The professionalism disconnect: do entering residents identify yet participate in unprofessional behaviors?

BACKGROUND: Professionalism has been an important tenet of medical education, yet defining it is a challenge. Perceptions of professional behavior may vary by individual, medical specialty, demographic group and institution. Understanding these differences should help institutions better clarify professionalism expectations and provide standards with which to evaluate resident behavior. METHODS: Duke University Hospital and Vidant Medical Center/East Carolina University surveyed entering PGY1 residents. Residents were queried on two issues: their perception of the professionalism of 46 specific behaviors related to training and patient care; and their own participation in those specified behaviors. The study reports data analyses for gender and institution based upon survey results in 2009 and 2010. The study received approval by the Institutional Review Boards of both institutions. RESULTS: 76% (375) of 495 PGY1 residents surveyed in 2009 and 2010 responded. A majority of responders rated all 46 specified behaviors as unprofessional, and a majority had either observed or participated in each behavior. For all 46 behaviors, a greater percentage of women rated the behaviors as unprofessional. Men were more likely than women to have participated in behaviors. There were several significant differences in both the perceptions of specified behaviors and in self-reported observation of and/or involvement in those behaviors between institutions.Respondents indicated the most important professionalism issues relevant to medical practice include: respect for colleagues/patients, relationships with pharmaceutical companies, balancing home/work life, and admitting mistakes. They reported that professionalism can best be assessed by peers, patients, observation of non-medical work and timeliness/detail of paperwork. CONCLUSION: Defining professionalism in measurable terms is a challenge yet critical in order for it to be taught and assessed. Recognition of the differences by gender and institution should allow for tailored teaching and assessment of professionalism so that it is most meaningful. A shared understanding of what constitutes professional behavior is an important first step.

When the library is located in prime real estate: a case study on the loss of space from the Duke University Medical Center Library and Archives.

The Duke University Medical Center Library and Archives is located in the heart of the Duke Medicine campus, surrounded by Duke Hospital, ambulatory clinics, and numerous research facilities. Its location is considered prime real estate, given its adjacency to patient care, research, and educational activities. In 2005, the Duke University Library Space Planning Committee had recommended creating a learning center in the library that would support a variety of educational activities. However, the health system needed to convert the library's top floor into office space to make way for expansion of the hospital and cancer center. The library had only five months to plan the storage and consolidation of its journal and book collections, while working with the facilities design office and architect on the replacement of key user spaces on the top floor. Library staff worked together to develop plans for storing, weeding, and consolidating the collections and provided input into renovation plans for users spaces on its mezzanine level. The library lost 15,238 square feet (29%) of its net assignable square footage and a total of 16,897 (30%) gross square feet. This included 50% of the total space allotted to collections and over 15% of user spaces. The top-floor space now houses offices for Duke Medicine oncology faculty and staff. By storing a large portion of its collection off-site, the library was able to remove more stacks on the remaining stack level and convert them to user spaces, a long-term goal for the library. Additional space on the mezzanine level had to be converted to replace lost study and conference room spaces. While this project did not match the recommended space plans for the library, it underscored the need for the library to think creatively about the future of its facility and to work toward a more cohesive master plan.

Evaluation of extended training for general practice in Northern Ireland: qualitative study.

Objective To evaluate participants' perceptions of the impact on them of an additional six months' training beyond the standard 12 month general practice vocational training scheme. Design Qualitative study using focus groups. Setting General practice vocational training in Northern Ireland. Participants 13 general practitioner registrars, six of whom participated in the additional six months' training, and four trainers involved in the additional six months' training. Main outcome measures: Participants' views about their experiences in 18 month and 12 month courses. Results Participants reported that the 12 month course was generally positive but was too pressurised and focused on examinations, and also that it had a negative impact on self care. The nature of the learning and assessment was reported to have left participants feeling averse to further continuing education and lacking in confidence. In contrast, the extended six month component was reported to have restimulated learning by focusing more on patient care and promoting self directed learning. It developed confidence, promoted teamwork, and gave experience of two practice contexts, and was reported as valuable by both ex-registrars and trainers. However, both the 12 and 18 month courses left participants feeling underprepared for practice management and self care. Conclusions 12 months' training in general practice does not provide doctors with the necessary competencies and confidence to enter independent practice. The extended period was reported to promote greater professional development, critical evaluation skills, and orientation to lifelong learning but does not fill all the gaps.

Monitoring treatment fidelity in a randomised controlled trial of a complex intervention.

Aim. This paper is a report of a study to describe how treatment fidelity is being enhanced and monitored, using a model from the National Institutes of Health Behavior Change Consortium. Background. The objective of treatment fidelity is to minimize errors in interpreting research trial outcomes, and to ascribe those outcomes directly to the intervention at hand. Treatment fidelity procedures are included in trials of complex interventions to account for inferences made from study outcomes. Monitoring treatment fidelity can help improve study design, maximize reliability of results, increase statistical power, determine whether theory-based interventions are responsible for observed changes, and inform the research dissemination process. Methods. Treatment fidelity recommendations from the Behavior Change Consortium were applied to the SPHERE study (Secondary Prevention of Heart DiseasE in GeneRal PracticE), a randomized controlled trial of a complex intervention. Procedures to enhance and monitor intervention implementation included standardizing training sessions, observing intervention consultations, structuring patient recall systems, and using written practice and patient care plans. The research nurse plays an important role in monitoring intervention implementation. Findings. Several methods of applying treatment fidelity procedures to monitoring interventions are possible. The procedure used may be determined by availability of appropriate personnel, fiscal constraints, or time limits. Complex interventions are not straightforward and necessitate a monitoring process at trial stage. Conclusion. The Behavior Change Consortium’s model of treatment fidelity is useful for structuring a system to monitor the implementation of a complex intervention, and helps to increase the reliability and validity of evaluation findings.

Wholeness of healing: an innovative Student-Selected Component introducing United Kingdom medical students to the spiritual dimension in healthcare.

Objective: This Student Selected Component (SSC) was designed to equip United Kingdom (UK) medical students to engage in whole-person care. The aim was to explore students' reactions to experiences provided, and consider potential benefits for future clinical practice.

Methods: The SSC was delivered in the workplace. Active learning was encouraged through facilitated discussion with and observation of clinicians, the palliative team, counselling services, hospital chaplaincy and healing ministries; sharing of medical histories by patients; and training in therapeutic communication. Assessment involved reflective journals, literature appraisal, and role-play simulation of the doctor-patient consultation. Module impact was evaluated by analysis of student coursework and a questionnaire.

Results: Students agreed that the content was stimulating, relevant, and enjoyable and that learning outcomes were achieved. They reported greater awareness of the benefit of clinicians engaging in care of the "whole person" rather than "the disease." Contributions of other professions to the healing process were acknowledged, and students felt better equipped for discussion of spiritual issues with patients. Many identified examples of activities which could be incorporated into core teaching to benefit all medical students.

Conclusion: The SSC provided relevant active learning opportunities for medical students to receive training in a whole-person approach to patient care.

The cost-effectiveness of the SPHERE intervention for the secondary prevention of coronary heart disease

Objectives: The Secondary Prevention of Heart disEase in geneRal practicE (SPHERE) trial has recently reported. This study examines the cost-effectiveness of the SPHERE intervention in both healthcare systems on the island of Ireland. Methods: Incremental cost-effectiveness analysis. A probabilistic model was developed to combine within-trial and beyond-trial impacts of treatment to estimate the lifetime costs and benefits of two secondary prevention strategies: Intervention - tailored practice and patient care plans; and Control - standardized usual care. Results: The intervention strategy resulted in mean cost savings per patient of 512.77 (95 percent confidence interval [CI], 1086.46-91.98) and an increase in mean quality-adjusted life-years (QALYs) per patient of 0.0051 (95 percent CI, 0.0101-0.0200), when compared with the control strategy. The probability of the intervention being cost-effective was 94 percent if decision makers are willing to pay €45,000 per additional QALY. Conclusions: Decision makers in both settings must determine whether the level of evidence presented is sufficient to justify the adoption of the SPHERE intervention in clinical practice. Copyright © Cambridge University Press 2010.

Management of varicella contacts in pregnancy: VZIG or Vaccination?

Background Varicella infection during pregnancy poses a serious risk for both foetus and mother. It has been suggested that it would be more cost-effective to screen antenatally with post-partum vaccination, which occurs in the US, than the current policy of checking immune status post varicella exposure, with VZIG administration where necessary. Additionally, it is doubtful whether the current policy provides best patient care, when a vaccine is available. Objectives The study aims to retrospectively compare the cost of the current policy with a cost estimate for antenatal screening with post-partum vaccination in NI. Study design A cost estimate of antenatal screening of primigravidas, with post-partum vaccination, was calculated for two models: (1) verbal screening, with serological testing of those with no history of varicella infection and (2) serological screening of all primigravidas. Results The cost of VZIG issued to pregnant women in 2006 was £100,800; 43% of births were to primigravidas therefore the estimated cost of VZIG issued to multigravidas was £58,100. The cost of verbal screening with post-partum vaccination is estimated at £23,750 p.a., saving £34,350 over current policy. The estimated cost of screening all primigravidas with post-partum vaccination is £43,000, saving £15,100. Conclusions This retrospective study suggests that in NI either of the proposed antenatal screening strategies would be less costly than current practice. This finding supports the suggestion that varicella immunity testing should be included in the Antenatal Infectious Diseases Screening Programme, either as part of the universal vaccination programme or solely as an antenatal programme.

An innovative approach to integrated medicines management

To determine whether an increased input by clinical pharmacists at each stage of the patient's hospital journey, from admission through discharge, resulted in an enhanced level of patient care as measured by a number of clinical and economic outcomes.

Creating continuity out of the disruption of a diagnosis of HIV during pregnancy

AIM: To understand the uniqueness of the experience of testing HIV positive from the perspective of pregnant women.

BACKGROUND: As more people learn of their HIV diagnosis through routine screening processes, it is timely to reflect on the impact of receiving an unexpected positive result.

DESIGN: A prospective qualitative study.

METHODS: This paper draws on the case studies of four women who were participating in a larger prospective qualitative study of reproductive decision-making, pregnancy and childbirth following HIV diagnosis. Multiple interviews were conducted following diagnosis during pregnancy, and, after the birth of their babies. Thematic data analysis was undertaken.

RESULTS: Drawing on Becker's theory of disruption, we document the 'sudden disjuncture' of their antenatal diagnosis and the embodied emotional struggle the women engaged in to create continuity in their lives. A diagnosis of HIV disrupted the women's biographies in terms of their health, relationships and social identity. As pregnant women, the threat of HIV was experienced most significantly in relation to their unborn child. However, their narratives also revealed how a diagnosis of HIV in the context of pregnancy, whilst traumatic, provided a focus for regaining continuity in their lives, as the baby became a metaphor for hope and orientation toward the future.

CONCLUSIONS: As HIV testing becomes more 'routine', the findings of this study serve to remind health professionals that a positive diagnosis continues to constitute a major trauma to individuals and families.

RELEVANCE TO CLINICAL PRACTICE: We propose that appropriately educated nursing and midwifery staff could facilitate the 'meaning making' process that is required for newly diagnosed HIV positive persons to find a subjective sense of well-being in their lives.

Managing Cultural Diversity in Healthcare Partnerships: The Case of LIFT

Purpose: The National Health Service (NHS) Local Improvement Finance Trust (LIFT) programme was launched in 2001 as an innovative public-private partnership to address the historical under-investment in local primary care facilities in England. The organisations from the public and private sector that comprise a local LIFT partnership each have their own distinctive norms of behaviour and acceptable working practices - ultimately different organisational cultures. The purpose of this article is to assess the role of organisational culture in facilitating (or impeding) LIFT partnerships and to contribute to an understanding of how cultural diversity in public-private partnerships is managed at the local level. Design/methodology/approach: The approach taken was qualitative case studies, with data gathering comprising interviews and a review of background documentation in three LIFT companies purposefully sampled to represent a range of background factors. Elite interviews were also conducted with senior policy makers responsible for implementing LIFT policy at the national level. Findings: Interpreting the data against a conceptual framework designed to assess approaches to managing strategic alliances, the authors identified a number of key differences in the values, working practices and cultures in public and private organisations that influenced the quality of joint working. On the whole, however, partners in the three LIFT companies appeared to be working well together, with neither side dominating the development of strategy. Differences in culture were being managed and accommodated as partnerships matured. Research limitations/implications: As LIFT develops and becomes the primary source of investment for managing, developing and channelling funding into regenerating the primary care infrastructure, further longitudinal work might examine how ongoing partnerships are working, and how changes in the cultures of public and private partners impact upon wider relationships within local health economies and shape the delivery of patient care. Originality/value: To the authors' knowledge this is the first study of the role of culture in mediating LIFT partnerships and the findings add to the evidence on public-private partnerships in the NHS

A self-reported work sampling study in community pharmacy practice

Lack of time to implement pharmaceutical care has been cited as a barrier to the routine provision of this extended patient-care service. Using self-reported work sampling methodology, this study investigated how community pharmacists utilise their time. Pharmacists working in community pharmacies in the Greater Belfast area were found to spend approximately 49% of their time engaged in professional activities, 29% in semi-professional activities and 22% involved in non-professional activities. The activity to which pharmacists devoted the majority of their time was product assembly and labelling, this being a task which can be performed by trained technical staff. Only 9.5% of community pharmacists' time was devoted to counselling patients on their prescription medicines. Wide variation in the amount of time apportioned to each activity was observed between the participating community pharmacists (n=30). Staffing levels within the community pharmacy were found to significantly influence pharmacists' involvement in a number of activities, with pharmacists who worked in pharmacies employing multiple pharmacists devoting more time to the assembly and labelling of products and less time to administrative tasks, non-professional encounters and to miscellaneous professional activities. Pharmacists working in pharmacies with a high prescription turnover were found to devote significantly less time to counselling patients regarding OTC products and in responding to patient symptoms.

Educating the dental team:exploring perceptions of roles and identities

Interprofessional education (IPE) should help to promote a team-based approach to professional practice but there are barriers to its implementation including professional identity. The aim of this study was to use a qualitative research methodology to explore dental and dental care professional (DCP) students' perceptions of professional roles and identities in the dental team. Data were collected by means of focus groups from a purposive sample of dental and DCP students and were audio recorded, transcribed and analysed using an explanatory framework. Five common themes emerged around the issue of professional roles and identity in the dental team. The results indicate that professional identity was an important factor in team development and was determined by direct responsibility for patient care and by the amount of clinical experience acquired. Professional identity within a team context was perceived as different from professional identity per se. Dental students were found to lack confidence in their role as team leaders which was related to their lack of knowledge of team roles, responsibilities and experience. The role of the dental technician was perceived as 'outside' the dental team due to lack of patient interaction.

"They come with multiple morbidities":a qualitative assessment of pharmacist prescribing

This paper presents qualitative findings from a larger sequential mixed methods study which sought to provide an in-depth understanding of pharmacist prescribing from the perspective of pharmacist prescribers, medical colleagues and key stakeholders in Northern Ireland. Transcriptions were analyzed using thematic analysis as the interviews progressed and emergent themes were identified and coded (along with supporting quotes) independently and by consensus of the research team. Three major themes emerged in relation to pharmacist prescribing: the effect on patient care; challenges facing pharmacist prescribers and the importance of the interprofessional team (where two or more different professions with varied, yet complementary experience work together with a common purpose). Pharmacist prescribing may have the potential to reduce the medication burden for patients (as reported by pharmacists) as pharmacists tend to provide a more comprehensive medication review than doctors; the additional time for consultations made this possible. Further research is required on how interprofessional team working can be maximized in the context of pharmacist prescribing, particularly in relation to the management of multi-morbidity.

Stress and eustress in nursing students

Aim. This paper is a report of a study to identify experiences that led to both distress and eustress and to make recommendations to help students cope with course demands.

Background. Much of the research on stress in nursing students is quantitative in focus and all draws on their experience of distress, with little attempt to understand experiences of eustress.

Method. A series of focus groups were carried out with a volunteer sample of final year nursing students (n = 16) in the United Kingdom in 2007. The data were thematically analysed.

Findings. The themes identified were clinical experience, support, learning and teaching experience and course structure. There were experiences within each that were perceived as sources of distress and eustress. Many of the sources of distress concur with earlier findings but they are more likely to be experienced and commented on because the demands of present-day programmes and the profile of many nursing students mean that more effort is invested in meeting educational demands. The experiential learning and patient-care opportunity that placements provided was an important source of eustress.

Conclusion. Students who coped well drew on effective support networks and adopted a positive, optimistic perspective towards programme issues. Effective educators did not offer more time than those perceived as less effective but seemed more effective at tuning into students' concerns, showing more empathy and offering clearer guidance.