Defining Goals and Learning Objectives for a Longitudinal Clerkship in the Complex Context of Health Care

In autumn 2007 the Swiss Medical School of Berne (Switzerland) implemented mandatory short-term clerkships in primary health care for all undergraduate medical students. Students studying for a Bachelor degree complete 8 half-days per year in the office of a general practitioner, while students studying for a Masters complete a three-week clerkship. Every student completes his clerkships in the same GP office during his four years of study. The purpose of this paper is to show how the goals and learning objectives were developed and evaluated. Method:A working group of general practitioners and faculty had the task of defining goals and learning objectives for a specific training program within the complex context of primary health care. The group based its work on various national and international publications. An evaluation of the program, a list of minimum requirements for the clerkships, an oral exam in the first year and an OSCE assignment in the third year assessed achievement of the learning objectives. Results: The findings present the goals and principal learning objectives for these clerkships, the results of the evaluation and the achievement of minimum requirements. Most of the defined learning objectives were taught and duly learned by students. Some learning objectives proved to be incompatible in the context of ambulatory primary care and had to be adjusted accordingly. Discussion: The learning objectives were evaluated and adapted to address students’ and teachers’ needs and the requirements of the medical school. The achievement of minimum requirements (and hence of the learning objectives) for clerkships has been mandatory since 2008. Further evaluations will show whether additional learning objectives need to be adopte

Predictors of health care professionals' attitudes towards involvement in safety-relevant behaviours

BACKGROUND Patients can make valuable contributions towards promoting the safety of their health care. Health care professionals (HCPs) could play an important role in encouraging patient involvement in safety-relevant behaviours. However, to date factors that determine HCPs' attitudes towards patient participation in this area remain largely unexplored. OBJECTIVE To investigate predictors of HCPs' attitudes towards patient involvement in safety-relevant behaviours. DESIGN A 22-item cross-sectional fractional factorial survey that assessed HCPs' attitudes towards patient involvement in relation to two error scenarios relating to hand hygiene and medication safety. SETTING Four hospitals in London PARTICIPANTS   Two hundred sixteen HCPs (116 doctors; 100 nurses) aged between 21 and 60 years (mean: 32): 129 female. OUTCOME MEASURES Approval of patient's behaviour, HCP response to the patient, anticipated effects on the patient-HCP relationship, support for being asked as a HCP, affective rating response to the vignettes. RESULTS HCPs elicited more favourable attitudes towards patients intervening about a medication error than about hand sanitation. Across vignettes and error scenarios, the strongest predictors of attitudes were how the patient intervened and how the HCP responded to the patient's behaviour. With regard to HCP characteristics, doctors viewed patients intervening less favourably than nurses. CONCLUSIONS HCPs perceive patients intervening about a potential error less favourably if the patient's behaviour is confrontational in nature or if the HCP responds to the patient intervening in a discouraging manner. In particular, if a HCP responds negatively to the patient (irrespective of whether an error actually occurred), this is perceived as having negative effects on the HCP-patient relationship.

Health Care Providers' Training Needs Related to Human Trafficking: Maximizing the Opportunity to Effectively Screen and Intervene

Human trafficking is a complex and multifaceted problem that takes the form of economic, physical and sexual exploitation of people, both adults and children, who are reduced to simple products for commerce. Human trafficking in the United States also has both a domestic and an international aspect. Health care providers are in a unique position to screen for victims of trafficking and may provide important medical and psychological care for victims while in captivity and thereafter. Trafficked persons are likely to suffer a wide spectrum of health risks that reflect the unique circumstances and experiences in a trafficked victim’s life. Although trafficked victims typically have experienced inadequate medical care, once contact is made by the victim with the health care professionals, the opportunity then exists to identify, treat, and assist such victims. The range of services and supports required to appropriately respond to human trafficking victims once identified is broad and typically goes beyond just what is immediately provided by the health care professional and includes safe housing, legal advice, income support, and, for international victims, immigration status related issues. An informed and responsive community is necessary to serve both the international and domestic victims of human trafficking, and needs assessments demonstrated a number of barriers that hindered the delivery of effective services to human trafficking victims. One of the consistent needs identified to combat these barriers was enhanced training among all professionals who might come in contact with human trafficking victims. We highlight the efforts of the Houston Rescue and Restore Coalition (HRRC), a local grassroots non-profit organization whose mission focuses on raising awareness of human trafficking in the Greater Houston Metropolitan area. HRRC responded to the consistent recommendation from various community needs assessments for additional training of front line professionals who would have the opportunity to identify human trafficking victims and supported the design and pilot testing of a health professions training program around human trafficking. Dissemination of this type of training along with careful evaluation and continued refinement will be one way for health care professionals to engage in a positive manner with human trafficking victims.

Effectiveness of Texas Children's Hospital's Saturday Wellness Program for Children with special health care needs

Children with Special Health Care Needs comprise approximately 13% of children within the state of Texas. In addition to their primary diagnosis, it is estimated that approximately 18% of these children with special health care needs are overweight. Many times parents of children with special health care needs are extremely busy dealing with the daily responsibilities required to care for a child with a chronic illness, and thus, lose connections with their local communities and available resources for health needs such as obesity. Texas Children’s Hospital’s Wellness Program for Children with Special Health Care Needs is a family-centered wellness program to prevent obesity in this population; however, no formal evaluation of the program has been conducted. The purpose of this study was to assess the effectiveness of the Texas Children’s Saturday Wellness Program on weight status, nutrition knowledge, and the frequency of physical activity of children who participated in the program. A secondary data analysis was conducted with 50 children with special health care needs and their families who participated in the program during 2007 and 2008. A pre post-test study design was used with data collected immediately before and after participation in the 4 week program. Data measures included demographics (age, race, etc.), anthropometrics (height and weight), a quality of life survey focusing on nutrition and physical activity behaviors, and a knowledge survey on physical activity and nutrition. Of 50 participants, 33 (66%) completed the program. Children participating in the program showed a significant decrease in BMI (mean=29.83 to mean=29.22, BMI z score p<0.01), as well as frequency of physical activity (p<0.05) and knowledge (p<0.01). Texas Children’s Hospital’s wellness program for children with special health care needs provided a promising structure for a wellness program within a multi-ethnic special needs population; however, long term effect research is needed with a larger sample size and more comprehensive outcomes and process measures. Nonetheless, this program indicates the effectiveness and feasibility of a family-based approach to weight loss in children with special needs.^

Health care providers' opinions on abortion: a study for the implementation of the legal abortion public policy in the Province of Santa Fe, Argentina

Background: In Argentina, abortion has been decriminalized under certain circumstances since the enactment of the Penal Code in 1922. Nevertheless, access to abortion under this regulatory framework has been extremely limited in spite of some recent changes. This article reports the findings of the first phase of an operations research study conducted in the Province of Santa Fe, Argentina, regarding the implementation of the local legal and safe abortion access policy. Methods: The project combined research and training to generate a virtuous circle of knowledge production, decision-making, and the fostering of an informed healthcare policy. The project used a pre-post design of three phases: baseline, intervention, and evaluation. It was conducted in two public hospitals. An anonymous self-administered questionnaire (n = 157) and semi-structured interviews (n = 27) were applied to gather information about tacit knowledge about the regulatory framework; personal opinions regarding abortion and its decriminalization; opinions on the requirements needed to carry out legal abortions; and service’s responses to women in need of an abortion. Results: Firstly, a fairly high percentage of health care providers lack accurate information on current legal framework. This deficit goes side by side with a restrictive understanding of both health and rape indications. Secondly, while a great majority of health care providers support abortion under the circumstances consider in the Penal Code, most of them are reluctant towards unrestricted access to abortion. Thirdly, health care providers’ willingness to perform abortions is noticeably low given that only half of them are ready to perform an abortion when a woman’s life is at risk. Willingness is even lower for each of the other current legal indications. Conclusions: Findings suggest that there are important challenges for the implementation of a legal abortion policy. Results of the study call for specific strategies targeting health care providers in order to better inform about current legal abortion regulations and to sensitize them about abortion social determinants. The interpretation of the current legal framework needs to be broadened in order to reflect a comprehensive view of the health indication, and stereotypes regarding women’s sexuality and abortion decisions need to be dismantled.

Developing a programme theory to explain how primary health care teams learn to respond to intimate partner violence: a realist case-study

Background: Despite the progress made on policies and programmes to strengthen primary health care teams’ response to Intimate Partner Violence, the literature shows that encounters between women exposed to IPV and health-care providers are not always satisfactory, and a number of barriers that prevent individual health-care providers from responding to IPV have been identified. We carried out a realist case study, for which we developed and tested a programme theory that seeks to explain how, why and under which circumstances a primary health care team in Spain learned to respond to IPV. Methods: A realist case study design was chosen to allow for an in-depth exploration of the linkages between context, intervention, mechanisms and outcomes as they happen in their natural setting. The first author collected data at the primary health care center La Virgen (pseudonym) through the review of documents, observation and interviews with health systems’ managers, team members, women patients, and members of external services. The quality of the IPV case management was assessed with the PREMIS tool. Results: This study found that the health care team at La Virgen has managed 1) to engage a number of staff members in actively responding to IPV, 2) to establish good coordination, mutual support and continuous learning processes related to IPV, 3) to establish adequate internal referrals within La Virgen, and 4) to establish good coordination and referral systems with other services. Team and individual level factors have triggered the capacity and interest in creating spaces for team leaning, team work and therapeutic responses to IPV in La Virgen, although individual motivation strongly affected this mechanism. Regional interventions did not trigger individual and/ or team responses but legitimated the workings of motivated professionals. Conclusions: The primary health care team of La Virgen is involved in a continuous learning process, even as participation in the process varies between professionals. This process has been supported, but not caused, by a favourable policy for integration of a health care response to IPV. Specific contextual factors of La Virgen facilitated the uptake of the policy. To some extent, the performance of La Virgen has the potential to shape the IPV learning processes of other primary health care teams in Murcia.

Health Care Reform or More Affordable Health Care?

This article investigates the impact on the U.S. economy of making health care more affordable. We compare health care cost reductions with the Patient Protection and Affordable Care Act (PPACA) using a rich life cycle general equilibrium model with heterogeneous agents. We found that all policies were able to reduce uninsured population, but the PPACA was the most effective: in the long run, less than 5% of Americans would remain uninsured. Cost reductions alleviated the government budget, while tax hikes were needed to finance the reform. Feasible cost reductions are less welfare improving than the PPACA.

Proprietary health care facilities and services in Illinois.

On prelim. p.: Office of Health Policy and Planning, Division of Health Information and Evaluation.

Pilot study to determine the ability of health-care professionals to undertake drug dose calculations

Background: It is essential for health-care professionals to calculate drug doses accurately. Previous studies have demonstrated that many hospital doctors were unable to accurately convert dilutions (e.g. 1:1000) or percentages (e.g. percentage w/v) of drug concentrations into mass concentrations (e.g. mg/mL). Aims: The aims of the present study were to evaluate the ability of health-care professionals to perform drug dose calculations accurately and to determine their preferred concentration convention when calculating drug doses. Methods: A selection of nurses, medical students, house surgeons, registrars and pharmacists undertook a written survey to assess their ability to perform five drug dose calculations. Participants were also asked which concentration convention they preferred when calculating drug doses. The surveys were marked then analysed for health-care professionals as a whole and then by subgroup analysis to assess the performance of each health-care-professional group. Results: Overall, less than 14% of the surveyed health-care professionals could answer all five questions correctly. Subgroup analysis revealed that health-care pro-fessionals' ability to calculate drug doses were ranked in the following order: registrars approximate to pharmacists > house surgeons > medical students >> nurses. Ninety per cent of health-care professionals preferred to calculate drug doses using the mass concentration convention. Conclusions: Overall, drug dose calculations were performed poorly. Mass concentration was clearly indicated as the preferred convention for calculating drug doses.

Impact of Australia's Better Outcomes in Mental Health Care program on psychologists

The aim of this paper was to consider the impact on psychologists of one component of the Australian Government's Better Outcomes in Mental Health Care (BOiMHC) program, namely the Access to Allied Psychological Services (ATAPS) component. This supports psychologists and general practitioners (GPs) to work together to provide optimal mental health care, via 102 projects being conducted by Divisions of General Practice. The paper was informed by data from five sources: a project-based minimum dataset; local project evaluation reports; a forum; a survey of projects: and a survey of Australian Psychological Society (APS) members. Taken together, the data from these sources showed that a significant number of psychologists are providing services through the projects, and the majority are finding it a positive and professionally rewarding experience. There is considerable variability regarding models of retaining, locating and referring to psychologists, and there are pros and cons associated with each. The major problem identified by psychologists is the level of remuneration. BOiMHC is currently moving into a new phase of continuation and expansion, and consideration was given to whether the data point to any changes that could be made to the ATAPS projects during this period of transition. In the main, the data suggest that the status quo should be retained, but the issue of remuneration must be addressed.

Why are health care interventions delivered over the internet? A systematic review of the published literature

Background: As Internet use grows, health interventions are increasingly being delivered online. Pioneering researchers are using the networking potential of the Internet, and several of them have evaluated these interventions. Objective: The objective was to review the reasons why health interventions have been delivered on the Internet and to reflect on the work of the pioneers in this field in order to inform future research. Methods: We conducted a qualitative systematic review of peer-reviewed evaluations of health interventions delivered to a known client/patient group using networked features of the Internet. Papers were reviewed for the reasons given for using the Internet, and these reasons were categorized. Results: We included studies evaluating 28 interventions plus 9 interventions that were evaluated in pilot studies. The interventions were aimed at a range of health conditions. Reasons for Internet delivery included low cost and resource implications due to the nature of the technology; reducing cost and increasing convenience for users; reduction of health service costs; overcoming isolation of users; the need for timely information; stigma reduction; and increased user and supplier control of the intervention. A small number of studies gave the existence of Internet interventions as the only reason for undertaking an evaluation of this mode of delivery. Conclusions: One must remain alert for the unintended effects of Internet delivery of health interventions due to the potential for reinforcing the problems that the intervention was designed to help. Internet delivery overcomes isolation of time, mobility, and geography, but it may not be a substitute for face-to-face contact. Future evaluations need to incorporate the evaluation of cost, not only to the health service but also to users and their social networks. When researchers report the outcomes of Internet-delivered health care interventions, it is important that they clearly state why they chose to use the Internet, preferably backing up their decision with theoretical models and exploratory work. Evaluation of the effectiveness of a health care intervention delivered by the Internet needs to include comparison with more traditional modes of delivery to answer the following question: What are the added benefits or disadvantages of Internet use that are particular to this mode of delivery? © Griffiths, Frances, Lindenmeyer, Antje, Powell, John, Thorogood, Margaret.