Barriers to providing palliative care in long-term care facilities

OBJECTIVE: To assess challenges in providing palliative care in long-term care (LTC) facilities from the perspective of medical directors. DESIGN: Cross-sectional mailed survey. A questionnaire was developed, reviewed, pilot-tested, and sent to 450 medical directors representing 531 LTC facilities. Responses were rated on 2 different 5-point scales. Descriptive analyses were conducted on all responses. SETTING: All licensed LTC facilities in Ontario with designated medical directors. PARTICIPANTS: Medical directors in the facilities. MAIN OUTCOME MEASURES: Demographic and practice characteristics of physicians and facilities, importance of potential barriers to providing palliative care, strategies that could be helpful in providing palliative care, and the kind of training in palliative care respondents had received. RESULTS: Two hundred seventy-five medical directors (61%) representing 302 LTC facilities (57%) responded to the survey. Potential barriers to providing palliative care were clustered into 3 groups: facility staff's capacity to provide palliative care, education and support, and the need for external resources. Two thirds of respondents (67.1%) reported that inadequate staffing in their facilities was an important barrier to providing palliative care. Other barriers included inadequate financial reimbursement from the Ontario Health Insurance Program (58.5%), the heavy time commitment required (47.3%), and the lack of equipment in facilities (42.5%). No statistically significant relationship was found between geographic location or profit status of facilities and barriers to providing palliative care. Strategies respondents would use to improve provision of palliative care included continuing medical education (80.0%), protocols for assessing and monitoring pain (77.7%), finding ways to increase financial reimbursement for managing palliative care residents (72.1%), providing educational material for facility staff (70.7%), and providing practice guidelines related to assessing and managing palliative care patients (67.8%). CONCLUSION: Medical directors in our study reported that their LTC facilities were inadequately staffed and lacked equipment. The study also highlighted the specialized role of medical directors, who identified continuing medical education as a key strategy for improving provision of palliative care.

The view from over there:reframing the OSCE through the experience of standardised patient raters

Ratings awarded by standardised patients (SPs) in UK objective structured clinical examinations (OSCEs) are typically based on humanistic (non-technical) skills and are complementary to clinician-examiner ratings. In psychometric terms, SP ratings appear to differ from examiner ratings and improve reliability. For the first time, we used qualitative methods from a constructivist perspective to explore SP experiences of rating, and consider how these impact our understanding of assessment.

The student experience in Objective Structured Clinical Examinations (OSCEs): phenomenological analysis

Background and purpose
The dominant psychometric discourse of OSCEs may lead to unexpected problems, such as a checklist-based student performance1 which under emphasises the clinical relationship with student and standardised patient (SP). Such encounters can be dehumanising for SPs2 and have implications for what students learn about relational skills through the assessment process. In this study we explore medical students’ experiences of undertaking OSCEs using a phenomenological frame.
Methodology
Interpretative phenomenological analysis is a form of qualitative methodology which has strong resonance with existentialism and focuses on the lived experience without significant reference to external political or discursive
forces.
Six 4th year undergraduate medical students from Queen’s University Belfast were recruited in December 2013. Maximum variation sampling was used. Students were interviewed by a researcher in the week prior to the
OSCE and then again in the week following the OSCE in Jan 2014. Interviews were minimally structured in order to be open to respondents, rather than adhering to a fixed topic guide, but focussed on participants’ experiences, thoughts and feelings about taking part in OSCEs. Interviews were audio-recorded and
transcribed. Students were also asked to complete a short diary entry in the days prior to the OSCEs and another immediately following. Diary entries were written, emailed or audio-recorded at student’s preference.
Results
Transcripts are currently being analysed by interpretative phenomenological analysis. Preliminary analysis has demonstrated the significance of students’ relationships within the OSCE triad (student, SP and examiner); the effect of the immediate examination environment; realism versus roleplay; students’ perceptions of the purpose of assessment; and coping mechanisms.
Full results will be available by the time of the conference.
Conclusion and Discussion
Understanding the student experience in OSCEs is a crucial step in understanding the complex construction of relationships within the OSCE triad. The focus in OSCEs is typically on standardisation and reliability, but in exploring social interactions we may refocus attention on their inherent potential for learning and effects on both students and patients.
References
1. Hodges B. Medical education and the maintenance of incompetence. Med Teach 2006;28(8):690-6
2. Johnston JL, Lundy G, McCullough M, Gormley GJ. The view from over there: reframing the OSCE through the experience of standardised patient
raters. Med Educ 2013;47(9):899-909

Factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for dying patients – a realist evaluation

Objectives: The Liverpool Care Pathway for the dying patient (LCP) was designed to improve end-of-life care in generalist health care settings. Controversy has led to its withdrawal in some jurisdictions. The main objective of this research was to identify the influences that facilitated or hindered successful LCP implementation.

Method: An organisational case study using realist evaluation in one health and social care trust in Northern Ireland. Two rounds of semi-structured interviews were conducted with two policy makers and twenty two participants with experience and/or involvement in management of the LCP during 2011 and 2012.

Results: Key resource inputs included facilitation with a view to maintaining LCP ‘visibility’, reducing anxiety among nurses and increasing their confidence regarding the delivery of end-of-life care; and nurse and medical education designed to increase professional self-efficacy and reduce misuse and misunderstanding of the LCP. Key enabling contexts were consistent senior management support; ongoing education and training tailored to the needs of each professional group; and an organisational cultural change in the hospital setting that encompassed end-of-life care.

Conclusion: There is a need to appreciate the organizationally complex nature of intervening to improve end-of-life care. Successful implementation of evidence-based interventions for end-of-life care requires commitment to planning, training and ongoing review that takes account of different perspectives, institutional hierarchies and relationships and the educational needs of professional disciplines. There is a need also to recognise that medical consultants require particular support in their role as gatekeepers and as a lead communication channel with patients and their relatives.

'Sorry I meant the patient's left side': impact of distraction on right/left discrimination

Context Medical students can have difficulty in distinguishing left from right. Many infamous medical errors have occurred when a procedure has been performed on the wrong side, such as in the removal of the wrong kidney. Clinicians encounter many distractions during their work. There is limited information on how these affect performance. 
Objectives Using a neuropsychological paradigm, we aim to elucidate the impacts of different types of distraction on left–right (LR) discrimination ability. 
Methods Medical students were recruited to a study with four arms: (i) control arm (no distraction); (ii) auditory distraction arm (continuous ambient ward noise); (iii) cognitive distraction arm (interruptions with clinical cognitive tasks), and (iv) auditory and cognitive distraction arm. Participants’ LR discrimination ability was measured using the validated Bergen Left–Right Discrimination Test (BLRDT). Multivariate analysis of variance was used to analyse the impacts of the different forms of distraction on participants’ performance on the BLRDT. Additional analyses looked at effects of demographics on performance and correlated participants’ self-perceived LR discrimination ability and their actual performance. 
Results A total of 234 students were recruited. Cognitive distraction had a greater negative impact on BLRDT performance than auditory distraction. Combined auditory and cognitive distraction had a negative impact on performance, but only in the most difficult LR task was this negative impact found to be significantly greater than that of cognitive distraction alone. There was a significant medium-sized correlation between perceived LR discrimination ability and actual overall BLRDT performance. 
Conclusions
Distraction has a significant impact on performance and multifaceted approaches are required to reduce LR errors. Educationally, greater emphasis on the linking of theory and clinical application is required to support patient safety and human factor training in medical school curricula. Distraction has the potential to impair an individual's ability to make accurate LR decisions and students should be trained from undergraduate level to be mindful of this.

Integrating elements of undergraduate curriculum learning

Integrating elements of undergraduate curriculum learning Rapidly advancing practice and recognition of nursing, midwifery and medicine as a vital interrelated workforce, implies a need for a variety of curricula opportunities. This project addresses the challenge for healthcare educators to widen student engagement and participation through inter-professional education by creating learning environments whereby student interactions foster the desire to develop situational awareness, independent learning and contribution to patient advocacy. Overall aim of this ‘Feeding and Nutrition in Infants and Children’ project is to provide opportunities for integrated learning to enable students to advance their knowledge and understanding of current best practice. This Inter-professional (IPE) student-lead workshop was initially implemented in 2006-07 in collaboration with the Centre for Excellence in IPE, within the curricula of medical and nursing programmes¹. Supported by the development of a student resource pack, this project is now being offered to Learning Disability nursing and Midwifery students since September 2014. Methods: Fourth year medical students, undertaking a ‘Child Healthcare module’, alongside nursing and /or midwifery students are divided into groups with three or four students from each profession. Each group focuses on a specific feeding problem that is scenario-based on a common real-life issue prior to the workshop and then present their findings / possible solutions to feeding problem. They are observed by both facilitators and peers, who provide constructive feedback on aspects of performance including patient safety, cultural awareness, communication, decision making skills, teamwork and an appreciation of the role of various professionals in managing feeding problems in infants and children. Results: Participants complete a Likert-scale questionnaire to ascertain their reactions to this integrated learning experience. Ongoing findings suggest that students evaluate this learning activity very positively and have stated that they value the opportunity to exercise their clinical judgement and decision making skills. Most recent comments: ‘appreciate working alongside other student’s / multidisciplinary team approach’ As a group students engage in this team problem-solving exercise, drawing upon their strengths and abilities to learn from each other. This project provides a crucial opportunity for learning and knowledge exchange for all those medical, midwifery and nursing students involved. Reference: 1. Purdy, J. & Stewart, M (2009) ‘Feeding and Nutrition in Infants and Children: An Interprofessional Approach’. The Clinical Teacher, vol 6, no.3. Authors: Dr. Angela Bell, Centre for Medical Education, Queen’s University Belfast. Doris Corkin, Senior Lecturer (education), Children’s Nursing, School of Nursing & Midwifery, Queen’s University Belfast. Carolyn Moorhead, Midwifery Lecturer, School of Nursing & Midwifery, Queen’s University Belfast. Ann Devlin, Lecturer (education), Learning Disability Nursing, School of Nursing & Midwifery, Queen’s University Belfast.

A strategy towards professionalism in the dissecting room

The teaching and cultivation of professionalism is an integral part of medical education as professionalism is central to maintaining the public’s trust in the medical profession. Traditionally professional values would have been acquired through an informal process of socialisation and observation of role models. Recently, however, medical educators have accepted the responsibility to explicitly teach and effectively evaluate professionalism. A comprehensive working definition of the term professionalism and a universally agreed list of the constituent elements of professionalism are currently debated. The School of Medicine and Dentistry of The Queen’s University of Belfast uses an approach of self-directed learning for teaching anatomy, and students are given the opportunity to learn anatomy from human dissection. Self-directed learning teams have been found to be underutilised as educational strategies and presented an opportunity to utilise the first year dissection room teaching environment to nurture the development of the attributes of professionalism. An educational strategy based on role-playing was developed to engage all students around the dissection table. Students received comprehensive background reviews on professionalism, its attributes and the identification of such attributes in the context of the dissection room. Roles, with specific duties attached, were allocated to each team member. Circulating academic staff members directly observed student participation and gave formative feedback. Students were given the opportunity to reflect on their ability to identify the attributes and reflect on their own and their peer’s ability to develop and practise these attributes. This strategy indicated that small group learning teams in the dissection room utilise widely accepted principles of adult learning and offer an opportunity to create learning activities that will instil in students the knowledge, values, attitudes and behaviours that characterise medical professionalism. Anatomy faculty have a responsibility to nurture and exemplify professionalism and play a significant role in the early promotion and inculcation of professionalism. It remains imperative not only to assess this strategy but also to create opportunities for critical reflection and evaluation within the strategy. Key words: Medical Education – Professionalism – Anatomy - Reflective Practise – Role-play

A survey of perceived training differences between ophthalmology residents in Hong Kong and China.

Background: To study the differences in ophthalmology resident training between China and the Hong Kong Special Administrative Region (HKSAR).Methods: Training programs were selected from among the largest and best-known teaching hospitals. Ophthalmology residents were sent an anonymous 48-item questionnaire by mail. Work satisfaction, time allocation between training activities and volume of surgery performed were determined.Results: 50/75 residents (66.7 %) from China and 20/26 (76.9 %) from HKSAR completed the survey. Age (28.9 ± 2.5 vs. 30.2 ± 2.9 years, p = 0.15) and number of years in training (3.4 ± 1.6 vs. 2.8 ± 1.5, p = 0.19) were comparable between groups. The number of cataract procedures performed by HKSAR trainees (extra-capsular, median 80.0, quartile range: 30.0, 100.0; phacoemulsification, median: 20.0, quartile range: 0.0, 100.0) exceeded that for Chinese residents (extra-capsular: median = 0, p < 0.0001; phacoemulsification: median = 0, p < 0.0001). Chinese trainees spent more time completing medical charts (>50 % of time on charts: 62.5 % versus 5.3 %, p < 0.0001) and received less supervision (≥90 % of training supervised: 4.4 % versus 65 %, p < 0.0001). Chinese residents were more likely to feel underpaid (96.0 % vs. 31.6 %, p < 0.0001) and hoped their children would not practice medicine (69.4 % vs. 5.0 %, p = 0.0001) compared HKSAR residents.Conclusions: In this study, ophthalmology residents in China report strikingly less surgical experience and supervision, and lower satisfaction than HKSAR residents. The HKSAR model of hands-on resident training might be useful in improving the low cataract surgical rate in China.

Beyond work-hour restrictions: a qualitative study of residents' subjective workload

INTRODUCTION: Following the introduction of work-hour restrictions, residents' workload has become an important theme in postgraduate training. The efficacy of restrictions on workload, however, remains controversial, as most research has only examined objective workload. The purpose of this study was to explore the less clearly understood component of subjective workload and, in particular, the factors that influenced residents' subjective workload.

METHOD: This study was conducted in Japan at three community teaching hospitals. We recruited a convenience sample of 31 junior residents in seven focus groups at the three sites. Audio-recorded and transcribed data were read iteratively and analyzed thematically, identifying, analyzing and reporting themes within the data and developing an interpretive synthesis of the topic.

RESULTS: Seven factors influenced residents' subjective workload: (1) interaction within the professional community, (2) feedback from patients, (3) being in control, (4) professional development, (5) private life, (6) interest and (7) protected free time.

DISCUSSION AND CONCLUSION: Our findings indicate that residents who have good interaction with colleagues and patients, are competent enough to control their work, experience personal development through working, have greater interest in their work, and have fulfilling private lives will have the least subjective workload.

Emotions and identity in the figured world of becoming a doctor

CONTEXT: There is little room in clerkship curricula for students to express emotions, particularly those associated with the development of a caring identity. Yet it is recognised that competence, alone, does not make a good doctor. We therefore set out to explore the relationship between emotions and identity in clerkship education. Our exploration was conceptually oriented towards Figured Worlds theory, which is linked to Bakhtin's theory of dialogism.

METHODS: Nine female and one male member of a mixed student cohort kept audio-diaries and participated in both semi-structured and cognitive individual interviews. The researchers identified 43 emotionally salient utterances in the dataset and subjected them to critical discourse analysis. They applied Figured Worlds constructs to within-case and cross-case analyses, supporting one another's reflexivity and openness to different interpretations, and constantly comparing their evolving interpretation against the complete set of transcripts.

RESULTS: Students' emotions were closely related to their identity development in the world of medicine. Patients were disempowered by their illnesses. Doctors were powerful because they could treat those illnesses. Students expressed positive emotions when they were granted positions in the world of medicine and were able to identify with the figures of doctors or other health professionals. They identified with doctors who behaved in caring and professionally appropriate ways towards patients and supportively towards students. Students expressed negative emotions when they were unable to develop their identities.

CONCLUSIONS: Critical discourse analysis has uncovered a link between students' emotions and their identity development in the powerful world of becoming and being a doctor. At present, identity development, emotions and power are mostly tacit in undergraduate clinical curricula. We speculate that helping students to express emotions and exercise power in the most effective ways might help them to develop caring identities.

Using genomics for drug discovery in medulloblastoma

Tese de doutoramento, Medicina (Neurocirurgia), Universidade de Lisboa, Faculdade de Medicina, 2014