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Objectives The use of theory in research is reflected in its presence in research writing. Theory is often an ineffective presence in medical education research papers. To progress the effective use of theory in medical education, we need to understand how theory is presented in research papers. This study aims to elicit how theory is being written into general practice (GP) vocational education research papers in order to elucidate how theory might be more effectively used. This has relevance for the field of GP and for medical education more broadly. Methods This is a scoping review of the presentation of theory in GP vocational education research published between 2013 and 2017. An interpretive approach is taken. We frame research papers as a form of narrative and draw on the theories of Aristotle's poetics and Campbell's monomyth. We seek parallels between the roles of theory in a research story and theories of characterisation. Results A total of 23 papers were selected. Theories of 'reflective learning', 'communities of practice' and 'adult learning' were most used. Six tasks were assigned to theory: to align with a position; to identify a research problem; to serve as a vehicle for an idea; to provide a methodological tool; to interpret findings, and to represent an object of examination. The prominence of theory in the papers ranged from cameo to major roles. Depending on the way theory was used and the audience, theory had different impacts. There were parallels between the tasks assigned to theory and the roles of four of Campbell's archetypal characters. Campbell's typology offers guidance on how theory can be used in research paper 'stories'. Conclusions Theory can be meaningfully present in the story of a research paper if it is assigned a role in a deliberate way and this is articulated. Attention to the character development of theory and its positioning in the research story is important.

In its mission to optimise the quality of patient care and the level of clinician training within the fields of biotherapy, the BioTherapeutics, Education and Research (BTER) Foundation and its Maggot Therapy Competency Committee identified qualities and achievements assessed to be the minimum standards that health care professionals should attain in order to be deemed competent in maggot therapy. The set of six standards were selected to reflect the same high degree of professionalism that is used by the Accreditation Council of Graduate Medical Education for assessing other medical specialists, but with an emphasis on the principles and practice of maggot therapy. For each domain in which competency is expected, the rationale has been explained, specific competencies have been articulated, and methods for demonstrating or evaluating those competencies have been suggested. Applicable to any clinician applying maggot dressings professionally, these recommendations should assist those who wish to identify, assess, or achieve competency in maggot therapy. Specifically, these six competencies include: (1) knowledge about wound care in general and maggot therapy in particular; (2) skill in general patient care, to a level commensurate with their professional role; (3) ability to communicate effectively with colleagues, patients, and the general public; (4) professional and ethical behaviour; (5) ability to deliver systems-based health care; (6) incorporation of continuing education and quality improvement into their practice.

IntroductionUnwarranted variation in patient care among physicians is associated with negative patient outcomes and increased healthcare costs. Care variation likely also exists for resident physicians. Despite the global movement towards outcomes-based and competency-based medical education, current assessment strategies in residency do not routinely incorporate clinical outcomes. The widespread use of electronic health records (EHRs) may enable the implementation of in-training assessments that incorporate clinical care and patient outcomes.Methods and analysisThe General Medicine Inpatient Initiative Medical Education Database (GEMINI MedED) is a retrospective cohort study of senior residents (postgraduate year 2/3) enrolled in the University of Toronto Internal Medicine (IM) programme between 1 April 2010 and 31 December 2020. This study focuses on senior IM residents and patients they admit overnight to four academic hospitals. Senior IM residents are responsible for overseeing all overnight admissions; thus, care processes and outcomes for these clinical encounters can be at least partially attributed to the care they provide. Call schedules from each hospital, which list the date, location and senior resident on-call, will be used to link senior residents to EHR data of patients admitted during their on-call shifts. Patient data will be derived from the GEMINI database, which contains administrative (eg, demographic and disposition) and clinical data (eg, laboratory and radiological investigation results) for patients admitted to IM at the four academic hospitals. Overall, this study will examine three domains of resident practice: (1) case-mix variation across residents, hospitals and academic year, (2) resident-sensitive quality measures (EHR-derived metrics that are partially attributable to resident care) and (3) variations in patient outcomes across residents and factors that contribute to such variation.Ethics and disseminationGEMINI MedED was approved by the University of Toronto Ethics Board (RIS#39339). Results from this study will be presented in academic conferences and peer-reviewed journals.

Short answer tests (SAT) are an assessment that examines nursing students' knowledge and can be used to evaluate expectations for student educational success. The purpose of this literature review is to combine the best available evidence as to whether short answer test papers meet nursing facility curricula learning outcomes. A literature review was performed consisting of data bases which included; ERIC, SCOPUS, CINAHL MEDLINE, COCHRANE LIBRARY and JOHANNA BIGGS INSTITUTE (JBI). The following keywords were used: Short answer test, written assessment, quiz, organisations, university, higher degree education, tertiary education, nursing, perceptions, attitude, opinions, thoughts, feeling and belief. The majority of studies demonstrated that short answer tests equip nursing students with the knowledge and critical thinking skills for the clinical setting. Three major themes were identified: the effects of increasing class sizes; authenticity and the validity of short answer tests. Short answer tests are commonly used in undergraduate nursing programs to evaluate students’ level of knowledge which consists of their ability to critically analyse and problem solve. To maintain authenticity and validity of an assessment, there is a need for an evidence-based approach to their design to meet the core learning objectives within the curriculum.

Purpose An important goal of medical education is to teach students to use an electronic health record (EHR) safely and effectively. The purpose of this study is to examine medical student accounts of EHR use during their core inpatient clinical clerkships using a national sample. Paper health records (PHRs) are similarly examined. Method An online survey about health record use within the inpatient component of six core clerkships was administered to medical students after they completed Step 2 Clinical Knowledge of the United States Medical Licensing Examination. The sample included 17,202 U.S. medical students graduating between 2012 and 2016. Mean percentages of clerkships in which students engaged in various health record activities were computed, and analysis of variance was used to examine differences. Results The mean percentages of clerkships in which a student accessed or entered information into an EHR increased from 78% to 93% and 59% to 72%, respectively. For students who used an EHR, the mean percentage of clerkships in which they entered information remained constant at 76%. Students entered notes during the majority of their clerkships, with increases over time. However, students entered orders in less than a quarter of their clerkships, with decreases over time. The percentage of clerkships in which students used PHRs was lower and declining. Conclusions Although students used an EHR in the majority of their inpatient core clerkships, they received limited educational experiences related to order and note writing, which could translate into a lack of preparedness for future training and practice.

In many European countries, paediatric junior staff has no formal training in adolescent medicine and is ill-equipped to deal with issues and health problems such as substance use, unprotected sex, eating disorders and transition to adult care. This position paper of the European Academy of Paediatrics proposes a set of competency-based training goals and objectives as well as pedagogic approaches that are expected to improve the capacity of paediatricians to meet the needs of this important segment of the paediatric population. The content has been developed from available publications and training programmes and mostly covers the generic aspects of adolescent healthcare, such as how to communicate effectively, how to review and address lifestyles, how to perform a respectful and relevant physical examination, how to address common problems of adolescents and how to support adolescents in coping with a chronic condition. Conclusion: The European Academy of Paediatrics urges national bodies, paediatric associations and paediatric teaching departments to adopt these training objectives and put them into practice, so that paediatricians will be better prepared in the future to meet the challenge of delivering appropriate and effective healthcare to adolescents.

The Quality and Safety Education for Nurses (QSEN) Institute RN-BSN Task Force presents a white paper on Recommendation for a Systems-based Practice Competency. The task force proposes a seventh QSEN competency, systems-based practice, to improve patient quality and safety. Recommendations to integrate systems-based practice into both education and practice settings, consistent with job descriptions and promotion criteria, involve a comprehensive continuing education program for nurses upon interview, orientation, residency programming, performance evaluation, and license renewal.

Background Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care. Objectives 1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies. Selection criteria We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions. Data collection and analysis Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach. Main results We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects. Authors' conclusions Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.

Background and purpose To evaluate an electronic counseling rubric to facilitate timely student feedback and explore differences in student performance, student anxiety, and self-perceived preparedness in a high stakes practical exam when using a paper rubric versus an electronic rubric. Educational activity and setting Two cohorts of students in the third professional year were evaluated using the same rubric criteria: cohort 1 (n = 97) used traditional paper rubrics and cohort 2 (n = 104) used electronic rubrics. Cohorts were surveyed to measure anxiety and perceived preparedness in patient counseling skills one week prior to a practical exam, and cohort responses were compared. Student practical exam performance was also compared between the two cohorts. Findings Results showed no significant relationship between electronic rubric use and student anxiety (p = 0.07) or student exam performance [average score 53.42 points (SD 3.65) and 53.93 points (SD 3.78) in Cohort 1 and Cohort 2, respectively]. Perceived exam preparedness was higher among students using electronic rubrics, with timing of feedback being the mediating process in increasing preparedness (p Discussion and summary Electronic rubrics resulted in more timely feedback on patient counseling skills, and students felt more prepared for their practical exam. This did not result in a significant difference in practical exam performance between the two cohorts. Additional methods to incorporate electronic rubrics into the course will be explored.

Aim A discussion of key considerations related to selecting instruments and tools for evaluating healthcare professionals' evidence-based practice (EBP) competencies. Design A discussion paper. Data sources Articles published in international peer-reviewed journals from January 2000 - November 2017 on validated instruments for assessing healthcare professionals' performance-based EBP competencies. Implications for nursing Validated EBP competency instruments based on actual performance to evaluate the EBP competencies of healthcare professionals are currently available in the field of medicine. Although some of these instruments have already been adapted for use in physical and occupational therapy, their modification for use in nursing has begun only in the last few months. Conclusion A concerted effort on modifying and validating objective measures of actual performance for use in nursing should be commenced to evaluate directly measurable EBP competencies, instead of continuing to rely on nurses' self-assessments. Future studies focusing on development and validation of objective instruments to evaluate EBP competencies based on actual performance and exploring the modification of currently available objective instruments from medicine are urgently needed in nursing. Impact Instead of measuring actual EBP competencies, the majority of competency evaluations in nursing are still being conducted via self-assessments, despite growing evidence of their poor accuracy in evaluating directly measurable constructs such as evidence-based practice knowledge and skills. Accurate measurement of nurses' EBP competencies is essential to increasing systematic implementation of EBP in healthcare organizations, thus promoting the attainment of improved care quality and patient outcomes in healthcare delivery.

Clinical reasoning competency is essential for an appropriate clinical dental treatment. Among the tools for the assessment of clinical reasoning competency, computer-based testing (CBT) is considered more useful than paper-based testing (PBT), because teachers can control the timing of information given to the examinees. Such timings could possibly affect the thinking process of examinees. However, few studies reported differences of reasoning between the two testing modes. In the present study, we developed an assessment of clinical reasoning and applied it using CBT and PBT to compare the examinees' performance. The participants comprised 60 students in the fifth-year class in 2012 of the School of Dentistry, Faculty of Dentistry, Tokyo Medical and Dental University. The tests comprised 25 problems, each with four questions, totaling 100 questions. The contents of the questions were the same in CBT and PBT. The students were assigned to CBT (Group C, n = 30) and PBT (Group P, n = 30) groups, with an almost equal gender ratio in the groups. The difference between scores was analyzed with a univariate analysis of variance. No significant intergroup differences were found regarding the test duration, total score, and average score of each question. The number of problems with perfect marks was higher in Group P than in Group C (P0.05), probably because Group P students could access the information of the previous question (s) within a problem. Thus, the differences of the examinees' performance between the two testing modes were small.

The use of continuous intravenous regular human insulin (RHI) infusion is often necessary to achieve glycemic control in critically ill patients. Because insulin is a high-risk medication owing to the potential for severe hypoglycemia, it is imperative that insulin infusion algorithms are designed to be safe, effective, and instructionally clear. The safety and efficacy of our intravenous RHI infusion algorithm protocol has been previously established (Nutrition 2008;24:536-45); however, the protocol violations by nursing personnel were not examined. The objective of this study was to assess nursing adherence to our RHI infusion algorithm.Continuous RHI infusion algorithm violations were retrospectively evaluated in adult patients admitted to a trauma intensive care unit who received concurrent continuous enteral and/or parenteral nutrition therapy and our algorithm for at least 3 d. Blood glucose (BG) monitoring was done every 1 to 2 h with the target BG at 70 to 149 mg/dL (3.9 to 8.3 mmol/L). Nursing adherence to the RHI infusion protocol was evaluated for each patient by comparing the adjustments in insulin infusion rates documented by the nursing personnel with the prescribed adjustments per our graduated continuous intravenous RHI infusion algorithm.A total of 4150 BG measurements necessitating the determination of the appropriate RHI dosage rate by nursing personnel in 40 patients occurred during the observational period. The target BG was achieved for a mean of 20 h/d and none of the patients had an episode of severe hypoglycemia (BG40 mg/dL or 2.2 mmol/L). The overall rate of algorithm violations was 12.1%. The algorithm violations accounted for a single episode of mild to moderate hypoglycemia (BG 40 to 60 mg/dL or 2.2 to 3.3 mmol/L) in 4 patients and 65 total episodes of hyperglycemia (BG ≥150 mg/dL or 8.3 mmol/L) in 18 patients.An adherence rate of nearly 90% is indicative of excellent nursing adherence compared with other published paper-based algorithms that examined protocol adherence. These data, combined with our previously published glycemic control data, indicate that this RHI infusion algorithm is an effective one for hyperglycemic trauma patients receiving continuous enteral and/or parenteral nutritional therapy.

Radial access use has been growing steadily but, despite encourag- ing results, still varies greatly among operators, hospitals, countries and continents. Twenty years from its introduction, it was felt that the time had come to develop a common evidence-based view on the technical, clinical and organisational implications of using the radial approach for coronary angiography and interventions. The European Association of Percutaneous Cardiovascular Interven- tions (EAPCI) has, therefore, appointed a core group of European and non-European experts, including pioneers of radial angioplasty and operators with different practices in vascular access supported by experts nominated by the Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology (ESC). Their goal was to define the role of the radial approach in modern interventional practice and give advice on technique, training needs, and optimal clinical indications.

Gastrointestinal ultrasound (GIUS) is an ultrasound application that has been practiced for more than 30 years. Recently, GIUS has enjoyed a resurgence of interest, and there is now strong evidence of its utility and accuracy as a diagnostic tool for multiple indications. The method of learning GIUS is not standardised and may incorporate mentorship, didactic teaching and e-learning. Simulation, using either low- or high-fidelity models, can also play a key role in practicing and honing novice GIUS skills. A course for training as well as establishing and evaluating competency in GIUS is proposed in the manuscript, based on established learning theory practice. We describe the broad utility of GIUS in clinical medicine, including a review of the literature and existing meta-analyses. Further, the manuscript calls for agreement on international standards regarding education, training and indications.

There is the need for well-trained advanced GI surgeons. The super specialization seen in academic and large community centers may not be applicable for surgeons practicing in other settings. The pendulum that has been swinging toward narrow specialization is swinging the other way, as many trained subspecialists are having a harder time finding positions after fellowship, and if they do find a position, the majority of their practice can actually be advanced GI surgery and not exclusively their area of focused expertise. Many hospitals/practices desire surgeons who are competent and specifically credentialed to perform a variety of advanced GI procedures from the esophagus through the anus. Furthermore, broader exposure in training may provide complementary and overlapping skills that may lead to an even better trained GI surgeon compared to someone whose experience is limited to just the liver and pancreas, or to just the colon and rectum, or to only bariatric and foregut surgery. With work hour restrictions and limitations on autonomy for current trainees in residency, many senior trainees have not developed the skills and knowledge to allow them to be competent and comfortable in the broad range of GI surgery. Such training should reflect the needs of the patients and their diseases, and reflect what many practicing surgeons are currently doing, and what many trainees say they would like to do, if there were such fellowship pathways available to them. The goal is to train advanced GI surgeons who are competent and proficient to operate throughout the GI tract and abdomen with open, laparoscopic, and endoscopic techniques in acute and elective situations in a broad variety of complex GI diseases. The program may be standalone, or prepare a surgeon for additional subspecialty training (transition to fellowship and/or to practice). This group of surgeons should be distinguished from subspecialist surgeons who focus in a narrow area of GI surgery. Advanced GI surgery training could occupy the area between general surgery residency and further subspecialty training as seen in the graph below. Visually, we are trying to define the red hash mark area. This is challenging as the inner border with core general surgery is ill defined and interpreted differently by various stakeholders. Similarly, the outer border of the red hash marks, which defines areas that require a surgical subspecialist, is also not clear. Inevitably, overlap exists in the care of these patients and is influenced by the complexity of the underlying disease presentations. The concept is noble, but the future is unclear. Challenges and uncertainties include whether the Certificate of Focused Expertise will go forward, and what the RRC and ABS might decide on the structure of General Surgery training. Funding and the ability to offer autonomy during training are additional challenges in today’s training environment. Currently, the ABS is considering a “Core Plus” concept, though what is “the Core” and what is the “Plus” are not yet determined, and these concepts have been promoted for years. Whether training becomes 4 +1, or 4 +1+1, 5+1 or some other model continues to be discussed. We, the Task Force of Advanced GI Surgery Training, have drafted a vision of what advanced GI training could/should look like to help guide the ABMS/ABS/RRC/ACGME as they contemplate surgery residency redesign goals. Despite the uncertainty, we will develop the curriculum, milestones, and case requirements for advanced GI surgery training, to not only provide this vision but so that an advanced GI training program is ready to go, to be plugged in to whatever the future structure for surgical training may be. Open image in new window

Item does not contain fulltext Sports cardiology is a new and rapidly evolving subspecialty. It aims to elucidate the cardiovascular effects of regular exercise and delineate its benefits and risks, so that safe guidance can be provided to all individuals engaging in sports and/or physical activity in order to attain the maximum potential benefit at the lowest possible risk. The European Society of Cardiology (ESC) advocates systematic preparticipation cardiovascular screening in an effort to identify competitive athletes at risk of exercise-related cardiovascular events and sudden cardiac death. However, the implementation of preparticipation screening is hindered because of lack of structured training and as a result lack of sufficient expertise in the field of sports cardiology. In 2008 the European Society of Cardiology published a core curriculum for the general cardiologist, in which sports cardiology was incorporated within the topic 'Rehabilitation and Exercise Physiology'. However, the exponential rise in knowledge and the growing demand for expertise in the field of sports cardiology dictates the need to systematically structure the knowledge base of sports cardiology into a detailed curriculum. We envisage that the curriculum would facilitate more uniform training and guideline implementation throughout Europe, and safeguard that evaluation and guidance of competitive athletes or individuals who wish to engage in leisure-time sports activities is performed by physicians with expertise in the field. The current manuscript provides a comprehensive curriculum for sports cardiology, which may serve as a framework upon which universities and national and international health authorities will develop the training, evaluation and accreditation in sports cardiology.

The ACR's RADPEER program began in 2002; the electronic version, e-RADPEER, was offered in 2005. To date, more than 10,000 radiologists and more than 800 groups are participating in the program. Since the inception of RADPEER, there have been continuing discussions regarding a number of issues, including the scoring system, the subspecialty-specific subcategorization of data collected for each imaging modality, and the validation of interfacility scoring consistency. This white paper reviews the task force discussions, the literature review, and the new recommended scoring process and lexicon for RADPEER.

Introduction: The aim of this systematic review was to compare the effectiveness of electronic recording with paper-based recording of clinical skills assessments for entry-level health professional students. Methods: A comprehensive database search was undertaken using AMED, CINAHL, CENTRAL, EMBASE, Medline, PsycINFO, Scopus, and Web of Science on 12–16 June 2017, and updated 9 April 2018. Studies investigating electronic and paper-based recordings of clinical skills assessments of students in entry-level health professional programs were eligible for inclusion. Two independent researchers completed screening of studies for inclusion, quality assessments, and data extraction, with discrepancies resolved by consensus. Quality assessment was performed using the Critical Appraisal Skills Program Diagnostic checklist. Results: From 2264 studies identified, five observational cohort studies were included. Published between 2006 and 2016, included studies investigated electronic and paper examinations of clinical skills assessments of students from medical, dentistry, and physical therapy programs. Electronic assessments were reported to be more time efficient than paper-based assessments with an added advantage of no missing data. Quality and quantity of quantitative and qualitative student feedback increased with electronic assessment compared to paper-based assessments. Conclusions: Electronic assessments were used successfully across a range of health professional programs, take significantly less time to complete and provide higher quality feedback to students. Future studies are needed with more robust psychometric testing and cost-effective analysis to inform the increasing uptake of electronic assessment tools in health professional training.

In this position paper, the American College of Physicians examines the health disparities experienced by the lesbian, gay, bisexual, and transgender (LGBT) community and makes a series of recommendations to achieve equity for LGBT individuals in the health care system. These recommendations include enhancing physician understanding of how to provide culturally and clinically competent care for LGBT individuals, addressing environmental and social factors that can affect their mental and physical well-being, and supporting further research into understanding their unique health needs.

Aims A discussion of an optimal set of indicators that can be used on a priority basis to assess the performance of nursing care. Background Recent advances in conceptualization of nursing care performance, exemplified by the Nursing Care Performance Framework, have revealed a broad universe of potentially nursing-sensitive indicators. Organizations now face the challenge of selecting, from this universe, a realistic subset of indicators that can form a balanced and common scorecard. Design Discussion paper drawing on a systematic assessment of selected performance indicators. Data sources Previous works, based on systematic reviews of the literature published between 1990 - 2014, have contributed to the development of the Nursing Care Performance Framework. These works confirmed a robust set of indicators that capture the universe of content currently supported by the scientific literature and cover all major areas of nursing care performance. Building on these previous works, this study consisted in gathering the specific evidence supporting 25 selected indicators, focusing on systematic syntheses, meta-analyses and integrative reviews. Implications for nursing This study has identified a set of 12 indicators that have sufficient breadth and depth to capture the whole spectrum of nursing care and that could be implemented on a priority basis. Conclusions This study sets the stage for new initiatives aiming at filling current gaps in operationalization of nursing care performance. The next milestone is to set up the infrastructure required to collect data on these indicators and make effective use of them.

In search for the Holy Grail: Suggestions for studies to define delta changes to diagnose or exclude acute myocardial infarction : a position paper from the study group on biomarkers of the Acute Cardiovascular Care Association

Objective: To determine the level of agreement of disease flare severity (distinguishing severe, moderate, and mild flare and persistent disease activity) in a large paper-patient exercise involving 988 individual cases of systemic lupus erythematosus. Methods: A total of 988 individual lupus case histories were assessed by 3 individual physicians. Complete agreement about the degree of flare (or persistent disease activity) was obtained in 451 cases (46%), and these provided the reference standard for the second part of the study. This component used 3 flare activity instruments (the British Isles Lupus Assessment Group [BILAG] 2004, Safety of Estrogens in Lupus Erythematosus National Assessment [SELENA] flare index [SFI] and the revised SELENA flare index [rSFI]). The 451 patient case histories were distributed to 18 pairs of physicians, carefully randomized in a manner designed to ensure a fair case mix and equal distribution of flare according to severity. Results: The 3-physician assessment of flare matched the level of flare using the 3 indices, with 67% for BILAG 2004, 72% for SFI, and 70% for rSFI. The corresponding weighted kappa coefficients for each instrument were 0.82, 0.59, and 0.74, respectively. We undertook a detailed analysis of the discrepant cases and several factors emerged, including a tendency to score moderate flares as severe and persistent activity as flare, especially when the SFI and rSFI instruments were used. Overscoring was also driven by scoring treatment change as flare, even if there were no new or worsening clinical features. Conclusion: Given the complexity of assessing lupus flare, we were encouraged by the overall results reported. However, the problem of capturing lupus flare accurately is not completely solved.

Article-at-a-Glance Background There is limited conformity among patient safety and quality improvement (QI) competencies of the knowledge, skills, and attitudes (KSA), by stage of skill acquisition, essential for all health professionals. A study was conducted to identify, categorize, critically appraise, and discuss implications of competency recommendations published in influential position papers. Methods A literature search was conducted of competency recommendations in position papers published by national and international professional associations, expert panels, consortia, centers and institutes, and convened committees, in the domain of patient safety and QI. To be included in the analysis, the competency had to be recommended in at least 20% (rounded) of the position papers. Qualitative content analysis was used to identify themes among the published competencies for the skill acquisition levels of competent and expert, using Dreyfus's definitions. Results On the basis of the 22 papers that met the inclusion criteria, 17 themes were identified among the 59 competencies for the skill level competent. Among the 23 competencies for the skill level expert, 13 themes were identified. Competencies within the theme "Evidence-Based Practice" were most frequently recommended across both skill levels. The themes "Interdisciplinary Teamwork and Collaboration" and "Evidence-Based Practice" were the themes identified among the greatest number of position papers for the skill level competent and expert, respectively. Conclusions The identified themes for competencies in patient safety and QI have implications for curriculum development and assessment of competence in education and practice. The findings in this study demonstrate a need to discourage publication of recommendations of yet more competencies and to instead encourage development of an international consensus on the essential KSA for patient safety and QI across all health professions and all levels of skill acquisition.