Mind mapping: A tool to facilitate learning; why not give it a try?

Schools of nursing continuously strive to facilitate learning through student engagement and teaching strategies that encourage active learning. This paper reports on the successful use of mind mapping, an underutilised and underdeveloped strategy, to enhance teaching and learning in undergraduate nurse education (Spencer et al., 2013). Mind mapping or concept mapping has been defined in the literature as a visual representation of one’s thoughts and ideas (Abel and Freeze, 2006). It is characterised by colour, images and text in a graphical, nonlinear style. Mind maps promote the linking of concepts and capitalise on the brain’s natural aptitude for visual recognition to enhance learning and memory recall (Buzan, 2006). Traditional teaching strategies depend on linear processes, which in comparison lack engagement, associations and creativity (Spencer et al., 2013). Mind mapping was introduced to nursing students undertaking modules in ‘Dimensions of Care’ and ‘Care Delivery’ on year two of the nursing degree programme in Queen’s University Belfast. The aim of introducing mind mapping was to help students make the critical link between the pathophysiology of conditions studied and the provision of informed, safe and effective patient care, which had challenged previous student cohorts. Initially maps were instructor-made as described by Boley (2008), as a template for note taking during class and as a study aid. However, students rapidly embraced the strategy and started creating their own mind maps. Meaningful learning occurs when students engage with concepts and organise them independently in a way significant to them (Buzan, 2006). Students reported high levels of satisfaction to this teaching approach. This paper will present examples of the mind maps produced and explore how mind mapping can be further utilised within the undergraduate nursing curriculum.

Integrating molecular diagnostics into histopathology training: the Belfast model

Molecular medicine is transforming modern clinical practice, from diagnostics to therapeutics. Discoveries in research are being incorporated into the clinical setting with increasing rapidity. This transformation is also deeply changing the way we practise pathology. The great advances in cell and molecular biology which have accelerated our understanding of the pathogenesis of solid tumours have been embraced with variable degrees of enthusiasm by diverse medical professional specialties. While histopathologists have not been prompt to adopt molecular diagnostics to date, the need to incorporate molecular pathology into the training of future histopathologists is imperative. Our goal is to create, within an existing 5-year histopathology training curriculum, the structure for formal substantial teaching of molecular diagnostics. This specialist training has two main goals: (1) to equip future practising histopathologists with basic knowledge of molecular diagnostics and (2) to create the option for those interested in a subspecialty experience in tissue molecular diagnostics to pursue this training. It is our belief that this training will help to maintain in future the role of the pathologist at the centre of patient care as the integrator of clinical, morphological and molecular information.

Enhanced clinical pharmacy service targeting tools: risk-predictive algorithms

Rationale, aims and objectives: This study aimed to determine the value of using a mix of clinical pharmacy data and routine hospital admission spell data in the development of predictive algorithms. Exploration of risk factors in hospitalized patients, together with the targeting strategies devised, will enable the prioritization of clinical pharmacy services to optimize patient outcomes. 

Methods: Predictive algorithms were developed using a number of detailed steps using a 75% sample of integrated medicines management (IMM) patients, and validated using the remaining 25%. IMM patients receive targeted clinical pharmacy input throughout their hospital stay. The algorithms were applied to the validation sample, and predicted risk probability was generated for each patient from the coefficients. Risk threshold for the algorithms were determined by identifying the cut-off points of risk scores at which the algorithm would have the highest discriminative performance. Clinical pharmacy staffing levels were obtained from the pharmacy department staffing database. 

Results: Numbers of previous emergency admissions and admission medicines together with age-adjusted co-morbidity and diuretic receipt formed a 12-month post-discharge and/or readmission risk algorithm. Age-adjusted co-morbidity proved to be the best index to predict mortality. Increased numbers of clinical pharmacy staff at ward level was correlated with a reduction in risk-adjusted mortality index (RAMI). 

Conclusions: Algorithms created were valid in predicting risk of in-hospital and post-discharge mortality and risk of hospital readmission 3, 6 and 12 months post-discharge. The provision of ward-based clinical pharmacy services is a key component to reducing RAMI and enabling the full benefits of pharmacy input to patient care to be realized.

Attending Physician Variability: A Model of Four Supervisory Styles

Purpose: There is wide variability in how attending physician roles on teaching teams, including patient care and trainee learning, are enacted. This study sought to better understand variability by considering how different attendings configured and rationalized direct patient care, trainee oversight, and teaching activities. 

Method: Constructivist grounded theory guided iterative data collection and analyses. Data were interviews with 24 attending physicians from two academic centers in Ontario, Canada, in 2012. During interviews, participants heard a hypothetical presentation and reflected on it as though it were presented to their team during a typical admission case review. 

Results: Four supervisory styles were identified: direct care, empowerment, mixed practice, and minimalist. Driven by concerns for patient safety, direct care involves delegating minimal patient care responsibility to trainees. Focused on supporting trainees’ progressive independence, empowerment uses teaching and oversight strategies to ensure quality of care. In mixed practice, patient care is privileged over teaching and is adjusted on the basis of trainee competence and contextual features such as patient volume. Minimalist style involves a high degree of trust in senior residents, delegating most patient care, and teaching to them. Attendings rarely discussed their styles with the team. 

Conclusions: The model adds to the literature on variability in supervisory practice, showing that the four styles reflect different ways of responding to tensions in the role and context. This model could be refined through observational research exploring the impact of context on style development and enactment. Making supervisory styles explicit could support improvement of team competence.

Learning from the QUEST multicentre feasibility randomization trials in breast reconstruction after mastectomy

BACKGROUND: Breast reconstruction aims to improve health-related quality of life after mastectomy. However, evidence guiding patients and surgeons in shared decision-making concerning the optimal type or timing of surgery is lacking.

METHODS: QUEST comprised two parallel feasibility phase III randomized multicentre trials to assess the impact of the type and timing of latissimus dorsi breast reconstruction on health-related quality of life when postmastectomy radiotherapy is unlikely (QUEST A) or highly probable (QUEST B). The primary endpoint for the feasibility phase was the proportion of women who accepted randomization, and it would be considered feasible if patient acceptability rates exceeded 25 per cent of women approached. A companion QUEST Perspectives Study (QPS) of patients (both accepting and declining trial participation) and healthcare professionals assessed trial acceptability.

RESULTS: The QUEST trials opened in 15 UK centres. After 18 months of recruitment, 17 patients were randomized to QUEST A and eight to QUEST B, with overall acceptance rates of 19 per cent (17 of 88) and 22 per cent (8 of 36) respectively. The QPS recruited 56 patients and 51 healthcare professionals. Patient preference was the predominant reason for declining trial entry, given by 47 (53 per cent) of the 88 patients approached for QUEST A and 22 (61 per cent) of the 36 approached for QUEST B. Both trials closed to recruitment in December 2012, acknowledging the challenges of achieving satisfactory patient accrual.

CONCLUSION: Despite extensive efforts to overcome recruitment barriers, it was not feasible to reach timely recruitment targets within a feasibility study. Patient preferences for breast reconstruction types and timings were common, rendering patients unwilling to enter the trial.

Hydrogel-forming microneedle arrays made from light-responsive materials for on-demand transdermal drug delivery

We describe, for the first time, stimuli-responsive hydrogel-forming microneedle (MN) arrays that enable delivery of a clinically-relevant model drug (ibuprofen) upon application of light. MN arrays were prepared using a polymer prepared from 2-hydroxyethyl methacrylate (HEMA) and ethylene glycol dimethacrylate (EGDMA) by micromolding. The obtained MN arrays showed good mechanical properties. The system was loaded with up to 5% (w/w) ibuprofen included in a light-responsive 3,5-dimethoxybenzoin conjugate. Raman spectroscopy confirmed the presence of the conjugate inside the polymeric MN matrix. In vitro, this system was able to deliver up to three doses of 50 mg of ibuprofen upon application of an optical trigger over a prolonged period of time (up to 160 hours). This makes the system appealing as a controlled release device for prolonged periods of time. We believe that this technology has potential for use in ?on-demand? delivery of a wide range of drugs in a variety of applications relevant to enhanced patient care.

Implications of aligning full registration of doctors with medical school graduation:a qualitative study of stakeholder perspectives

OBJECTIVES: The Shape of Training report recommended that full registration is aligned with medical school graduation. As part of a General Medical Council-funded study about the preparedness for practice of UK medical graduates, we explored UK stakeholders' views about this proposal using qualitative interviews (30 group and 87 individual interviews) and Framework Analysis.

SETTING: Four UK study sites, one in each country.Save

PARTICIPANTS: 185 individuals from eight stakeholder groups: (1) foundation year 1 (F1) doctors (n=34); (2) fully registered trainee doctors (n=33); (3) clinical educators (n=32); (4) undergraduate/postgraduate Deans, and Foundation Programme Directors (n=30); (5) other healthcare professionals (n=13); (6) employers (n=7); (7) policy and government (n=11); (8) patient and public representatives (n=25).

RESULTS: We identified four main themes: (1) The F1 year as a safety net: patients were protected by close trainee supervision and 'sign off' to prevent errors; trainees were provided with a safe environment for learning on the job; (2) Implications for undergraduate medical education: if the proposal was accepted, a 'radical review' of undergraduate curricula would be needed; undergraduate education might need to be longer; (3) Implications for F1 work practice: steps to protect healthcare team integration and ensure that F1 doctors stay within competency limits would be required; (4) Financial, structural and political implications: there would be cost implications for trainees; clarification of responsibilities between undergraduate and postgraduate medical education would be needed. Typically, each theme comprised arguments for and against the proposal.

CONCLUSIONS: A policy change to align the timing of full registration with graduation would require considerable planning and preliminary work. These findings will inform policymakers' decision-making. Regardless of the decision, medical students should take on greater responsibility for patient care as undergraduates, assessment methods in clinical practice and professionalism domains need development, and good practice in postgraduate supervision and support must be shared.

Pharmacy students' use and views on over-the-counter (OTC) medicines; a questionnaire study

Introduction
The role of the pharmacist centers on ensuring the safe and effective use of medicines, including over-the-counter (OTC) medicines. It is important to ascertain pharmacy students’ use and opinions on OTC medicines, given that they are the pharmacists of the future and that this market continues to expand. This study aimed to investigate Queen’s University Belfast (QUB) final year pharmacy students’ use and views on OTC medicines. Scarce work has been conducted in this area to date.

Methods
Following ethical approval and a pilot study, all students (n=155) were invited to participate in a self-completed questionnaire (n=20 questions), distributed at a mandatory class. Descriptive statistics and non-parametric tests (Chi-squared and Mann Whitney U-test) were used for data analyses.

Results
The response rate was 99.4% (154/155). The majority (153/155) reported using OTC medicines; the key consideration during personal product selection was effectiveness. Most [96.1% (147/153)] were in agreement that safety was the over-riding concern during OTC consultations. While 96.1% (149/155) considered that using an evidence-based approach improved the quality of patient care, 68.0% (104/153) would be prepared to sell a product that lacks evidence of effectiveness, provided it would not cause harm.

Conclusions
The importance of evidence of effectiveness was acknowledged, yet many students in this study were prepared to recommend unproven products. Further strategies are required at QUB to ensure this routine consideration alongside safety in practice.

Undergraduate interprofessional education using high-fidelity paediatric simulation

BACKGROUND: High-fidelity simulation is becoming increasingly important in the delivery of teaching and learning to health care professionals within a safe environment. Its use in an interprofessional context and at undergraduate level has the potential to facilitate the learning of good communication and teamworking, in addition to clinical knowledge and skills.

METHODS: Interprofessional teaching and learning workshops using high-fidelity paediatric simulation were developed and delivered to undergraduate medical and nursing students at Queen's University Belfast. Learning outcomes common to both professions, and essential in the clinical management of sick children, included basic competencies, communication and teamworking skills. Quantitative and qualitative evaluation was undertaken using published questionnaires.

RESULTS: Quantitative results - the 32-item questionnaire was analysed for reliability using spss. Responses were positive for both groups of students across four domains - acquisition of knowledge and skills, communication and teamworking, professional identity and role awareness, and attitudes to shared learning. Qualitative results - thematic content analysis was used to analyse open-ended responses. Students from both groups commented that an interprofessional education (IPE) approach to paediatric simulation improved clinical and practice-based skills, and provided a safe learning environment. Students commented that there should be more interprofessional and simulation learning opportunities.

DISCUSSION: High-fidelity paediatric simulation, used in an interprofessional context, has the potential to meet the requirements of undergraduate medical and nursing curricula. Further research is needed into the long-term benefits for patient care, and its generalisability to other areas within health care teaching and learning.

Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews

Background Physical rehabilitation interventions aim to ameliorate the effects of critical illness-associated muscle dysfunction in survivors. We conducted an overview of systematic reviews (SR) evaluating the effect of these interventions across the continuum of recovery.

Methods Six electronic databases (Cochrane Library, CENTRAL, DARE, Medline, Embase, and Cinahl) were searched. Two review authors independently screened articles for eligibility and conducted data extraction and quality appraisal. Reporting quality was assessed and the Grading of Recommendations Assessment, Development and Evaluation approach applied to summarise overall quality of evidence.

Results Five eligible SR were included in this overview, of which three included meta-analyses. Reporting quality of the reviews was judged as medium to high. Two reviews reported moderate-to-high quality evidence of the beneficial effects of physical therapy commencing during intensive care unit (ICU) admission in improving critical illness polyneuropathy/myopathy, quality of life, mortality and healthcare utilisation. These interventions included early mobilisation, cycle ergometry and electrical muscle stimulation. Two reviews reported very low to low quality evidence of the beneficial effects of electrical muscle stimulation delivered in the ICU for improving muscle strength, muscle structure and critical illness polyneuropathy/myopathy. One review reported that due to a lack of good quality randomised controlled trials and inconsistency in measuring outcomes, there was insufficient evidence to support beneficial effects from physical rehabilitation delivered post-ICU discharge.

Conclusions Patients derive short-term benefits from physical rehabilitation delivered during ICU admission. Further robust trials of electrical muscle stimulation in the ICU and rehabilitation delivered following ICU discharge are needed to determine the long-term impact on patient care. This overview provides recommendations for design of future interventional trials and SR.

The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: An evidence synthesis

DESIGN We will address our research objectives by searching the published and unpublished literature and conducting an evidence synthesis of i) studies of the effectiveness of psychosocial interventions provided for children and adolescents who have suffered maltreatment, ii) economic evaluations of these interventions and iii) studies of their acceptability to children, adolescents and their carers. SEARCH STRATEGY: Evidence will be identified via electronic databases for health and allied health literature, social sciences and social welfare, education and other evidence based depositories, and economic databases. We will identify material generated by user-led,voluntary sector enquiry by searching the internet and browsing the websites of relevant UK government departments and charities. Additionally, studies will be identified via the bibliographies of retrieved articles/reviews; targeted author searches; forward citation searching. We will also use our extensive professional networks, and our planned consultations with key stakeholders and our study steering committee. Databases will be searched from inception to time of search. REVIEW STRATEGY Inclusion criteria: 1) Infants, children or adolescents who have experienced maltreatment between the ages of 0 17 years. 2) All psychosocial interventions available for maltreated children and adolescents, by any provider and in any setting, aiming to address the sequelae of any form of maltreatment, including fabricated illness. 3) For synthesis of evidence of effectiveness: all controlled studies in which psychosocial interventions are compared with no-treatment, treatment as usual, waitlist or other-treated controls. For a synthesis of evidence of acceptability we will include any design that asks participants for their views or provides data on non-participation. For decision-analytic modelling we may include uncontrolled studies. Primary and secondary outcomes will be confirmed in consultation with stakeholders. Provisional primary outcomes are psychological distress/mental health (particularly PTSD, depression and anxiety, self-harm); ii) behaviour; iii) social functioning; iv) cognitive / academic attainment, v) quality of life, and vi) costs. After studies that meet the inclusion criteria have been identified (independently by two reviewers), data will be extracted and risk of bias (RoB) assessed (independently by two reviewers) using the Cochrane Collaboration RoB Tool (effectiveness), quality hierarchies of data sources for economic analyses (cost-effectiveness) and the CASP tool for qualitative research (acceptability). Where interventions are similar and appropriate data are available (or can be obtained) evidence synthesis will be performed to pool the results. Where possible, we will explore the extent to which age, maltreatment history (including whether intra- or extra-familial), time since maltreatment, care setting (family / out-of-home care including foster care/residential), care history, and characteristics of intervention (type, setting, provider, duration) moderate the effects of psychosocial interventions. A synthesis of acceptability data will be undertaken, using a narrative approach to synthesis. A decision-analytic model will be constructed to compare the expected cost-effectiveness of the different types of intervention identified in the systematic review. We will also conduct a Value of information analysis if the data permit. EXPECTED OUTPUTS: A synthesis of the effectiveness and cost effectiveness of psychosocial interventions for maltreated children (taking into account age, maltreatment profile and setting) and their acceptability to key stakeholders.

Stellenabbau im Pflegedienst der Krankenhäuser. Eine Analyse der Entwicklung zwischen 1991 und 2005

Hintergrund: Seit Mitte der 1990er Jahre findet ein Stellenabbau in Krankenhäusern statt, von dem insbesondere auch der Pflegedienst betroffen ist. Obwohl die Tatsache seit längerem bekannt ist, fehlt es noch an einer gründlichen Analyse und Aufbereitung der verfügbaren Daten, um sich ein fundiertes Bild über den Umfang, die Entwicklung, Ursachen und Auswirkungen machen zu können. Methoden: Primäre Datengrundlage sind die Daten der Krankenhausstatistik sowie der Gesundheitsausgabenrechnung des Statistisches Bundesamtes. Ergebnisse: Die Analyse führt zu dem Ergebnis, dass zwischen 1995 und 2005 insgesamt ca. 104.000 Vollzeitstellen für nicht-ärztliches Personal in Allgemeinkrankenhäusern abgebaut wurden. Der ärztliche Dienst wurde hingegen um ca. 19.000 Vollkräfte ausgebaut. Im Saldo ergibt dies einen Gesamtstellenabbau von ca. 85.000 Vollkräften. Der größte Teil des Stellenabbaus entfiel mit ca. 44.000 Vollzeitstellen auf den Pflegedienst. Im Jahr 2005 lag die Zahl der Vollkräfte im Pflegedienst der Allgemeinkrankenhäuser um 13,7 % unter dem Wert des Jahres 1995 und sogar noch unter dem Wert des Jahres 1991, als über einen Pflegenotstand in Krankenhäusern gesellschaftlich diskutiert wurde. Eine Analyse der Kostendaten der Allgemeinkrankenhäuser zeigt, dass der Stellenabbau im Pflegedienst nicht allein durch die Budgetdeckelung und Einführung des DRG-Systems erklärt werden kann. Mehr als die Hälfte des Stellenabbaus wäre auf Grund der allgemeinen Budgetentwicklung nicht erforderlich gewesen, sondern erfolgte offenbar, um im Rahmen einer internen Umverteilung Mittel für andere Zwecke freizusetzen. Gewinner der internen Umverteilung war der ärztliche Dienst. Vor dem Hintergrund der Ergebnisse zahlreicher internationaler Studien muss davon ausgegangen werden, dass der Stellenabbau bereits negative Auswirkungen auf die Qualität der Patientenversorgung hat. Die Ergebnisse internationaler Forschung zu diesem Thema weisen darauf hin, dass eine niedrigere Personalbesetzung in Pflegedienst das Risiko erhöht, als Patient im Krankenhaus eine schwerwiegende Komplikation zu erleiden oder sogar zu versterben. Schlussfolgerungen: Es besteht dringender Handlungsbedarf, da sich die Personalbesetzung des Pflegedienstes in Allgemeinkrankenhäusern seit mehr als 10 Jahren in einer Abwärtsspirale befindet und mit weiterem Stellenabbau zu rechnen ist.

Intramuscular Injection Technique: an Evidence-based Approach

Intramuscular injections require a thorough and meticulous approach to patient assessment and injection technique. This article, the second in a series of two, reviews the evidence base to inform safer practice and to consider the evidence for nursing practice in this area. A framework for safe practice is included, identifying important points for safe technique, patient care and clinical decision making. It also highlights the ongoing debate in selection of intramuscular injection sites, predominately the ventrogluteal and dorsogluteal muscles.

A Review of National Guidelines for Management of COPD in Europe

The quality of care can be improved by the development and implementation of evidence-based treatment guidelines. Different national guidelines for chronic obstructive pulmonary disease (COPD) exist in Europe and relevant differences may exist among them.This was an evaluation of COPD treatment guidelines published in Europe and Russia in the past 7 years. Each guideline was reviewed in detail and information about the most important aspects of patient diagnosis, risk stratification and pharmacotherapy was extracted following a standardised process. Guidelines were available from the Czech Republic, England and Wales, Finland, France, Germany, Italy, Poland, Portugal, Russia, Spain and Sweden. The treatment goals, criteria for COPD diagnosis, consideration of comorbidities in treatment selection and support for use of long-acting bronchodilators, were similar across treatment guidelines. There were differences in measures used for stratification of disease severity, consideration of patient phenotypes, criteria for the use of inhaled corticosteroids and recommendations for other medications (e.g. theophylline and mucolytics) in addition to bronchodilators.There is generally good agreement on treatment goals, criteria for diagnosis of COPD and use of long-acting bronchodilators as the cornerstone of treatment among guidelines for COPD management in Europe and Russia. However, there are differences in the definitions of patient subgroups and other recommended treatments.

Fatores individuais de risco de infeção hospitalar : conhecer para prevenir

RESUMO - Medidas efetivas de prevenção e controlo de infeção, assim como a sua aplicação diária e consistente, devem fazer parte da cultura de segurança dos profissionais de saúde para promover a excelência da prestação de cuidados. Também a identificação dos fatores de riscos individuais de infeção é crucial e indispensável para a adoção de medidas para a gestão desses mesmos riscos. A avaliação do risco pretende determinar a probabilidade que um doente tem de adquirir ou disseminar uma infeção hospitalar (IH) (WIRRAL, 2008) nas unidades de saúde. A avaliação deve ser efetuada na admissão do doente e, de forma periódica durante o internamento, usando uma grelha de avaliação, integrada no processo global de cuidados do doente. Efetuada a avaliação de risco individual, que pressupõe a identificação dos fatores de risco do doente (fatores de risco intrínsecos e extrínsecos) pode ser implementado um plano de cuidados individualizado para os gerir. Pretendeu-se com este estudo identificar os fatores de risco de infeção hospitalar do doente que estão presentes na admissão e/ou que podem surgir durante o seu internamento, para que posteriormente seja possível determinar as medidas de prevenção (gestão do risco) a aplicar individualmente. Foi realizado um estudo de caso-controlo com os doentes internados no Hospital dos Lusíadas em 2011 com o objetivo de, por um lado, determinar os fatores de risco individuais que contribuem para a aquisição da IH e, por outro, caraterizar os fatores de risco para uma futura identificação de possíveis medidas de prevenção e controlo da aquisição e transmissão cruzada da infeção hospitalar. A população em estudo foi constituída pelos doentes que foram internados, entre 1 de Janeiro e 31 de Dezembro de 2011 sendo os casos os doentes em que foi identificada a presença de infeção hospitalar através do programa institucional de vigilância epidemiológica das infeções, tendo os controlos sido selecionados numa razão de 3:1 caso. Foi utilizado um suporte estruturado para a colheita de dados, com a listagem de fatores de risco identificados na revisão bibliográfica e de todos os fatores de risco apresentados pelos doentes em estudo. Os fatores de risco identificados que apresentaram um maior significado estatístico foram: a idade acima dos 50 anos, o género masculino, a administração de antimicrobianos nas três semanas anteriores ao internamento, a colocação de cateter venoso central, a algaliação e, no caso dos doentes cirúrgicos, a cirurgia de urgência e a classificação ASA 3. Após a identificação dos fatores de risco da população estudada neste hospital, é agora possível utilizar a informação obtida e delinear investigações adicionais, objetivando a construção de instrumentos para a identificação de doentes com risco aumentado de infeção.