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Metacognition, the ability to self-regulate one's learning and performance, has been shown to improve student outcomes. Anatomy is recognized as one of the toughest courses in allied health curricula, and students could benefit from metacognitive activities. The purpose of this study was to explore the changes in metacognition of allied health students in an anatomy course and identify which groups need support with this skill. First-year physician assistant (MPAS), physical therapy (DPT), and occupational therapy (OTD) students (n = 129) were invited to participate. At the beginning and end of the course, students completed a questionnaire including the metacognitive awareness inventory (MAI) that assesses metacognition. Students were also asked to reflect on their examination performances using a modified Likert scale and participated in reflective discussion boards to encourage development of metacognitive skills, which were thematically analyzed. Paired metacognition scores had increased significantly by the end of the course. However, middle-performers anticipated high grades and were less satisfied with their grade, indicating a disconnect in their metacognition compared to high- and low-performers. Students' receptiveness to modifying study strategies to improve performance declined throughout the course; by mid-way through, they relied more on existing strategies. Increasing time constraints were frequently cited as a major factor when considering study strategies and modification of such strategies. To maximize the effectiveness of metacognitive activities, they should be positioned early in the course when students are most receptive. In addition, middle performers may benefit from additional support to improve metacognition.

Rationale: Patients managed at a long-term acute-care hospital (LTACH) for weaning from prolonged mechanical ventilation are at risk for profound muscle weakness and disability. Objectives: To investigate effects of prolonged ventilation on survival, muscle function, and its impact on quality of life at 6 and 12 months after LTACH discharge. Methods: This was a prospective, longitudinal study conducted in 315 patients being weaned from prolonged ventilation at an LTACH. Measurements and Main Results: At discharge, 53.7% of patients were detached from the ventilator and 1-year survival was 66.9%. On enrollment, maximum inspiratory pressure (Pi(max)) was 41.3 (95% confidence interval, 39.4–43.2) cm H(2)O (53.1% predicted), whereas handgrip strength was 16.4 (95% confidence interval, 14.4–18.7) kPa (21.5% predicted). At discharge, Pi(max) did not change, whereas handgrip strength increased by 34.8% (P

It is important to have a variety of local anesthetic techniques available to the cosmetic surgeon in order to provide comfortable and safe cosmetic surgical procedures. This is especially important when performing surgery on the awake or mildly sedated patient. This chapter will cover the anesthetic techniques and the important regional anatomy for intraoral local anesthesia in the maxilla.

While the terms “self-regulated learning” (SRL) and “self-directed learning” (SDL) are commonly used in medical education, they are often used incorrectly. This paper aims to clarify these terms by describing their origins and the implementation of these constructs in medical education as well as explaining their connections to other terms in learning theories such as self-evaluation, self-assessment, metacognition, and lifelong learning. The iterative cycles of SDL and SRL that are important to the learning process will also be illustrated, as a common understanding of SDL and SRL is necessary to guide the development of educational programs and interventions.

Medical students learn about death, dying, and palliative care (DDPC) through formal curricular offerings and informal clinical experiences; however, the lessons learned in the clinic may be at odds with the formal curriculum. Reflective writing is a means for students to "bracket" their DDPC experiences and reconcile conflicts between the formal and informal curriculum.The aim of this study is to compare the level of reflection demonstrated in medical students' narratives on DDPC with other experiences and to examine the domains of professionalism that students perceive to be prevalent in their DDPC experiences.Third-year medical students submitted professionalism narratives during their internal medicine clerkship. We identified a subset of narratives related to DDPC (n = 388) and randomly selected control narratives (n = 153). We assessed the level of reflection demonstrated in the narratives using a validated rubric and analyzed the professionalism domains that students identified as relevant to their experience.There was no difference in reflective level between DDPC and control narratives. Within the DDPC group, female students demonstrated higher reflection (2.24 ± 0.71) than male students (2.01 ± 0.77; P.001). Caring, compassion and communication, and honor and integrity were prominent among DDPC narratives. More females identified caring, compassion, and communication as relevant to their DDPC experiences, whereas more males identified altruism.Males and females have different perceptions of DDPC experiences, and female students appear to be more deeply impacted. These findings can help clinical faculty engage students more effectively with this challenging topic.

Acute care nurse practitioners (ACNPs) are increasingly being employed as members of critical care teams, an outcome driven by increasing demand for intensive care services, a mandated reduction in house officer hours, and evidence supporting the ability of ACNPs to provide high-quality care as collaborative members of critical care teams. Integration of adult ACNPs into critical care teams is most likely to be successful when practitioners have appropriate training, supervision, and mentoring to facilitate their ability to practice efficiently and effectively. Accomplishing this goal requires understanding the educational preparation and skill set potential hires bring to the position as well as the development of an orientation program designed to integrate the practitioner into the critical care team. Pediatric ACNPs are also commonly employed in critical care settings; however, this commentary focuses on the adult ACNP role.

Peer and self-assessments are widely used to assess professionalism during medical school as part of a multisource feedback model. The purpose of this study was to examine the associations between peer and self-assessments and professionalism lapses at a large medical school. A retrospective case–control study design was used to compare peer and self-assessment scores from Years 1 to 3 of medical school for students who had been cited for professionalism lapses during medical school (case group; n = 78) with those of a randomly selected control group ( n = 230). Students in the case group had significantly lower peer assessment scores than students in the control group during all 3 years. Year 3 peer assessment scores showed the greatest difference (cases = 7.81 ± 0.65, controls = 8.22 ± 0.34, p < .01). Students with lower peer assessment scores were also significantly more likely to have been cited for a professionalism lapse (odds ratio = 6.25, 95% CI [3.13, 11.11], p < .01). This study reinforces the value of peer assessments of professionalism, which may be useful to help identify students who may be at risk for professionalism lapses during medical school.

Palliative care has been recommended as a means to assist patients with idiopathic pulmonary fibrosis (IPF) in managing symptom burden and advanced care planning. Timing of referral is important because although most patients display a gradually progressive course, a minority experience acute deterioration, an outcome associated with high mortality.To describe characteristics of IPF patients referred to a specialty lung disease center over a 10-year period who experienced acute deterioration and subsequent intensive care unit (ICU) admission, including frequency and timing of referral to palliative care.Retrospective review.We identified 106 patients admitted to the ICU with acute deterioration due to a respiratory or nonrespiratory cause. Variables examined included demographics, date of first center visit, forced vital capacity, diffusing capacity of the lung for carbon monoxide (DLCO), and palliative care referral.ICU admission occurred early (median 9.5 months) and, for 34%, within four months of their first center visit. For nearly one-half of these patients, ICU admission occurred before their third clinic visit. Only 4 (3.8%) patients received a palliative care referral before ICU admission. The majority (77%) died during ICU admission. With exception of the relationship between DLCO% predicted at first visit and time to ICU admission (r = 0.32, p = 0.005), no variables identified those most likely to experience acute deterioration.Due to high mortality associated with ICU admission, patients and families should be informed about palliative care early following diagnosis of IPF.

BACKGROUND: Hospitalized patients who develop at least one instance of cardiorespiratory instability (CRI) have poorer outcomes. We sought to describe the admission characteristics, drivers, and time to onset of initial CRI events in monitored step-down unit (SDU) patients. METHODS: Admission characteristics and continuous monitoring data (frequency 1/20 Hz) were recorded in 307 subjects. Vital sign deviations beyond local instability trigger threshold criteria, with a tolerance of 40 s and cumulative duration of 4 of 5 min, were classified as CRI events. The CRI driver was defined as the first vital sign to cross a threshold and meet persistence criteria. Time to onset of initial CRI was the number of days from SDU admission to initial CRI, and duration was length of the initial CRI epoch. RESULTS: Subjects transferred to the SDU from units with higher monitoring capability were more likely to develop CRI (CRI n = 133 [44%] vs no CRI n = 174 [31%] P = .042). Time to onset varied according to the CRI driver. Subjects with at least one CRI event had a longer hospital stay (CRI 11.3 ± 10.2 d vs no CRI 7.8 ± 9.2 d, P < .001) and SDU stay (CRI 6.1 ± 4.9 d vs no CRI 3.5 ± 2.9 d, P < .001). First events were more often due to S(pO(2)), whereas breathing frequency was the most common driver of all CRI. CONCLUSIONS: Initial CRI most commonly occurred due to S(pO(2)) and was associated with prolonged SDU and hospital stay. Findings suggest the need for clinicians to more closely monitor SDU patients transferred from an ICU and parameters (S(pO(2)), breathing frequency) that more commonly precede CRI events.

Phenomenon: Given the growing number of medical science educators, an examination of institutions' promotion criteria related to educational excellence and scholarship is timely. This study investigates the extent to which medical schools' promotion criteria align with published standards for documenting and evaluating educational activities. Approach: This document analysis systematically analyzed promotion and tenure (PT 52 of 120) documented a well-defined education-related pathway for advancement in academic rank. Across five education-specific domains, only 24% (12 of 50) of the investigated criteria were referenced by at least half of the schools. The least represented domain within P&T documents was "Educational Measurement and Evaluation." P&T documents for 47% of schools were rated as "below average" or "very vague" in their clarity/specificity. Insights: Less than 10% of U.S. medical schools have thoroughly embraced published recommendations for documenting and evaluating educational excellence. This raises concern for medical educators who may be evaluated for promotion based on vague or incomplete promotion criteria. With greater awareness of how educational excellence is currently documented and how promotion criteria can be improved, education-focused faculty can better recognize gaps in their own documentation practices, and more schools may be encouraged to embrace change and align with published recommendations.

Introduction: Graduate medical education depends on senior residents to facilitate peer education. Previous studies have described the benefits of resident-as-teacher (RaT) curricula; however, means of assessing these interventions have proven difficult. The purpose of this study was to provide meaningful evaluation of a novel RaT curriculum and scribing activity. Methods: Didactic sessions on teaching skills were presented in July, 2017. First- and third-year residents then alternated scribing for each other for 4 weeks within the outpatient clinic to allow for near-peer educational exchange. Residents’ attitudes toward teaching and perceptions of teaching abilities were assessed using pre- and postintervention surveys. Independent reviewers reviewed charts completed by PGY-1 residents during the scribing activity, and compared them to charts from the previous academic year. Results: All first-year (n=12; 100%) and third-year (n=10; 100%) residents participated in the study. After participating in the RaT curriculum, residents were more comfortable giving feedback to other residents and felt better prepared to teach and assess the effectiveness of their teaching. Although there was no significant difference in ratings between the 2016 and 2017 charts, reviewers noted that the 2017 charts contained fewer obvious omissions, and third-year residents felt the charts were completed in a timelier manner. First-year residents saw 16% more patients in 2017 than they had in 2016, which expedited integration into the clinic. Conclusion: This innovative RaT curriculum with scribing activity improved residents’ teaching and communication skills and provided first-year residents with a more efficient and meaningful orientation into the outpatient clinic.

Summary Objective To describe changes in sleep quality in family caregivers of ICU survivors from the patients’ ICU admission until two months post-ICU discharge. Design Descriptive repeated measure design. Setting Academic hospital medical ICU. Main outcome measures Subjective sleep quality (Pittsburgh Sleep Quality Index [PSQI]) and objective sleep/wake variables (SenseWear Armband™) were measured in family caregivers at patients’ ICU admission, within two weeks post-ICU discharge and two months post-ICU discharge. Results In 28 family caregivers of ICU survivors, most caregivers reported poor sleep quality (i.e. PSQI >5) across the three time points (64.3% during patients’ ICU admission, 53.6% at each post-ICU time point). Worse trends in sleep quality and objective sleep/wake pattern were observed in caregivers who were employed, and a non-spouse. There were trends of worsening sleep quality in caregivers of patients unable to return home within two months post-ICU discharge compared to patients able to return home. Conclusions Poor sleep quality was highly prevalent and persisted in family caregivers of ICU survivors for two months post-ICU discharge. Our data support the need for a larger longitudinal study to examine risk factors associated with sleep quality in family caregivers of ICU survivors to develop targeted interventions.

Background The association between intensive care unit (ICU) survivors' psychological sequelae, individual care needs, and discharge disposition has not been evaluated. Objective To describe depressive symptoms and anxiety in ICU survivors and explore these symptoms based on individual care needs and discharge disposition for 4 months post-ICU discharge. Methods We analyzed data from 39 ICU survivors who self-reported measures of depressive symptoms (Center for Epidemiologic Studies-Depression 10 items [CESD-10]) and anxiety (Shortened Profile of Mood States-Anxiety subscale [POMS-A]). Results A majority of patients reported CESD-10 scores above the cut off (≥ 8) indicating risk for clinical depression. POMS-A scores were highest within 2 weeks post-ICU discharge and decreased subsequently. Data trends suggest worse depressive symptoms and anxiety when patients had moderate to high care needs and/or were unable to return home. Conclusion ICU survivors who need caregiver assistance and extended institutional care reported trends of worse depressive symptoms and anxiety.

Barriers to following dietary recommendations have been described; however, they remain poorly understood. The purpose of this qualitative study was to explore perceived barriers to adherence to dietary recommendations in a diverse hemodialysis patient population. Participants were eligible to participate in a semi-structured qualitative telephone interview prior to randomization for an ongoing clinical trial to evaluate the efficacy of an intervention designed to reduce dietary sodium intake. Interviews were digitally recorded, transcribed verbatim and coded using an iterative qualitative process. In total, 30 (37% females, 53% Caucasians) participants, 63.2 ± 13.3 years, were interviewed. Time, convenience, and financial constraints hindered dietary adherence. Dietary counseling efforts were rated positively but require individualization. Ability to follow recommended guidelines was challenging. Suggestions for addressing barriers include technology-based interventions that allow patients to improve food choices and real-time decision-making, and permit tailoring to individual barriers and preferences.

The purpose of this study was to calculate the event rate for in-patients in the Radiology Department (RD) developing instability leading to calls for Medical Emergency Team assistance (MET-RD) compared to general ward (MET-W) patients. A retrospective comparison was done of MET-RD and MET-W calls in 2009 in a U.S. tertiary hospital with a well-established MET system. MET-RD and MET-W event rates represented as MET calls/hour/1000 admissions, adjusted for length of stay (LOS); rates also calculated for RD modalities. There were 31,320 hospital ward admissions had 1,230 MET-W, and among 149,569 radiology admissions there were 56 MET-RD. When adjusted for LOS, the MET-RD event rate was 2 times higher than the MET-W rate (0.48 vs. 0.24 events/hour/1000 admissions). Event rates differed by procedure: computed tomography (CT) had 38% of MET-RDs (event rate 0.89); magnetic resonance imaging (MRI) accounted for 27% (event rate 1.56). Nuclear medicine had 1% of RD admissions but these patients accounted for 5% of MET-RD (event rate 1.53). Interventional radiology (IR) had 6% of RD admissions but 16% of MET-RD (event rate 0.61). While general x-ray comprised 63% of RD admissions, only 11% of MET-RD involved their care (event rate 0.09). In conclusion, the overall MET-RD event rate was twice the MET-W event rate; CT, MRI and IR rates were 3.7-6.5 times higher than on wards. RD patients are at increased risk for a MET call compared to ward patients when the time at risk is considered. Increased surveillance of RD patients is warranted.

BACKGROUND Palliative care, integrated early, may reduce symptom burden in patients with idiopathic pulmonary fibrosis (IPF). However, limited information exists on timing and clinical practice. The purpose of this study was to describe the time course of events prior to death in patients with IPF managed at a specialty center with a focus on location of death and timing of referral for palliative care. METHODS Data were retrospectively extracted from the health system's data repository and obituary listings. The sample included all decedents, excluding lung transplant recipients, who had their first visit to the center between 2000 and 2012. RESULTS Median survival for 404 decedents was 3 years from diagnosis and 1 year from first center visit. Of 277 decedents whose location of death could be determined, > 50% died in the hospital (57%). Only 38 (13.7%) had a formal palliative care referral and the majority (71%) was referred within 1 month of their death. Decedents who died in the academic medical center ICU were significantly younger than those who died in a community hospital ward (P = .04) or hospice (P = .001). CONCLUSIONS The majority of patients with IPF died in a hospital setting and only a minority received a formal palliative care referral. Referral to palliative care occurred late in the disease. These findings indicate the need to study adequacy of end-of-life management in IPF and promote earlier discussion and referral to palliative care.

This pilot study evaluated effects of a video-guided T'ai Chi group intervention on center of balance (COB) and falls efficacy, using a one arm, pre/post design. Thirty-two participants began the study, 17 completed pre- and post-testing and 15 were lost to follow-up. Outcomes were compared for the 17 participants who completed pre- and post-testing and subgroups based on session attendance. Irrespective of session attendance, participant COB scores improved. There was a significant negative correlation between number of sessions attended and pre and post scores on the fall efficacy (fear of falling) measure, indicating those with higher fear of falling were less likely to complete the study. Older participants were also less likely to continue participation. Findings indicate potential benefits of T'ai Chi in improving COB (a fall risk factor) among community-dwelling older adults. However, those with greater potential benefit (higher fear scores, older participants) were less likely to continue participation.

This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Southern Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of 4 experts who shared their thoughts stimulated by the study. These thoughts explore the value of the Observed Structured Teaching Encounter in providing structured opportunities for medical students to engage with the complexities of providing peer feedback on professionalism.

Background Few studies have longitudinally explored the experience and needs of family caregivers of ICU survivors after patients' home discharge. Methods Qualitative content analysis of interviews drawn from a parent study that followed family caregivers of adults ICU survivors for 4 months post-ICU discharge. Results Family caregivers (n = 20, all white, 80% woman) viewed home discharge as positive progress, but reported having insufficient time to transition from family visitor to the active caregiver role. Caregivers expressed feelings of relief during the steady recovery of family members' physical and cognitive function. However, the slow pace of improvement conflicted with their expectations. Even after patients achieved independent physical function, emotional needs persisted and these issues contributed to caregivers' anxiety, worry, and view that recovery was incomplete. Conclusion Family caregivers of ICU survivors need information and skills to help managing patients' care needs, pacing expectations with actual patients' progress, and caregivers' health needs.

Cardiorespiratory instability (CRI) in monitored step-down unit (SDU) patients has a variety of etiologies, and likely manifests in patterns of vital signs (VS) changes. We explored use of clustering techniques to identify patterns in the initial CRI epoch (CRI1; first exceedances of VS beyond stability thresholds after SDU admission) of unstable patients, and inter-cluster differences in admission characteristics and outcomes. Continuous noninvasive monitoring of heart rate (HR), respiratory rate (RR), and pulse oximetry (SpO2) were sampled at 1/20 Hz. We identified CRI1 in 165 patients, employed hierarchical and k-means clustering, tested several clustering solutions, used 10-fold cross validation to establish the best solution and assessed inter-cluster differences in admission characteristics and outcomes. Three clusters (C) were derived: C1) normal/high HR and RR, normal SpO2 (n = 30); C2) normal HR and RR, low SpO2 (n = 103); and C3) low/normal HR, low RR and normal SpO2 (n = 32). Clusters were significantly different based on age (p

The use of quick response (QR) codes within undergraduate university courses is on the rise, yet literature concerning their use in medical education is scant. This study examined student perceptions on the usefulness of QR codes as learning aids in a medical gross anatomy course, statistically analyzed whether this learning aid impacted student performance, and evaluated whether performance could be explained by the frequency of QR code usage. Question prompts and QR codes tagged on cadaveric specimens and models were available for four weeks as learning aids to medical (n = 155) and doctor of physical therapy (n = 39) students. Each QR code provided answers to posed questions in the form of embedded text or hyperlinked web pages. Students' perceptions were gathered using a formative questionnaire and practical examination scores were used to assess potential gains in student achievement. Overall, students responded positively to the use of QR codes in the gross anatomy laboratory as 89% (57/64) agreed the codes augmented their learning of anatomy. The users' most noticeable objection to using QR codes was the reluctance to bring their smartphones into the gross anatomy laboratory. A comparison between the performance of QR code users and non-users was found to be nonsignificant (P = 0.113), and no significant gains in performance (P = 0.302) were observed after the intervention. Learners welcomed the implementation of QR code technology in the gross anatomy laboratory, yet this intervention had no apparent effect on practical examination performance. Anat Sci Educ 8: 421–428. © 2014 American Association of Anatomists.

Context Family caregivers are a vital resource in the recovery of intensive care unit (ICU) survivors. Of concern, the stress associated with this role can negatively affect caregiver health. Fatigue, an important health indicator, has been identified as a predictor of various illnesses, greater use of health services, and early mortality. Examining the impact of fatigue on caregivers' physical health can assist in identifying critical time points and potential targets for intervention. Objectives To describe self-reported fatigue in caregivers of ICU survivors from patients' ICU admission to ≤2 weeks, two- and four-months post-ICU discharge. Methods Patient-caregiver pairs were enrolled from a medical ICU. Caregiver fatigue was measured using the Short-Form 36 Health Survey Vitality subscale (SF-36 Vitality). Caregiver psychobehavioral stress responses included depressive symptoms, burden, health risk behaviors, and sleep quality. Patient data included self-reported physical symptoms and disposition (home vs. institution). Results Forty-seven patient-caregiver pairs were initially enrolled. Clinically significant fatigue (SF-36 Vitality ≤45) was reported by 43%–53% of caregivers across the time points, and these caregivers reported worse scores in measures of depressive symptoms, burden, health risk behaviors and sleep quality, and patients' symptom burden. In 26 caregivers with data for all time points (55% of the total sample), SF-36 Vitality scores showed trends of improvement when the patient returned home and greater impairment when institutionalization continued. Conclusion In caregivers of ICU survivors, fatigue is common and potentially linked with poor psychobehavioral responses. Worsening fatigue was associated with greater symptom distress and long-term patient institutionalization.

Objective To identify characteristics of hemodialysis patients most likely to experience difficulty adhering to sodium restrictions associated with their dietary regimen. Design Secondary analysis using baseline data from an ongoing randomized clinical trial examining the effects of a technology-supported behavioral intervention on dietary sodium intake in hemodialysis patients. Setting Thirteen dialysis centers in southwestern Pennsylvania. Subjects We included 122 participants (61% women; 48% African American) aged 61 ± 14 years undergoing maintenance, intermittent hemodialysis for end-stage renal disease. Main Outcome Measures Normalized dietary sodium intake, adjusted interdialytic weight gain, perceived problems, and self-efficacy for restricting dietary sodium. Results Younger participants were more likely to report problems managing their hemodialysis diet and low self-efficacy for restricting sodium intake. Consistent with these findings, younger participants had a higher median sodium intake and higher average adjusted interdialytic weight gain. Females reported more problems managing their diet. Race, time on dialysis, and perceived income adequacy did not seem to influence outcome measures. Conclusion Our findings suggest that patients who are younger and female encounter more difficulty adhering to the hemodialysis regimen. Hence, there may be a need to individualize counseling and interventions for these individuals. Further investigation is needed to understand the independent effects of age and gender on adherence to hemodialysis dietary recommendations and perceived self-efficacy.

Context Survivors of critical illness must overcome persistent physical and psychological challenges. Few studies have longitudinally examined self-reported physical symptoms in intensive care unit (ICU) survivors. Objectives To describe prevalence and severity of self-reported symptoms in 28 adult medical ICU survivors during the first four months post-ICU discharge and their associations with family caregiver responses. Methods Patients completed the Modified Given Symptom Assessment Scale. Caregivers completed the Shortened 10-item Center for Epidemiologic Studies Depression Scale, Brief Zarit Burden Score, Pittsburgh Sleep Quality Index, and the Caregiver Health Behavior form. Data at ICU discharge (two weeks or less), and two and four months post-ICU discharge were analyzed. Results Across the time points, most patients reported one or more symptoms (88.5–97%), with sleep disturbance, fatigue, weakness, and pain the most prevalent. For these four symptoms with the highest prevalence, there were: 1) moderate correlations among symptom severity at two and four months post-ICU discharge; and 2) no difference in prevalence or severity by patients' disposition (home vs. institution), except worse fatigue in patients at home at two weeks or less post-ICU discharge. Patients' overall symptom burden showed significant correlation with caregivers' depressive symptoms two weeks or less post-ICU discharge. There were trends of moderate correlations between patients' overall symptom burden and caregivers' health risk behaviors and sleep quality at two and four months post-ICU discharge. Conclusion In our sample, sleep disturbance, fatigue, weakness, and pain were the four key symptoms during first four months post-ICU discharge. Future studies focusing on these four symptoms are necessary to promote quality in post-ICU symptom management.

Background Despite recognized benefits, many children with cystic fibrosis (CF) do not consistently participate in physical activities. There is little empirical literature regarding the feelings and attitudes of children with CF toward exercise programs, parental roles in exercise, or factors influencing exercise experiences during research participation. Objectives The aim of this study is to describe the exercise experiences of children with CF and their parents during participation in a 6-month program of self-regulated, home-based exercise. Methods This qualitative descriptive study was nested within a randomized controlled trial of a self-regulated, home-based exercise program and used serial semistructured interviews conducted individually at 2 and 6 months with 11 purposively selected children with CF and their parent(s). Results Six boys and five girls, ages 10-16 years, and parents(nine mothers, four fathers) participated in a total of 44 interviews. Five major thematic categories describing child and parent perceptions and experience of the bicycle exercise program were identified in the transcripts: (a) motivators, (b) barriers, (c) effort/work, (d) exercise routine, and (e) sustaining exercise. Research participation, parent-family participation, health benefits, and the child's personality traits were the primary motivators. Competing activities, priorities, and responsibilities were the major barriers in implementing the exercise program as prescribed. Motivation waned, and the novelty wore off for several (approximately half) parent-child dyads, who planned to decrease or stop the exercise program after the study ended. Discussion We identified motivators and barriers to a self-regulated, home-based exercise program for children with CF that can be addressed in planning future exercise interventions to maximize the health benefits for children with CF and the feasibility and acceptability to the children and their families.

Recently, many have argued that learning to reflect on one's experiences is a critical component of professional identity formation and of professionalism. However, little empirical evidence exists to support this claim. This study explored the association between reflective ability and professionalism lapses among medical students.The authors conducted a retrospective case-control study of all students who matriculated at Indiana University School of Medicine from 2001 to 2009. The case group (n = 70) included those students who had been cited for a professionalism lapse during medical school; the students in the control group (n = 230) were randomly selected from the students who had not been cited for a professionalism lapse. Students' professionalism journal entries were scored using a validated rubric to assess reflective ability. Mean reflection scores were compared across groups using t tests, and logistic regression analysis was used to assess the relationship between reflective ability and professionalism lapses.Reflection scores for students in the case group (2.46 ± 1.05) were significantly lower than those for students in the control group (2.82 ± 0.83) (P = .01). A lower reflection score was associated with an increased likelihood that the student had been cited for a professionalism lapse (odds ratio = 1.56; P.01).This study revealed a significant relationship between reflective ability and professionalism, although further study is needed to draw any conclusions regarding causation. These findings provide quantitative evidence to support current anecdotal claims about the relationship between reflection and professionalism.

Prescribing exercise at intensities that improve fitness is difficult in children with cystic fibrosis (CF) due to ventilatory limitations and fluctuating health status. Our aim was to determine if children with CF could regulate the intensity of cycle ergometer and treadmill exercise using target ratings of perceived exertion (RPE) derived from the Children's OMNI Scale. We examined prescription congruence (similar oxygen consumption [VO₂] and heart rate [HR] for target RPE) and intensity discrimination (different VO₂ and HR for different RPEs), from cycle to cycle and cycle to treadmill. Subjects were 24 children (12 male, 12 female), aged 10-17 years with varying disease severity. Each child participated in one orientation, one estimation trial (graded maximal exercise test), and two production trials (cycle and treadmill, alternating between RPE 4 and 7). At RPE 4, congruence was evident for both VO₂ and HR on the treadmill. On the cycle at RPE 4, VO₂ was significantly higher only in the first production trial, although HRs tended to be higher in the production trials than the estimation trial. Prescription congruence was also supported at RPE 7, with no significant differences in VO₂ or HR between estimation and production trials on cycle or treadmill. Results fully supported intensity discrimination, with significant differences between VO₂ and HR at RPE 4 and 7 (P

Objective We sought to identify the characteristics of patients who experience medical emergency team calls in the radiology department (MET-RD) and the relationship between these characteristics and patient outcomes. Design/participants Retrospective review of 111 inpatient MET-RD calls (May 2008–April 2010). Setting Academic medical centre with a well established MET system. Measurements The characteristics of patients before, during and after transport to radiology were extracted from medical records and administrative databases. These characteristics were compared between patients with good and poor outcomes. Main results The majority of patients who experience MET-RD calls had a Charlson Comorbidity Index ≥4 and were from non-intensive care units (60%). Almost half (43%) of MET-RD calls occurred during patients9 first day in hospital. Patients commonly arrived with nasal cannula oxygen (38%), recent tachypnoea (28%) and tachycardia (34%). A minority (16%) fulfilled MET call criteria in the 12 h before the MET-RD. MET-RD etiologies were cardiac (41%), respiratory (29%) or neurological (25%), and occurred most frequently during CT (44%) and MRI (22%) testing. Post MET-RD, the majority of patients (70%) required a higher level of care. Death before discharge (25%) was associated with need for cardiovascular support prior to RD transport (p=0.02), need for RD monitoring (p=0.02) and need for heightened RD surveillance (p=0.04). Conclusions The majority of patients who experienced MET-RD calls came from non-intensive care units, with comorbidities and vital sign alterations prior to arrival at the RD. Risk appeared to be increased for those requiring CT and MRI. These findings suggest that prior identification of a subset of patients at risk of instability in the RD may be possible.

OBJECTIVE: This study compared nursing staff perceptions of safety climate in clinical units characterized by high and low ratings of leader-member exchange (LMX) and explored characteristics that might account for differences. BACKGROUND: Frontline nursing leaders' actions are critical to ensure patient safety. Specific leadership behaviors to achieve this goal are underexamined. The LMX perspective has shown promise in nonhealthcare settings as a means to explain safety climate perceptions. METHODS: Cross-sectional survey of staff (n = 711) and unit directors from 34 inpatient units in an academic medical center was conducted. RESULTS: Significant differences were found between high and low LMX scoring units on supervisor safety expectations, organizational learning-continuous improvement, total communication, feedback and communication about errors, and nonpunitive response to errors. CONCLUSION: The LMX perspective can be used to identify differences in perceptions of safety climate among nursing staff. Future studies are needed to identify strategies to improve staff safety attitudes and behaviors.

During an ethnography conducted in an intensive care unit (ICU), we found that anxiety and agitation occurred frequently and were important considerations in the care of 30 patients weaning from prolonged mechanical ventilation. We conducted a secondary analysis to (a) describe characteristics of anxiety and agitation experienced by mechanically ventilated patients, (b) explore how clinicians recognized and interpreted anxiety and agitation, and (c) describe strategies and interventions used to manage anxiety and agitation with mechanically ventilated patients. We constructed the Anxiety/Agitation in Mechanical Ventilation Model to illustrate the multidimensional features of symptom recognition and management. Patients’ ability to interact with the environment served as a basis for identification and management of anxiety or agitation. Clinicians’ attributions about anxiety or agitation, and “knowing the patient,” contributed to their assessment of patient responses. Clinicians chose strategies to overcome either the stimulus or the patient’s appraisal of risk of the stimulus. This article contributes to the body of knowledge about symptom recognition and management in the ICU by providing a comprehensive model to guide future research and practice.

It is estimated that 50 million people in the United States provide care for a chronically ill, disabled, or aged family member or friend.1 For caregivers of persons with cancer and dementia, extensive evidence shows that negative psychological and behavioral consequences are common and may be linked to a decline in caregivers’ overall health.2,3 Caregivers of critically ill patients also experience high levels of stress. Recovery from critical illness may occur quickly or gradually over an extended period. The term chronically critically ill (CCI) is commonly used to describe persons who require an extended duration of mechanical ventilation and hospitalization after recovery from critical illness.4 Evidence from a variety of sources suggests that growing numbers of caregivers will face the need to support CCI patients after hospital discharge. Demand for critical care, including mechanical ventilation, is anticipated to increase sharply as the generation of “baby boomers” grows to 20% of the total US population by 2030.5 Currently, 5% to 20% of patients in intensive care units (ICUs) require mechanical ventilation for periods that can extend to weeks or months,6 and those percentages are expected to increase.7,8 It has been estimated that by 2020 more than 600 000 patients per year will require extended critical care support.9 Such patients encounter enormous difficulties, including psychoemotional stress, reduced physical and neurocognitive function, symptom burden, and frequent hospital readmissions.7,10,11 Concurrently, family caregivers must cope with financial, emotional, and physical stressors.12 In several prior studies,12–18 caregivers of CCI patients were surveyed about their psychological responses. Despite heterogeneous characteristics of patients (eg, severity of illness, days of mechanical ventilation) and follow-up intervals (2 to 23 months), findings uniformly included a high incidence of depression12–18 that was comparable to the incidence of depression in caregivers of the frail elderly and twice the incidence of depression in the general population. Douglas and Daly12 reported decreased physical health and increased risk of depression in caregivers of CCI patients that exceeded reports for other populations of patients who require long-term caregiving, such as patients with Alzheimer’s disease and patients with spinal cord injury. When patients remained institutionalized, family caregivers reported a higher incidence of depression and burden, more disruption in daily schedules, more health problems, and less family support.14,16 Depressive symptoms decreased over time,13,18 but remained higher than in the general population. Notably, in an analysis of a national data set comprising almost 300 000 cases, a significantly higher risk of death was reported in spouses of persons who received mechanical ventilation for 4 days or longer.19 Reports of prior studies13,16–18 have described the challenges encountered by caregivers of CCI patients. However, most did not identify the specific lifestyle restrictions, distress, or problem behaviors of patients that were of most concern. In an effort to identify ways to support caregivers of CCI patients, it may be helpful to explore longitudinal changes in caregiver response as influenced by changes in the characteristics of patients. It is also important to identify specific areas that cause caregivers to experience greater lifestyle restriction and distress. Therefore, the purpose of this study was to describe perceived lifestyle restrictions and distress among caregivers of CCI patients at 1 and 6 months after ICU discharge. We also explored how caregivers’ lifestyle restrictions and distress differed according to the characteristics of the patients and the caregivers.

Background Bathing is a fundamental nursing care activity performed for or with the self-assistance of critically ill patients. Few studies address caregiver or patient–family perspectives about bathing activity during weaning from prolonged mechanical ventilation (PMV). Objective To describe practices and beliefs about bathing patients during weaning from PMV. Methods Secondary analysis of qualitative data (observational field notes, interviews, and clinical record review) from a larger ethnographic study involving 30 patients weaning from PMV and the clinicians who cared for them using basic qualitative description. Results Bathing, hygiene, and personal care were highly valued and equated with “good” nursing care by families and nurses. Nurses and respiratory therapists reported “working around” bath time and promoted conducting weaning trials before or after bathing. Patients were nevertheless bathed during weaning trials despite clinicians' expressed concerns for energy conservation. Clinicians recognized individual patient response to bathing during PMV weaning trials. Conclusion Bathing is a central care activity for patients on PMV and a component of daily work processes in the intensive care unit. Bathing requires assessment of patient condition and activity tolerance and nurse–respiratory therapist negotiation and accommodation with respect to the initiation or continuation of PMV weaning trials during bathing. Further study is needed to validate the impact (or lack of impact) of various timing strategies for bathing patients who are on PMV.

Weaning from prolonged mechanical ventilation may be associated with mental discomfort. It is not known whether such discomfort is linked with the development of post-traumatic stress disorder (PTSD). Accordingly, we investigated whether PTSD occurs in patients after weaning from prolonged ventilation. We also determined whether administering a questionnaire would identify patients at risk for developing PTSD.A prospective longitudinal study of patients transferred to a long-term acute-care hospital for weaning from prolonged ventilation was undertaken: 72 patients were studied 1 week after weaning, and 41 patients were studied again 3 months later. An experienced psychologist conducted a structured clinical interview 3 months after weaning to establish a diagnosis of PTSD. To assess for the presence of PTSD-related symptoms, the post-traumatic stress syndrome (PTSS-10) questionnaire was administered 1 week after weaning and 3 months later.The psychologist diagnosed PTSD in 12% of patients 3 months after ventilator weaning. Patients who developed PTSD were more likely to have a previous history of psychiatric disorders (P0.02). A PTSS-10 score20 one week after weaning reliably identified patients who were diagnosed with PTSD 3 months later: sensitivity 1.0; specificity 0.76; area under the receiver-operating characteristic curve 0.91.PTSD was diagnosed in 12% of patients who were weaned from prolonged ventilation. A PTSS-10 score20 one week after weaning identified patients diagnosed with PTSD 3 months later. This finding suggests that a simple questionnaire administered before hospital discharge can identify patients at risk for developing PTSD.

fero l.j., o’donnell j.m., zullo t.g., dabbs a.d., kitutu j., samosky j.t. & hoffman l.a. (2010) Critical thinking skills in nursing students: comparison of simulation-based performance with metrics. Journal of Advanced Nursing 66(10), 2182–2193. Abstract Aim This paper is a report of an examination of the relationship between metrics of critical thinking skills and performance in simulated clinical scenarios. Background Paper and pencil assessments are commonly used to assess critical thinking but may not reflect simulated performance. Methods In 2007, a convenience sample of 36 nursing students participated in measurement of critical thinking skills and simulation-based performance using videotaped vignettes, high-fidelity human simulation, the California Critical Thinking Disposition Inventory and California Critical Thinking Skills Test. Simulation-based performance was rated as ‘meeting’ or ‘not meeting’ overall expectations. Test scores were categorized as strong, average, or weak. Results Most (75·0%) students did not meet overall performance expectations using videotaped vignettes or high-fidelity human simulation; most difficulty related to problem recognition and reporting findings to the physician. There was no difference between overall performance based on method of assessment (P = 0·277). More students met subcategory expectations for initiating nursing interventions (P ≤ 0·001) using high-fidelity human simulation. The relationship between videotaped vignette performance and critical thinking disposition or skills scores was not statistically significant, except for problem recognition and overall critical thinking skills scores (Cramer’s V = 0·444, P = 0·029). There was a statistically significant relationship between overall high-fidelity human simulation performance and overall critical thinking disposition scores (Cramer’s V = 0·413, P = 0·047). Conclusion Students’ performance reflected difficulty meeting expectations in simulated clinical scenarios. High-fidelity human simulation performance appeared to approximate scores on metrics of critical thinking best. Further research is needed to determine if simulation-based performance correlates with critical thinking skills in the clinical setting.

Background Patients were recruited from the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, located within the University of Pittsburgh Medical Center. Idiopathic pulmonary fibrosis results in scarring of the lung and respiratory failure, and has a median survival of 3 to 5 years from the time of diagnosis. The purpose of this study was to determine whether patients with idiopathic pulmonary fibrosis and their care partners could be more optimally managed by a disease-management intervention entitled “Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management,” which nurses delivered using the format of a support group. We hypothesized that participation would improve perceptions of health-related quality of life (HRQoL) and decrease symptom burden. Methods Subjects were 42 participants randomized to an experimental (10 patient/care partner dyads) or control (11 patient/care partner dyads) group. Experimental group participants attended the 6-week program, and controls received usual care. Before and after the program, all participants completed questionnaires designed to assess symptom burden and HRQoL. Patients and care partners in the intervention group were also interviewed in their home to elicit information on their experience after participating in the Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management. Results After the intervention, experimental group patients rated their HRQoL less positively ( P = .038) and tended to report more anxiety ( P = .077) compared with controls. Care partners rated their stress at a lower level ( P = .018) compared with controls. Course evaluations were uniformly positive. Post-study qualitative interviews with experimental group participants suggested benefits not exemplified by these scores. Patient participants felt less isolated, were able to put their disease into perspective, and valued participating in research and helping others. Conclusion Further exploration of the impact of disease-management interventions in patients with advanced lung disease and their care partners is needed using both qualitative and quantitative methodology. Disease-management interventions have the potential to positively affect patients with advanced lung disease and their care partners.

Patients who require mechanical ventilation are at risk of emotional stress because of total dependence on a machine for breathing. The stress may negatively impact ventilator weaning and survival. The purpose of this study was to determine whether depressive disorders in patients being weaned from prolonged mechanical ventilation are linked to weaning failure and decreased survival.A prospective study of 478 consecutive patients transferred to a long-term acute care hospital for weaning from prolonged ventilation was undertaken. A clinical psychologist conducted a psychiatric interview to assess for the presence of depressive disorders.Of the 478 patients, 142 had persistent coma or delirium and were unable to be evaluated for depressive disorders. Of the remaining 336 patients, 142 (42%) were diagnosed with depressive disorders. In multivariate analysis, co-morbidity score [odds ratio (OR), 1.23; P = 0.007], functional dependence before the acute illness (OR, 1.70, P = 0.03) and history of psychiatric disorders (OR, 3.04, P = 0.0001) were independent predictors of depressive disorders. The rate of weaning failure was higher in patients with depressive disorders than in those without such disorders (61 vs. 33%, P = 0.0001), as was mortality (24 vs. 10%, P = 0.0008). The presence of depressive disorders was independently associated with mortality (OR, 4.3; P = 0.0002); age (OR, 1.06; P = 0.001) and co-morbidity score (OR, 1.24; P = 0.02) also predicted mortality.Depressive disorders were diagnosed in 42% of patients who were being weaned from prolonged ventilation. Patients with depressive disorders were more likely to experience weaning failure and death.

Cognitive deficits in participants and the abrupt and traumatic way in which many neurological conditions present are two examples of the unique challenges in recruiting and retaining participants with neurological injury for research studies. The purpose of this investigation was to identify obstacles to recruitment and retention in three ongoing research studies. These studies involve persons with neurological disorders across the continuum of care, from those newly diagnosed and with emergent presentation to those with more established chronic neurological conditions. For this analysis, we evaluated the effectiveness of the strategies employed to improve participation rates. The first study was a project funded by the National Institutes of Health designed to identify biomarkers of vasospasm in persons (n = 496) with aneurysmal subarachnoid hemorrhage who presented to the neurovascular intensive care unit (National Institute of Nursing Research, R01 NR004339). The purpose of the second study was to examine biobehavioral interactions in family caregivers (n = 59) of persons with a primary malignant brain tumor recruited in the community setting. The third project involved recruiting persons (n = 1,019) within an outpatient neurosurgical center to participate in a research registry. To determine differential effectiveness of strategies, consent and attrition rates were calculated at serial points over time in three studies, and recruitment and retention strategies were compared. Sentinel time points in participants' disease trajectories played a key role in determining whether those who were approached to participate gave consent and were retained, particularly in the studies involving persons with aneurysmal subarachnoid hemorrhage (consent = 85%; retention = 89%) and persons with primary malignant brain tumors and their caregivers (consent = 68%; retention = 83%). In addition, several specific recruiter and interviewer training techniques were associated with higher recruitment and retention. Targeted strategies to improve participation rates are vital for neuroscience nurses involved in any aspect of clinical research, including those who conduct studies, assist with data collection, and recruit potential participants.

Aneurysmal subarachnoid hemorrhage (SAH) is a hemorrhagic stroke subtype with a poor recovery profile. Cerebral vasospasm (CV), a narrowing of the cerebral vasculature, significantly contributes to the poor recovery profile. Variation in the endothelial nitric oxide (NO) synthase (eNOS) gene has been implicated in CV and outcome after SAH. The purpose of this project was to explore the potential association between three eNOS tagging single nucleotide polymorphisms (SNPs) and recovery from SAH. We included 195 participants with a diagnosis of SAH and DNA and 6-month outcome data available but without preexisting neurologic disease/deficit. Genotyping was performed using an ABI Prism 7000 Sequence Detection System and TaqMan assays. CV was verified by cerebral angiogram independently read by a neurosurgeon on 118 participants. Modified Rankin Scores (MRS) and Glasgow Outcome Scale (GOS) scores were collected 6 months posthemorrhage. Data were analyzed using descriptive statistics, analysis of variance (ANOVA) and chi-square analysis as appropriate. The sample was primarily female (n = 147; 75.4%) and White (n = 178; 91.3%) with a mean age of 54.6 years. Of the participants with CV data, 56 (47.5%) developed CV within 14 days of SAH. None of the SNPs individually were associated with CV presence; however, a combination of the three variant SNPs was significantly associated with CV (p = .017). Only one SNP (rs1799983, variant allele) was associated with worse 6-month GOS scores (p < .001) and MRS (p < .001). These data indicate that the eNOS gene plays a role in the response to SAH, which may be explained by an influence on CV.

Intracellular calcium (Ca++) regulation of cerebral vessels is impaired after subarachnoid hemorrhage (SAH), making secondary pathways, such as that involving apolipoprotein E, potentially more influential. To evaluate cerebrospinal fluid (CSF) apolipoprotein E and Ca++levels as biomarkers of cerebral vasospasm, we examined changes in levels over time and apolipoprotein E (APOE) ε4 allele presence after SAH in individuals with and without vasospasm. We hypothesized that individuals with low apolipoprotein E levels, increased Ca++levels and/or at least one copy of the APOE ε4 allele would have vasospasm. Daily samples from 50 participants, aged 18—75, with SAH were used to quantify apolipoprotein E and Ca++levels. Vasospasm was verified using cerebral angiogram and/or elevated transcranial Dopplers in combination with clinical neurologic deterioration. Overall apolipoprotein E levels were higher in individuals with the APOE ε4 allele (p = .02) or angiographic vasospasm (p = .01), but there were no differences between individuals with and without symptomatic vasospasm. There were no significant changes in apolipoprotein E levels over time. Individuals with the ε4 allele had lower Ca++levels (p = .02) with trends suggesting a different pattern of change over time (p = .07). CSF Ca++levels were lower in individuals with symptomatic vasospasm (p < .01). Change in apolipoprotein E and Ca++levels (p = .006) correlated over time regardless of genotype or vasospasm status. These findings suggest that apolipoprotein E and Ca++may be interacting after SAH, but this interaction does not appear to influence vasospasm.

Survivors of critical illness often undergo an extended recovery trajectory. Reduced functional ability is one of several adverse outcomes of prolonged bed rest and mechanical ventilation during critical illness. Skeletal muscle weakness is known to be one of the major phenomena that account for reduced functional ability. Although skeletal muscle weakness is evident after prolonged mechanical ventilation, few studies have tested the benefits of various types of mobility interventions in this population. The purpose of this article is to review the published research on improving mobility outcomes in patients undergoing prolonged mechanical ventilation. For this review, published studies were retrieved from MEDLINE, PubMed, CINAHL, and the Cochrane Database of Systematic Reviews from January 1990 to July 2007. A total of 10 relevant articles were selected that examined the effect of whole body physical therapy, electrical stimulation, arm exercise and inspiratory muscle training. Overall, there is support for the ability of mobility interventions to improve outcomes in patients on prolonged mechanical ventilation but limited evidence of how to best accomplish this goal. Generating more data from multicenter studies and randomized controlled trials is recommended.