Academic Integrity and Senior Nursing Undergraduate Clinical Practice

Background: Academic integrity (AI) has been defined as the commitment to the values of honesty, trust, fairness, respect, and responsibility with courage in all academic endeavours. The senior years of nursing studies provide an intersection for students to transition to professional roles through student clinical practice. It is essential to understand what predicts senior nursing students’ intention to behave with AI so that efforts can be directed to initiatives focused on strengthening their commitment to behaving with AI. Research Questions: To what extent do students differ on Theory of Planned Behaviour (TPB) variables? What predicts intention to behave with academic integrity among senior nursing students in clinical practice across three different Canadian Schools of Nursing? Method: The TPB framework, an elicitation (n=30) and two pilot studies (n=59, n=29) resulted in the development of a 38 question (41-item) self-report survey (Miron Academic Integrity Nursing Survey—MAINS: α>0.70) that was administered to Year 3 and 4 students (N=339). Three predictor variables (attitude, subjective norm, perceived behavioural control) were measured with students’ intention to behave with AI in clinical. Age, sex, year of study, program stream, students’ understanding of AI policies, and locations where students accessed AI information were also measured. Results: Hierarchical multiple regression analyses revealed that background, site, and TPB variables explained 32.6% of the variance in intention to behave with academic integrity. The TPB variables explained 26.8% of the variance in intention after controlling for background and site variables. In the final model, only the TPB predictor variables were statistically significant with Attitude having the highest beta value (beta=0.35, p<0.001), followed by Subjective Norm (beta=0.21, p<0.001) and Perceived Behavioural Control (beta=0.12, p<0.02). Conclusion: Student attitude is the strongest predictor to intention to behave with AI in clinical practice and efforts to positively influence students’ attitudes need to be a focus for schools, curricula, and clinical educators. Opportunities for future research should include replicating the current study with students enrolled in other professional programs and intervention studies that examine the effectiveness of specific endeavours to promote AI in practice.

How can we use systematic reviews to inform clinical practice?

Aims/purpose: Systematic reviews provide the highest quality evidence and inform clinical practice. For patient benefit, it is imperative that nurses keep abreast of evidence-based practice. This presentation highlights where to find systematic reviews and how the information presented can be used to inform care.
Presentation description: Clinical research is increasing at an incredible rate. In the clinical trials database alone, more than 2000 new studies are registered/month and this does not include qualitative studies that do not require registration. Keeping abreast of current evidence can not only be a time consuming process, but can be problematic when studies produce conflicting results. Systematic reviews can be useful for summarizing the increasing amount of knowledge that is gained from scientific papers. In addition, combining individual studies in a meta-analysis increases statistical power, resulting in more precise effect estimates. This presentation draws upon a few systematic reviews relevant to ICU nursing practice, highlights their findings and demonstrates how the information can be used to inform translation of evidence into practice. Additionally, although these reviews include steps to minimize bias, nurses should be aware of some of the biases that may reduce confidence in the findings.
Conclusion: Systematic reviews can be useful tools for informing evidence based practice, although careful interpretation is necessary for understanding their relevance to local practice.

Focused molecular analysis of small cell lung cancer: feasibility in routine clinical practice.

Background: There is an urgent need to identify molecular signatures in small cell lung cancer (SCLC) that may select patients who are likely to respond to molecularly targeted therapies. In this study, we investigate the feasibility of undertaking focused molecular analyses on routine diagnostic biopsies in patients with SCLC.

Methods: A series of histopathologically confirmed formalin-fixed, paraffin-embedded SCLC specimens were analysed for epidermal growth factor receptors (EGFR), KRAS, NRAS and BRAF mutations, ALK gene rearrangements and MET amplification. EGFR and KRAS mutation testing was evaluated using real time polymerase chain reaction (RT-PCR cobas®), BRAF and NRAS mutations using multiplex PCR and capillary electrophoresis-single strand conformation analysis, and ALK and MET aberrations with fluorescent in situ hybridization. All genetic aberrations detected were validated independently.

Results: A total of 105 patients diagnosed with SCLC between July 1990 and September 2006 were included. 60 (57 %) patients had suitable tumour tissue for molecular testing. 25 patients were successfully evaluated for all six pre-defined molecular aberrations. Eleven patients failed all molecular analysis. No mutations in EGFR, KRAS and NRAS were detected, and no ALK gene rearrangements or MET gene amplifications were identified. A V600E substitution in BRAF was detected in a Caucasian male smoker diagnosed with SCLC with squamoid and glandular features.

Conclusion: The paucity of patients with sufficient tumour tissue, quality of DNA extracted and low frequency of aberrations detected indicate that alternative molecular characterisation approaches are necessary, such as the use of circulating plasma DNA in patients with SCLC.

IMPLEMENTING BACK PAIN TREATMENT PATHWAYS IN CLINICAL PRACTICE: QUALITATATIVE ANALYSIS OF STAKEHOLDER PERCEPTIONS

Background
Evidence-based practice advocates utilising best current research evidence, while reflecting patient preference and clinical expertise in decision making. Successfully incorporating this evidence into practice is a complex process. Based on recommendations of existing guidelines and systematic evidence reviews conducted using the GRADE approach, treatment pathways for common spinal pain disorders were developed.

Aims
The aim of this study was to identify important potential facilitators to the integration of these pathways into routine clinical practice.

Methods
A 22 person stakeholder group consisting of patient representatives, clinicians, researchers and members of relevant clinical interest groups took part in a series of moderated focus groups, followed up with individual, semi-structured interviews. Data were analysed using content analysis.

Results
Participants identified a number of issues which were categorized into broad themes. Common facilitators to implementation included continual education and synthesis of research evidence which is reflective of everyday practice; as well as the use of clear, unambiguous messages in recommendations. Meeting additional training needs in new or extended areas of practice was also recognized as an important factor. Different stakeholders identified specific areas which could be associated with successful uptake. Patients frequently defined early involvement in a shared decision making process as important. Clinicians identified case based examples and information on important prognostic indicators as useful tools to aiding decisions.

Conclusion
A number of potential implementation strategies were identified. Further work will examine the impact of these and other important factors on the integration of evidence-based treatment recommendations into clinical practice.

Chief Medical Officer's Report - Evidential Base and Clinical Practice Aspects of Congenital Cardiac Services (August 2013) (PDF 77KB)

Report on Evidential Base and Clinical Practice Aspects of Congenital Cardiac Services The principle drivers that should determine the optimal arrangements for the provision of congenital cardiac services, including  paediatric and adult cardiac surgery, for the population of Northern Ireland is how best those services can be configured to ensure the safest possible care that is of the highest quality possible in order to optimise outcomes and experience for patients and carers. Of necessity, this requires consideration of all requisite supporting services and arrangements to ensure access across the continuum of care. Such a configuration should support safe, high quality service provision on an on-going basis i.e. ensure sustainability as far as can be determined. In addressing this issue, consideration to the changing profile of population need and the evolving nature specialist services is required.  

Clinical practice guideline on diagnosis and treatment of hyponatraemia

Hyponatraemia, defined as a serum sodium concentration <135 mmol/l, is the most common disorder of body fuid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution-and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.

New clinical practice guideline on enteral feeding in very low birth weight infants: first part

Introduction: The nutrition of very low birth weight (VLBW) infants is aimed at promoting a similar growth to that occurring in the uterus. However, in practice this is difficult to achieve and extrauterine growth restriction is frequent. The current tendency is to avoid this restriction by means of early parenteral and enteral nutrition. Nonetheless, uncertainty about many of the practices related with nutrition has resulted in a great variation in the way it is undertaken. In 2009 and 2011 in our hospital there was an unexpected increase in necrotizing enterocolitis. To check to see whether our nutrition policy was involved, we undertook a systematic review and drew up clinical practice guidelines (CPG) about enteral feeding in VLBW infants. New considerations about the duration of the fortification and the use of probiotics have led to an update of these CPG. Methods: A total of 21 clinical questions were designed dealing with the type of milk, starting age, mode of administration, rate and volume of the increments, fortification, use of probiotics and protocol. After conducting a systematic search of the available evidence, the information was contrasted and summarized in order to draw up the recommendations. The quality of the evidence and the strength of the recommendations were determined from the SIGN scale Comment: These CPG aim to help physicians in their decision making. The protocolized application of well-proven measurements reduces the variation in clinical practice and improves results.

New clinical practice guideline on enteral feeding in very low birth weight infants: second part

Introduction: The nutrition of very low birth weight (VLBW) infants is aimed at promoting a similar growth to that occurring in the uterus. However, in practice this is difficult to achieve and extrauterine growth restriction is frequent. The current tendency is to avoid this restriction by means of early parenteral and enteral nutrition. Nonetheless, uncertainty about many of the practices related with nutrition has resulted in a great variation in the way it is undertaken. In 2009 and 2011 in our hospital there was an unexpected increase in necrotizing enterocolitis. To check to see wether our nutrition policy was involved, we underlook a systematic review and drewup clinical practice guidelines (CPG) about enteral feeding in VLBW infants. New considerations about the duration of the fortification and the use of probiotics have led to an update of these CPG. Methods: A total of 21 clinical questions were designed dealing with the type of milk, starting age, mode of administration, rate and volume of the increments, fortification, use of probiotics and protocol. Afete conducting a systematic search of the available evidence, the information was contrasted and summarized in order to draw up the recommendations. The quality of the evidence and the strength of the recommendations were determined from the SIGN scale. Comment: These CPG aim to help physicians in their decision making. The protocolized application of well-proven measurements reduces the variation in clinical practice and improves results.

Good laboratory practice: preventing introduction of bias at the bench

Background and Purpose—As a research community, we have failed to demonstrate that drugs which show substantial efficacy in animal models of cerebral ischemia can also improve outcome in human stroke. Summary of Review—Accumulating evidence suggests this may be due, at least in part, to problems in the design, conduct and reporting of animal experiments which create a systematic bias resulting in the overstatement of neuroprotective efficacy. Conclusions—Here, we set out a series of measures to reduce bias in the design, conduct and reporting of animal experiments modeling human stroke.

Implementation of an enhanced planar processing protocol in clinical practice

Introdução: A cintigrafia óssea é um dos exames mais frequentes em Medicina Nuclear. Esta modalidade de imagem médica requere um balanço apropriado entre a qualidade de imagem e a dose de radiação, ou seja, as imagens obtidas devem conter o número mínimo de contagem necessárias, para que apresentem qualidade considerada suficiente para fins diagnósticos. Objetivo: Este estudo tem como principal objetivo, a aplicação do software Enhanced Planar Processing (EPP), nos exames de cintigrafia óssea em doentes com carcinoma da mama e próstata que apresentam metástases ósseas. Desta forma, pretende-se avaliar a performance do algoritmo EPP na prática clínica em termos de qualidade e confiança diagnóstica quando o tempo de aquisição é reduzido em 50%. Material e Métodos: Esta investigação teve lugar no departamento de Radiologia e Medicina Nuclear do Radboud University Nijmegen Medical Centre. Cinquenta e um doentes com suspeita de metástases ósseas foram administrados com 500MBq de metilenodifosfonato marcado com tecnécio-99m. Cada doente foi submetido a duas aquisições de imagem, sendo que na primeira foi seguido o protocolo standard do departamento (scan speed=8 cm/min) e na segunda, o tempo de aquisição foi reduzido para metade (scan speed=16 cm/min). As imagens adquiridas com o segundo protocolo foram processadas com o algoritmo EPP. Todas as imagens foram submetidas a uma avaliação objetiva e subjetiva. Relativamente à análise subjetiva, três médicos especialistas em Medicina Nuclear avaliaram as imagens em termos da detetabilidade das lesões, qualidade de imagem, aceitabilidade diagnóstica, localização das lesões e confiança diagnóstica. No que respeita à avaliação objetiva, foram selecionadas duas regiões de interesse, uma localizada no terço médio do fémur e outra localizada nos tecidos moles adjacentes, de modo a obter os valores de relação sinal-ruído, relação contraste-ruído e coeficiente de variação. Resultados: Os resultados obtidos evidenciam que as imagens processadas com o software EPP oferecem aos médicos suficiente informação diagnóstica na deteção de metástases, uma vez que não foram encontradas diferenças estatisticamente significativas (p>0.05). Para além disso, a concordância entre os observadores, comparando essas imagens e as imagens adquiridas com o protocolo standard foi de 95% (k=0.88). Por outro lado, no que respeita à qualidade de imagem, foram encontradas diferenças estatisticamente significativas quando se compararam as modalidades de imagem entre si (p≤0.05). Relativamente à aceitabilidade diagnóstica, não foram encontradas diferenças estatisticamente significativas entre as imagens adquiridas com o protocolo standard e as imagens processadas com o EPP software (p>0.05), verificando-se uma concordância entre os observadores de 70.6%. Todavia, foram encontradas diferenças estatisticamente significativas entre as imagens adquiridas com o protocolo standard e as imagens adquiridas com o segundo protocolo e não processadas com o software EPP (p≤0.05). Para além disso, não foram encontradas diferenças estatisticamente significativas (p>0.05) em termos de relação sinal-ruído, relação contraste-ruído e coeficiente de variação entre as imagens adquiridas com o protocolo standard e as imagens processadas com o EPP. Conclusão: Com os resultados obtidos através deste estudo, é possível concluir que o algoritmo EPP, desenvolvido pela Siemens, oferece a possibilidade de reduzir o tempo de aquisição em 50%, mantendo ao mesmo tempo uma qualidade de imagem considerada suficiente para fins de diagnóstico. A utilização desta tecnologia, para além de aumentar a satisfação por parte dos doentes, é bastante vantajosa no que respeita ao workflow do departamento.

Initial experience with golimumab in clinical practice for ulcerative colitis

Background: Golimumab is a TNF-blocking agent indicated as a second-line therapy in ulcerative colitis. Purpose: To research the effectiveness and safety of golimumab in patients with ulcerative colitis in clinical practice. Methods: Retrospective study of the effectiveness and safety of golimumab in patients with ulcerative colitis. All patients received golimumab 200 mg subcutaneously at week 0, and golimumab 100 mg subcutaneously at week 2. After the induction treatment, each patient received 50 mg sc. every 4 weeks in patients with body weight less than 80 kg, and 100 mg every 4 weeks in patients with body weight greater than or equal to 80 kg. Results: Study of a group of 23 ulcerative colitis patients, 7 of whom were naive to any anti-TNF therapy, and 16 patients who had previously been treated with an anti-TNF agent other than golimumab (non-naive patients). The average treatment time with golimumab was 14.3 weeks. Globally, withdrawal of corticosteroids was observed in 74% of cases. Clinical response was observed in 85.5% of patients who had not received biological treatment previously, and in patients who had previously received biological treatment the response rate was 75%. Conclusions: In this short study, golimumab seems to be an alternative treatment in naive and non-naive anti-TNF ulcerative colitis patients. It is also a safe therapy, given that there were no adverse effects in the patients studied.

Clinical Practice Guideline: irritable bowel syndrome with constipation and functional constipation in the adult

In this Clinical Practice Guideline we discuss the diagnostic and therapeutic approach of adult patients with constipation and abdominal complaints at the confluence of the irritable bowel syndrome spectrum and functional constipation. Both conditions are included among the functional bowel disorders, and have a significant personal, healthcare, and social impact, affecting the quality of life of the patients who suffer from them. The first one is the irritable bowel syndrome subtype, where constipation represents the predominant complaint, in association with recurrent abdominal pain, bloating, and abdominal distension. Constipation is characterized by difficulties with or low frequency of bowel movements, often accompanied by straining during defecation or a feeling of incomplete evacuation. Most cases have no underlying medical cause, and are therefore considered as a functional bowel disorder. There are many clinical and pathophysiological similarities between both disorders, and both respond similarly to commonly used drugs, their primary difference being the presence or absence of pain, albeit not in an "all or nothing" manner. Severity depends not only upon bowel symptom intensity but also upon other biopsychosocial factors (association of gastrointestinal and extraintestinal symptoms, grade of involvement, and perception and behavior variants). Functional bowel disorders are diagnosed using the Rome criteria. This Clinical Practice Guideline has been made consistent with the Rome IV criteria, which were published late in May 2016, and discuss alarm criteria, diagnostic tests, and referral criteria between Primary Care and gastroenterology settings. Furthermore, all the available treatment options (exercise, fluid ingestion, diet with soluble fiber-rich foods, fiber supplementation, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antidepressants, psychological therapy, acupuncture, enemas, sacral root neurostimulation, surgery) are discussed, and practical recommendations are made regarding each of them.

Relevance of anatomy to medical education and clinical practice: perspectives of medical students, clinicians, and educators

Introduction: Against a backdrop of ever-changing diagnostic and treatment modalities, stakeholder perceptions (medical students, clinicians, anatomy educators) are crucial for the design of an anatomy curriculum which fulfils the criteria required for safe medical practice. This study compared perceptions of students, practising clinicians, and anatomy educators with respect to the relevance of anatomy education to medicine. Methods: A quantitative survey was administered to undergraduate entry (n = 352) and graduate entry students (n = 219) at two Irish medical schools, recently graduated Irish clinicians (n = 146), and anatomy educators based in Irish and British medical schools (n = 30). Areas addressed included the association of anatomy with medical education and clinical practice, mode of instruction, and curriculum duration. Results: Graduate-entry students were less likely to associate anatomy with the development of professionalism, teamwork skills, or improved awareness of ethics in medicine. Clinicians highlighted the challenge of tailoring anatomy education to increase student readiness to function effectively in a clinical role. Anatomy educators indicated dissatisfaction with the time available for anatomy within medical curricula, and were equivocal about whether curriculum content should be responsive to societal feedback. Conclusions: The group differences identified in the current study highlight areas and requirements which medical education curriculum developers should be sensitive to when designing anatomy courses.