsAn anonymous survey was conducted of third-year medical students while on the surgical clerkship. We sought to quantify student's experiences and expectations by assessing the students' confidence levels before and after the rotation. ResultsOver a 26 month period from July 2013–August 2015, 250 surveys were conducted. In terms of confidence gained on the surgical rotation, students reported a statistically significant (p < 0.01) increase in confidence in fifteen different areas of interest. However, in terms of expectations, students reported discordance between anticipated experience and actual experience. Students' responses indicate that students felt confident with their knowledge of diseases; however, they desire more involvement in complex patient care and procedural skills. ConclusionsThe third-year clerkship is the first exposure to surgery for many medical students. Surgical educators are tasked with providing a foundation for clinical medicine; however, students have expressed an expectation to be more involved with complex patient care and management.

Development of Formative Capstone Simulations to Prepare Novice Students for Initial Clinical Practicum.

Nursing students often describe initial clinical experiences as extremely anxiety producing. Anxiety can decrease performance ability and, consequently, increase the risk for patient harm. Strategies to decrease this anxiety related to clinical experiences are limited within the nursing education literature. Faculty in a 4-year baccalaureate nursing program developed and implemented formative capstone simulation scenarios with standardized patients, integrating therapeutic communication, essential patient care skills, and clinical reasoning for novice nursing students prior to their entry into their first clinical practicum. This article discusses the rationale, development, and implementation of these formative capstone simulation scenarios. Anecdotal student and faculty comments related to the formative capstone simulation scenarios were positive. Formative capstone simulation scenarios offer a method to prepare novice students for initial clinical practicum that is well received. Research is needed to formally examine the relationship between formative capstone simulation scenarios and student anxiety related to initial clinical practicum. [J Nurs Educ. 2016;55(10):587-589.].

The sunset of ADAPT and the sunrise of continuous professional development at CPhA.

AFTER AN IMMENSELY SUCCESSFUL 6-YEAR RUN, ADAPT, our foundational and innovative patient care skills program designed to support pharmacists in patient assessment, documentation, collaboration and medication assessment, is coming to an end in 2017. While ADAPT may be winding down, the pioneering peer-to-peer continuous learning delivery model has raised the bar for future innovative course offerings.

Use of Web-Based Timelines to Enhance Patient Care Skills of Dietetics Students

Editor’s Note: This article is part of a series from the Nutrition and Dietetic Educators and Preceptors group on emerging topics of interest in dietetics education.Advances in communication technologies allow for parallel advances in knowledge acquisition. Familiarization with varied, cutting-edge active learning techniques, such as timelining, helps students in their future professions and educational endeavors. 1 Clesson K.M. Backchanneling, Communication Apprehension, and Student Engagement in Discussion-based High School Classes. Illinois State University, Normal, IL2011 Google Scholar , 2 Wankel C. Blessinger P. Cutting-Edge Technologies in Higher Education: Increasing Student Engagement and Retention Using Classroom Technologies: Classroom Response Systems and Mediated Discourse Technologies. Emerald Insight, Bingley, UK2013 Crossref Google Scholar Historically, timelines were paper documents with dates, descriptions, and pictures used to focus attention on specific ideas, experiences, and topics. An emerging timelining approach is web-based software that allows visual representation and graphic methods to be combined with time and text. 3 Sheridan J. Chamberlain K. Dupuis A. Timelining: Visualizing experience. Qual Res. 2011; 11: 552-569 Crossref Scopus (122) Google Scholar

Development of an interprofessional third-year (P3) student rotation in pediatric asthma clinics

BackgroundA pediatric asthma-focused Introductory Pharmacy Practice Experience (IPPE) was developed during which pharmacist-trained third-year (P3) pharmacy students provided asthma-focused patient education to patients and families at pediatric asthma clinics. To assess the impact of this novel experience, students’ perceptions regarding the experience and satisfaction of families receiving education were assessed. Basic proceduresStudents completed pre-rotation and post-rotation surveys to gather perspectives of the value of this learning experience, confidence working with an interprofessional team and providing patient education, and areas for improvement of the IPPE. Patient family members evaluated the impact of the student-led education via a survey measuring their perceived understanding of asthma, asthma medications, and proper device technique, as well as satisfaction. Main findingsIn total, 23 students participated in the IPPE over three semesters and completed pre-surveys and post-surveys (100% response rate). For survey items assessing confidence in patient care skills, there was statistically significant improvement from pre-IPPE to post-IPPE (p < 0.05). All students agreed or strongly agreed that the orientation prepared them for the IPPE and they recommend this experience to other students. In total, 81 patients were seen by the students in the first semester of the IPPE, and 45 patient families completed surveys (56% response rate). Overall, 95% of patient families would meet with the student again if given the opportunity. Principal conclusionsThis independent IPPE resulted in a positive experience for both students and patient families. Survey results showed improvement in student confidence after this unique rotation experience as well as patient family satisfaction with student-led asthma education.