A virtual surgery in general practice: evaluation of a novel undergraduate virtual patient learning package

Background: A suite of 10 online virtual patients developed using the IVIMEDS ‘Riverside’ authoring tool has been introduced into our undergraduate general practice clerkship. These cases provide a multimedia-rich experience to students. Their interactive nature promotes the development of clinical reasoning skills such as discriminating key clinical features, integrating information from a variety of sources and forming diagnoses and management plans.

Aims: To evaluate the usefulness and usability of a set of online virtual patients in an undergraduate general practice clerkship.
Method: Online questionnaire completed by students after their general practice placement incorporating the System Usability Scale questionnaire.

Results: There was a 57% response rate. Ninety-five per cent of students agreed that the online package was a useful learning tool and ranked virtual patients third out of six learning modalities. Questions and answers and the use of images and videos were all rated highly by students as useful learning methods. The package was perceived to have a high level of usability among respondents.

Conclusion: Feedback from students suggest that this implementation of virtual patients, set in primary care, is user friendly and rated as a valuable adjunct to their learning. The cost of production of such learning resources demands close attention to design.

The level playing field: the impact of assessment practice on professional development

Context: The effects of assessment practice on students’ learning are unclear, particularly regarding professional development. Corralling in objective structured clinical examinations (OSCEs) is designed to reduce illicit passing of examination information. Candidates completing an examination are kept secluded until the next cohort of examinees has begun. We used the introduction of corralling as a context in which to explore social influences on examination misconduct, with the aims of improving understanding of the hidden effects of assessment, and evaluating the acceptability of corralling from the student perspective.

Methods: A questionnaire was administered to students corralled post-OSCE for the first time. Eleven semi-structured interviews were subsequently conducted. Questionnaire data were analysed for descriptive statistics and thematic analysis of interview transcripts was carried out.

Results: The questionnaire response rate was 95.4% (251/263). Before corralling, 80.9% (203/251) of students were aware of the sharing of information among peers and 78.5% (197/251) agreed that such misconduct was unprofessional. The majority were in favour of corralling (90.8%, 228/251). Four themes emerged from the semi-structured interviews: the student network versus the individual; assessment-driven culture; the deferring of professionalism, and the ‘level playing field’. Students saw interaction within the student network, on a background of assessment-driven culture, as the key driver in examination misconduct. Conforming to the rules of the social network was prioritised over individual agency, although the mismatch between the rules of the network and the dominant professional discourse caused some conflict for individuals. Deferred professionalism (described as the practice of taking on the norms of professional behaviour only when qualified) was a rationalisation used to minimise this conflict. Corralling provided a ‘level playing field’ in which the influences of the network were minimised.

Conclusions: Examination misconduct is thus a complex social construction with implications for individual learners in terms of professional development. Corralling is one mechanism for addressing misconduct that is acceptable to students, but assessment processes have important hidden effects which educators should acknowledge.

Third harmonic order imaging as a focal spot diagnostic for high intensity laser-solid interactions

As the state of the art for high power laser systems increases from terawatt to petawatt level and beyond, a crucial parameter for routinely monitoring high intensity performance is laser spot size on a solid target during an intense interaction in the tight focus regime ( 10(19) Wcm(-2) is demonstrated experimentally and shown to provide the basis for an effective focus diagnostic. Importantly, this technique is also shown to allow in-situ diagnosis of focal spot quality achieved after reflection from a double plasma mirror setup for very intense high contrast interactions (> 10(20) Wcm(-2)) an important application for the field of high laser contrast interaction science.

Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials

Background: As trials of 5 years of tamoxifen in early breast cancer mature, the relevance of hormone receptor measurements (and other patient characteristics) to long-term outcome can be assessed increasingly reliably. We report updated meta-analyses of the trials of 5 years of adjuvant tamoxifen.
Methods: We undertook a collaborative meta-analysis of individual patient data from 20 trials (n=21457) in early breast cancer of about 5 years of tamoxifen versus no adjuvant tamoxifen, with about 80% compliance. Recurrence and death rate ratios (RRs) were from log-rank analyses by allocated treatment.
Findings: In oestrogen receptor (ER)-positive disease (n=10 645), allocation to about 5 years of tamoxifen substantially reduced recurrence rates throughout the first 10 years (RR 0.53 [SE 0.03] during years 0-4 and RR 0.68 [0.06] during years 5-9 [both 2p<0.00001]; but RR 0.97 [0.10] during years 10-14, suggesting no further gain or loss after year 10). Even in marginally ER-positive disease (10-19 fmol/mg cytosol protein) the recurrence reduction was substantial (RR 0.67 [0.08]). In ER-positive disease, the RR was approximately independent of progesterone receptor status (or level), age, nodal status, or use of chemotherapy. Breast cancer mortality was reduced by about a third throughout the first 15 years (RR 0.71 [0.05] during years 0-4, 0.66 [0.05] during years 5-9, and 0.68 [0.08] during years 10-14; p<0.0001 for extra mortality reduction during each separate time period). Overall non-breast-cancer mortality was little affected, despite small absolute increases in thromboembolic and uterine cancer mortality (both only in women older than 55 years), so all-cause mortality was substantially reduced. In ER-negative disease, tamoxifen had little or no effect on breast cancer recurrence or mortality.
Interpretation: 5 years of adjuvant tamoxifen safely reduces 15-year risks of breast cancer recurrence and death. ER status was the only recorded factor importantly predictive of the proportional reductions. Hence, the absolute risk reductions produced by tamoxifen depend on the absolute breast cancer risks (after any chemotherapy) without tamoxifen.
Funding: Cancer Research UK, British Heart Foundation, and Medical Research Council.

Evidencing reflective practice in social work education: Theoretical uncertainties and practical challenges

Reflective practice has become an increasingly influential idea in social work education and, in the UK context, it has recently been acknowledged as key to ensuring that social workers are better equipped to engage in complex decision making and effective practice. However, there remains a lack of clarity about how this concept is defined and operationalised in teaching and learning and there has been little systematic empirical examination of its utility in facilitating professional development. Drawing on research with undergraduates at Queen's University Belfast, this paper aims to develop understanding of students' experience of reflective practice. The results suggest that agency systems that have become over-reliant on rules and procedures present formidable obstacles to learning both at an individual and at an organisational level. The paper argues that the relationship between how reflective practice is taught and how it is enacted in practice needs to be better understood if such obstacles are to be overcome. The paper concludes by considering the implications of the findings for developing reflective practice in social work education and practice and highlights the challenges that need to be addressed if reflection and critical thinking are to become more firmly embedded within agency systems and practice cultures.

All-cause mortality and periodontitis in 60-70-year-old men: A prospective cohort study

Objective To investigate the association between periodontitis and mortality from all causes in a prospective study in a homogenous group of 60- to 70-year-old West European men. Methodology A representative sample of 1400 dentate men, (mean age 63.8, SD 3.0 years), drawn from the population of Northern Ireland, had a comprehensive periodontal examination between 2001 and 2003. Men were divided into thirds on the basis of their mean periodontal attachment loss (PAL). The primary endpoint, death from any cause, was analysed using Kaplan-Meier survival plots and Cox's proportional hazards model. Results In total, 152 (10.9%) of the men died during a mean follow-up of 8.9 (SD 0.7) years; 37 (7.9%) men in the third with the lowest PAL (<1.8 mm) died compared with 73 (15.7%) in the third with the highest PAL (>2.6 mm). The unadjusted hazard ratio (HR) for death in the men with the highest level of PAL compared with those with the lowest PAL was 2.11 (95% CI 1.42-3.14), p < 0.0001. After adjustment for confounding variables (age, smoking, hypertension, BMI, diabetes, cholesterol, education, marital status and previous history of a cardiovascular event) the HR was 1.57 (1.04-2.36), p = 0.03. Conclusion The European men in this prospective cohort study with the most severe loss of periodontal attachment were at an increased risk of death compared with those with the lowest loss of periodontal attachment.

The place(s) of student voice in 14-19 education policy reform: reflections on consultation and participation

Certain policy areas with considerable impact on young people's educational experiences and achievements, notably assessment and qualifications, do not involve consultation with young people to any meaningful extent. Findings from a national study, which included focus groups with 243 students in the 14-19 phase, are presented with respect to student consultation and participation in such policy areas. A lack of meaningful consultation regarding what students see as ‘higher level’ policy agendas was found (such as qualifications provision, choice or structure). Students are therefore ‘voiceless’ in relation to major qualifications reforms

Explaining Social Class Inequalities in Smoking: The Role of Education, Self-Efficacy, and Deprivation

Rates of smoking have decreased dramatically in most Northern European countries over the last 50 years or so, but manual working class groups are substantially more likely to smoke daily than are the professional and managerial classes. This article examines three hypotheses about the processes producing these inequalities. The first argues that social class inequalities reflect differences across education groups in knowledge of the risks of smoking. The second suggests that the living conditions of lower social class groups leads to the development of lower self-efficacy and a lower propensity to quit smoking. The third states that smoking has a functional use among poorer individuals. This article draws upon data from the Republic of Ireland to assess these hypotheses. Our analysis provides some support for the first hypothesis in that education independently reduces the odds of a manual class person smoking relative to a non-manual by 12 per cent. The second hypothesis is not supported by the data. The third hypothesis gains the most support: measures of disadvantage and deprivation account for almost one-third of the class differential in smoking. The results suggest that smoking cessation policy should reflect the importance of social and economic context in quitting behaviour.

FROM ASCRIPTION TO ACHIEVEMENT - ORIGINS, EDUCATION AND ENTRY TO THE LABOR-FORCE IN THE REPUBLIC OF IRELAND DURING THE 20TH-CENTURY

This paper examines the relationship between class of origin, educational attainment, and class of entry to the labour force, in three cohorts of men in the Republic of Ireland using data collected in 1987. The three cohorts comprise men born (i) before 1937; (ii) between 1937 and 1949; and (iii) between 1950 and 1962. The paper assesses the degree of change over the three cohorts in respect of (a) the gross relationship between origins and entry class; (b) the partial effect (controlling for education) of origin class on entry class; (c) the partial effect of education (controlling for origins) on class of entry. In broad terms the liberal theory of industrialism would imply a movement, over the three cohorts, towards (a) increasing social fluidity; (b) a weakening of the partial effect of origin class; (c) a strengthening of the partial effect of education. These latter two trends should be particularly noticeable in the youngest cohort, which would, to some degree, have benefited from the introduction of free post-primary education in Ireland in 1967.

Our results provide almost no support for these hypotheses. We find that patterns of social fluidity in the origin/entry relationship remain unchanged over the cohorts. The partial effect of class remains relatively constant; and, while the partial effect of education on entry class changes over the cohorts, the most striking result in this area is the declining returns to higher levels of education. While the average level of educational attainment increased over the three cohorts, the advantages accruing to the possession of higher levels of education simultaneously diminished. Taken together our results suggest that, in Ireland, those classes that have historically enjoyed advantages in access to more desirable entry positions in the labour market have been remarkably adept at retaining their advantages during the course of industrialization and through the various educational and other labour market changes that have accompanied this process.

The palliative care education needs of nursing home staff

Background: Palliative care is delivered in a number of settings, including nursing homes, where staff often have limited training in palliative care. Aim: We explored the level of palliative care knowledge among qualified staff delivering end-of-life care in nursing home settings, to inform the development of an appropriate education and training programme. Design: An audit of the educational needs assessment was performed using an anonymous postal questionnaire sent to 528 qualified nursing staff within 48 nursing homes. Findings: In total, 227 questionnaires were returned giving a response rate of 43%. Results indicated that less than half the sample had obtained formal training in the area of pain assessment and management and less than a quarter had obtained training in non-malignant conditions. Registered nurses in this study reported a lack of awareness of palliative care principles or national guidelines. Conclusion: Qualified nursing home staff agree that palliative care is a valuable model for care in their setting. There are clear opportunities for improvement in nursing home care, based on education and training in palliative care. Results also support the need for enhanced liaison between nursing homes and specialist palliative care services. © 2006 Elsevier Ltd. All rights reserved.

Building partnerships in social work education: Towards achieving collaborative advantage for employers and universities

Summary: Better partnership working between employers and academic institutions has recently been identified as one of the key developments needed to improve social work education and practice in the UK (Social Work Reform Board, 2010). However, the praxis of collaborative working in social work education remains under-researched and it is unclear what factors are significant in promoting effective partnership. This article contributes to this debate by reporting research that examined the experience of social work academics working with employers to deliver qualifying level social work education in Northern Ireland.

Findings: This analysis explores key factors in the dynamics of the collaborative process and identifies both congruence and discord in academic and employer perspectives. The findings highlight the collaborative advantage accruing from partnership working, which include the benefits of a centrally coordinated system for the management and delivery of practice learning. However, the results also indicate that engaging in partnership working is a complex process that can create conflict and tensions, and that it is important to ground collaborations in realistic expectations of what can be achieved.

Application: This article identifies opportunities for achieving collaborative advantage and the challenges. It identifies lessons learned about the value of partnership working in social work education and ways to increase its efficacy.

‘Reforming Social Work Education: Some Reflections on the Contribution of Practice Learning’

Social work in the UK is currently undergoing a process of major reform and a wide range of recommendations have been made aimed at improving practice and education. This paper focuses on the Social Work Reform Board's proposals for improving practice learning in qualifying level social work education. It examines how recommendations for better partnership working between Higher Education Institutions and employers and developing critical reflection in agencies are likely to impact on student learning. Drawing on experience of social work education in Northern Ireland it considers the potential of the Reform Board's proposals for improving the quality of practice learning and enhancing students' preparedness for employment. The paper concludes that differences in educational aims and priorities, resistant practice cultures and cut-backs in resourcing could present major obstacles that must be overcome if this potential is to be realised.