Patience, Persistence and Pragmatism: Experiences and Lessons Learnt from the Implementation of Clinically Integrated Teaching and Learning of Evidence-Based Health Care - A Qualitative Study

Background

Clinically integrated teaching and learning are regarded as the best options for improving evidence-based healthcare (EBHC) knowledge, skills and attitudes. To inform implementation of such strategies, we assessed experiences and opinions on lessons learnt of those involved in such programmes.

Methods and Findings

We conducted semi-structured interviews with 24 EBHC programme coordinators from around the world, selected through purposive sampling. Following data transcription, a multidisciplinary group of investigators carried out analysis and data interpretation, using thematic content analysis. Successful implementation of clinically integrated teaching and learning of EBHC takes much time. Student learning needs to start in pre-clinical years with consolidation, application and assessment following in clinical years. Learning is supported through partnerships between various types of staff including the core EBHC team, clinical lecturers and clinicians working in the clinical setting. While full integration of EBHC learning into all clinical rotations is considered necessary, this was not always achieved. Critical success factors were pragmatism and readiness to use opportunities for engagement and including EBHC learning in the curriculum; patience; and a critical mass of the right teachers who have EBHC knowledge and skills and are confident in facilitating learning. Role modelling of EBHC within the clinical setting emerged as an important facilitator. The institutional context exerts an important influence; with faculty buy-in, endorsement by institutional leaders, and an EBHC-friendly culture, together with a supportive community of practice, all acting as key enablers. The most common challenges identified were lack of teaching time within the clinical curriculum, misconceptions about EBHC, resistance of staff, lack of confidence of tutors, lack of time, and negative role modelling.

Conclusions

Implementing clinically integrated EBHC curricula requires institutional support, a critical mass of the right teachers and role models in the clinical setting combined with patience, persistence and pragmatism on the part of teachers.

Demand response to improved walking infrastructure: A study into the economics of walking and health behaviour change

Walking is the most common form of moderate‐intensity physical activity among adults, is widely accessible and especially appealing to obese people. Most often policy makers are interested in valuing the effect on walking of changes in some characteristics of a neighbourhood, the demand response for walking, of infrastructure changes. A positive demand response to improvements in the walking environment could help meet the public health target of 150 minutes of at least moderate‐intensity physical activity per week. We model walking in an individual’s local neighbourhood as a ‘weak complement’ to the characteristics of the neighbourhood itself. Walking is affected by neighbourhood
characteristics, substitutes, and individual’s characteristics, including their opportunity cost of time.  Using compensating variation, we assess the economic benefits of walking and how walking behaviour is affected by improvements to the neighbourhood.  Using a sample of 1,209 respondents surveyed over a 12 month period (Feb 2010‐Jan 2011) in East Belfast, United Kingdom, we find that a policy that increased walkability and people’s perception of access to shops and facilities  would lead to an increase in walking of about 36 minutes/person/week, valued at £13.65/person/week. When focusing on inactive residents, a policy that improved the walkability of the area would lead to guidelines for physical activity being reached by only 12.8% of the population who are currently inactive. Additional interventions would therefore be needed to encourage inactive residents to
achieve the recommended levels of physical activity, as it appears that interventions that improve the walkability of an area are particularly effective in increasing walking among already active citizens, and, among the inactive ones, the best response is found among healthier, younger and wealthier citizens.

Hardware Software Interface: a Strategy for the implementation of Urban Agriculture

This paper describes how urban agriculture differs from conventional agriculture not only in the way it engages with the technologies of growing, but also in the choice of crop and the way these are brought to market. The authors propose a new model for understanding these new relationships, which is analogous to a systems view of information technology, namely Hardware-Software- Interface.
The first component of the system is hardware. This is the technological component of the agricultural system. Technology is often thought of as equipment, but its linguistic roots are in ‘technis’ which means ‘know how’. Urban agriculture has to engage new technologies, ones that deal with the scale of operation and its context which is different than rural agriculture. Often the scale is very small, and soils are polluted. There this technology in agriculture could be technical such as aquaponic systems, or could be soil-based agriculture such as allotments, window-boxes, or permaculture. The choice of method does not necessarily determine the crop produced or its efficiency. This is linked to the biotic that is added to the hardware, which is seen as the ‘software’.
The software of the system are the ecological parts of the system. These produce the crop which may or may not be determined by the technology used. For example, a hydroponic system could produce a range of crops, or even fish or edible flowers. Software choice can be driven by ideological preferences such as permaculture, where companion planting is used to reduce disease and pests, or by economic factors such as the local market at a particular time of the year. The monetary value of the ‘software’ is determined by the market. Obviously small, locally produced crops are unlikely to compete against intensive products produced globally, however the value locally might be measured in different ways, and might be sold on a different market. This leads to the final part of the analogy - interface.
The interface is the link between the system and the consumer. In traditional agriculture, there is a tenuous link between the producer of asparagus in Peru and the consumer in Europe. In fact very little of the money spent by the consumer ever reaches the grower. Most of the money is spent on refrigeration, transport and profit for agents and supermarket chains. Local or hyper-local agriculture needs to bypass or circumvent these systems, and be connected more directly to the consumer. This is the interface. In hyper-localised systems effectiveness is often more important than efficiency, and direct links between producer and consumer create new economies.

Working with the complexities of adolescent mental health problems: applying Time‐limited Adolescent Psychodynamic Psychotherapy (TAPP)

This article discusses the application in a CAMHS setting of a distinctive intervention for adolescent mental health difficulties, Time‐limited Adolescent Psychodynamic Psychotherapy (TAPP). TAPP has been developed specifically for working with adolescents and the characteristic developmental and psychosocial complexities they present to mental health services. It is widely recognised that supporting the developmental process in adolescence is central to therapeutic interventions and the therapeutic aim of TAPP is to enable recovery of the capacity to meet developmental challenges. The key factors of TAPP are described, including the formulation and working with a developmental focus, the therapeutic stance, working with transference and counter‐transference, working with time limits, and the emphasis on engagement of adolescents in therapy in TAPP. The experiences of introducing and developing TAPP in the CAMHS service are discussed with two brief and one extended case examples and this leads to a discussion of the kinds of outcomes achieved. It is concluded that TAPP is a key and relevant intervention for adolescents in complex and vulnerable situations; further work will be undertaken to continue its application in these settings and to formally assess outcomes.

Monitoring of urban transportation networks using wireless sensor networks

Dissertação de mestrado, Engenharia Informática, Faculdade de Ciências e Tecnologia, Universidade do Algarve, 2015