Routine use of point-of-care tests: usefulness and application in clinical microbiology.

Point-of-care (POC) tests offer potentially substantial benefits for the management of infectious diseases, mainly by shortening the time to result and by making the test available at the bedside or at remote care centres. Commercial POC tests are already widely available for the diagnosis of bacterial and viral infections and for parasitic diseases, including malaria. Infectious diseases specialists and clinical microbiologists should be aware of the indications and limitations of each rapid test, so that they can use them appropriately and correctly interpret their results. The clinical applications and performance of the most relevant and commonly used POC tests are reviewed. Some of these tests exhibit insufficient sensitivity, and should therefore be coupled to confirmatory tests when the results are negative (e.g. Streptococcus pyogenes rapid antigen detection test), whereas the results of others need to be confirmed when positive (e.g. malaria). New molecular-based tests exhibit better sensitivity and specificity than former immunochromatographic assays (e.g. Streptococcus agalactiae detection). In the coming years, further evolution of POC tests may lead to new diagnostic approaches, such as panel testing, targeting not just a single pathogen, but all possible agents suspected in a specific clinical setting. To reach this goal, the development of serology-based and/or molecular-based microarrays/multiplexed tests will be needed. The availability of modern technology and new microfluidic devices will provide clinical microbiologists with the opportunity to be back at the bedside, proposing a large variety of POC tests that will allow quicker diagnosis and improved patient care.

Collective learning within nursing clinical groups /

This qualitative study examined collective learning within nursing clinical groups. Specifically, it explored the influence of the individual on the group and the impact of the group on the individual. The study was organized using the concepts from Debbie Kilgore's theory of collective learning (1999). The sample consisted of 1 8 second-year university nursing students and 3 clinical instructors. Data were collected via individual interviews with each participant and researcher's observations during a group conference. The interviews were tape-recorded, transcribed, and analyzed using key concepts from Kilgore's framework. Several interesting findings emerged. Overall, it appeared that individual components and group components contributed to the quality and quantity of collective learning that occurred in the groups. Individually, each person's past group experiences, personality, culture, and gender influenced how that individual acted in the group, their roles, and how much influence they had over group decisions. Moreover, the situation which seemed to cause the greatest sense of helplessness and loss of control was when one of their group members was breaking a norm. They were unable to deal with such situations constructively. Also, the amount of sense of worthiness (respect) and sense of agency (control) the member felt within the group had an impact on the person's role in group decisions. Finally, it seemed that students felt more connected with their peers within the clinical setting when they were close with them on a personal and social level. With respect to the group elements, it seemed that the instructors' values and way of being were instrumental in shaping the group's identity. In group 2, there were clear examples of group consciousness and the students' need to go along with the majority viewpoint, even when it was contrary to their own beliefs. Finally, the common goal of passing clinical and dealing with the fears of being in the clinical setting brought solidarity among the group members, and there seemed to be a high level of positive interdependence among them. From the discussion and analysis of the findings, recommendations were given on how to improve the learning within clinical groups.

Clinical methods for quantifying body segment posture: a literature review

Purpose. Clinicians commonly assess posture in persons with musculoskeletal disorders and tend to do so subjectively. Evidence-based practice requires the use of valid, reliable and sensitive tools to monitor treatment effectiveness. The purpose of this article was to determine which methods were used to assess posture quantitatively in a clinical setting and to identify psychometric properties of posture indices measured from these methods or tools. Methods. We conducted a comprehensive literature review. Pertinent databases were used to search for articles on quantitative clinical assessment of posture. Searching keywords were related to posture and assessment, scoliosis, back pain, reliability, validity and different body segments. Results. We identified 65 articles with angle and distance posture indices that corresponded to our search criteria. Several studies showed good intra- and inter-rater reliability for measurements taken directly on the persons (e.g., goniometer, inclinometer, flexible curve and tape measurement) or from photographs, but the validity of these measurements was not always demonstrated. Conclusion. Taking measurements of all body angles directly on the person is a lengthy process and may affect the reliability of the measurements. Measurement of body angles from photographs may be the most accurate and rapid way to assess global posture quantitatively in a clinical setting.

Validity of a Quantitative Clinical Measurement Tool of Trunk Posture in Idiopathic Scoliosis

STUDY DESIGN: Concurrent validity between postural indices obtained from digital photographs (two-dimensional [2D]), surface topography imaging (three-dimensional [3D]), and radiographs. OBJECTIVE: To assess the validity of a quantitative clinical postural assessment tool of the trunk based on photographs (2D) as compared to a surface topography system (3D) as well as indices calculated from radiographs. SUMMARY OF BACKGROUND DATA: To monitor progression of scoliosis or change in posture over time in young persons with idiopathic scoliosis (IS), noninvasive and nonionizing methods are recommended. In a clinical setting, posture can be quite easily assessed by calculating key postural indices from photographs. METHODS: Quantitative postural indices of 70 subjects aged 10 to 20 years old with IS (Cobb angle, 15 degrees -60 degrees) were measured from photographs and from 3D trunk surface images taken in the standing position. Shoulder, scapula, trunk list, pelvis, scoliosis, and waist angles indices were calculated with specially designed software. Frontal and sagittal Cobb angles and trunk list were also calculated on radiographs. The Pearson correlation coefficients (r) was used to estimate concurrent validity of the 2D clinical postural tool of the trunk with indices extracted from the 3D system and with those obtained from radiographs. RESULTS: The correlation between 2D and 3D indices was good to excellent for shoulder, pelvis, trunk list, and thoracic scoliosis (0.81>r<0.97; P<0.01) but fair to moderate for thoracic kyphosis, lumbar lordosis, and thoracolumbar or lumbar scoliosis (0.30>r<0.56; P<0.05). The correlation between 2D and radiograph spinal indices was fair to good (-0.33 to -0.80 with Cobb angles and 0.76 for trunk list; P<0.05). CONCLUSION: This tool will facilitate clinical practice by monitoring trunk posture among persons with IS. Further, it may contribute to a reduction in the use of radiographs to monitor scoliosis progression.

Intra-tumor heterogeneity: lessons from microbial evolution and clinical implications

Multiple subclonal populations of tumor cells can coexist within the same tumor. This intra-tumor heterogeneity will have clinical implications and it is therefore important to identify factors that drive or suppress such heterogeneous tumor progression. Evolutionary biology can provide important insights into this process. In particular, experimental evolution studies of microbial populations, which exist as clonal populations that can diversify into multiple subclones, have revealed important evolutionary processes driving heterogeneity within a population. There are transferrable lessons that can be learnt from these studies that will help us to understand the process of intra-tumor heterogeneity in the clinical setting. In this review, we summarize drivers of microbial diversity that have been identified, such as mutation rate and environmental influences, and discuss how knowledge gained from microbial experimental evolution studies may guide us to identify and understand important selective factors that promote intra-tumor heterogeneity. Furthermore, we discuss how these factors could be used to direct and optimize research efforts to improve patient care, focusing on therapeutic resistance. Finally, we emphasize the need for longitudinal studies to address the impact of these potential tumor heterogeneity-promoting factors on drug resistance, metastatic potential and clinical outcome.

Direct patient contacts of dietetic students during their final clinical placement

Direct student-patient contacts, during the professional clinical placement of a Master of Nutrition and Dietetics course, were collected and analysed for the first time using a computerised method. In the final eight-week hospital placement, 26 dietetic students submitted data on direct patient contacts which included: dietetic activities (e.g. assessing, counselling and reviewing); the primary nutritional condition of the patient (e.g. type 2 diabetes and liver disease); and the time spent in contact with patients. The most common dietetic activities were reviews, followed by collection of dietary information and counselling. The most common nutritional condition encountered by students was an inadequate nutrient intake, followed by patients receiving enteral nutrition. Contact time with patients increased over the placement, with proportionately more time spent by students seeing patients independently than when being observed by supervising dietitians. The data collected provided valuable informa tion on the amount of time spent by students in direct patient contacts, the range of dietetic activities undertaken and the amount of time student activities were directly observed. This information will be useful in the development of benchmarks for clinical skill development, hospital and university staff planning and the assessment of the impact of any changes to the format of student placement experience in the clinical setting.

The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinoplasty

Background: There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy. Objective: To develop and test a questionnaire based instrument that would serve as an index of severity of Achilles tendinopathy. Methods: Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire to assess the severity of Achilles tendinopathy. The final version consisted of eight  questions that measured the domains of pain, function in daily living, and sporting activity. Results range from 0 to 100, where 100 represents the perfect score. Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy (n = 45), presurgical patients with Achilles tendinopathy (n = 14), and two normal control populations (total n = 87). Results: The VISA-A questionnaire had good test-retest (r = 0.93), intrarater (three tests, r = 0.90), and interrater (r = 0.90) reliability as well as good stability when compared one week apart (r = 0.81). The mean (95% confidence interval) VISA-A score in the non-surgical patients was 64 (59–69), in presurgical patients 44 (28–60), and in control subjects it exceeded 96 (94–99). Thus the VISA-A score was higher in non-surgical than presurgical patients (p = 0.02) and higher in control subjects than in both patient populations (p<0.001). Conclusions: The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects. The continuous numerical result of the VISA-A questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis.

Triage nurses' clinical decision making : an observational study of urgency assessment

Background. Researchers have described both the various decision tasks performed by triage nurses using self-report methods and identified time as a factor influencing the quality of triage decisions. However, little is known about the decision tasks performed by triage nurses when making acuity assessments, or the factors influencing triage duration in the real world.

Aims. The aims of this study were to: describe the data triage nurses collect from patients in order to allocate a triage priority using the Australasian Triage Scale (ATS); describe the duration of nurses' decision making for ATS categories 2–5; and to explore the impact of patient and nurse variables on the duration of the triage nurses' decision making in the clinical setting.

Design. A structured observational study was employed to address the research aims. Observational data was collected in one adult emergency department located in metropolitan Melbourne, Australia. A total of 26 triage nurses consented and were observed performing 404 occasions of triage. Data was collected by a single observer using a 20-item instrument that recorded the performance frequencies of a range of decision tasks and a number of observable patient, nurse and environmental variables. Additionally, the nurse–patient interaction was recorded as time in minutes.

Results. It was found that there was limited use of objective physiological data collected by the nurses' in order to decide patient acuity, and large variability in the duration of triage decisions observed. In addition, analysis of variance indicated strong evidence of a true difference between triage duration and a range of nurse, patient and environmental variables.

Conclusion. These findings have implications for the development of practice standards and triage education. In particular, it is argued that practice standards should include routine measurement of physiological parameters in all but the collapsed or obviously unwell patient, where further delay may impede the delivery oftime-critical intervention. Furthermore, the inclusion of arbitrary time frames for triage assessment in practice standards are not an appropriate method of evaluating triage decision making in the real world.

The questioning skills of clinical teachers and preceptors: a comparative study

Aim of the study. The purpose of this study, conducted as partial requirement for a Master of Nursing Studies Degree, was to explore, describe and compare the level of questions asked by clinical teachers and preceptors.

Background. Questioning is one of many teaching/learning strategies thought to facilitate the development of critical thinking skills which are integral to nursing practice. As such the type and number of questions asked have implications for student learning. Currently in Melbourne, Australia, many undergraduate nursing degree courses utilize both clinical teachers and preceptors to facilitate student learning in the clinical setting.

Design. A comparative descriptive design was used. Participants were given three acute care patient scenarios involving an undergraduate nursing student, as part of a questionnaire, and asked to identify the questions they would ask the student in relation to the scenario.

Findings. Data revealed that the clinical teachers had considerably more years of experience in their role and higher academic qualifications than did the preceptors. The clinical teachers also asked a greater number of questions overall and more from the higher cognitive level. Despite this, the findings suggest that both clinical teachers and especially preceptors need to increase the number of higher level questions they ask.

Conclusions. Based on the findings of this study, it is evident that there is a need for further comparative studies into the questioning skills of clinical teachers and preceptors. Also, these two groups require education about the importance of higher level questioning for student learning as well as how to ask questions generally.

Pilot study of an innovative model for clinical education in dietetics

Aim: To pilot and evaluate a new model of clinical dietetics education to address the sustainability of dietetic placements in the clinical setting.

Methods: Final-year dietetics students (n = 14) completed all nine weeks of clinical placement in the pilot program at two large tertiary referral and teaching health services in metropolitan Melbourne. Staff and students completed surveys about their experience within a week of completing placement. Data collected included paid and unpaid staff working hours, hours in clinical and teaching activity, hours of student attendance and student clinical work hours. Data for the last month of the placement programs in the preceding three years were used for comparison with the pilot program.

Results: Combined data for the two providers showed that the model reduced the amount of supervision hours per student hour on placement by 16% while maintaining quality indicators during the pilot compared with previous years. Students in the pilot program were more positive about their experience compared with students in the existing program. The overall trend of responses in the staff surveys was positive for the pilot program, but the trend was not as marked as that of student responses.

Conclusion: The new model of clinical dietetics education was successfully piloted and demonstrated the potential to increase student training capacity without a negative impact on student achievement or major resource demands. Refinements to the model and opportunities to enhance integration into the dietetics degree program were identified during the project. The learning needs of non-English-speaking background students require further scrutiny.

Clinical teachers' conceptions of nursing

Lack of knowledge exists about clinical teachers’ understanding of nursing. A likely relationship between teachers’ conceptions of nursing and what they focus on when teaching nursing students in the clinical setting means that the identification of different conceptions of nursing is important. This study investigated clinical teachers’ experiences of nursing and clinical teaching of undergraduate nursing students. This article reports on clinical teachers’ conceptions of nursing. Semistructured interviews of 20 nurses employed as clinical teachers in Australian universities were conducted. Data were analyzed using a phenomenographic approach. The findings suggest that nursing is conceived as performing tasks; providing appropriate care; providing individualized patient care aimed at achieving patient outcomes; or collaborating with health care team members to provide appropriate, individualized patient care aimed at achieving patient outcomes. Insights will assist with future preparation and support of clinical teachers, the education of nursing students, and improved curriculum design.

Issues in assessing students in the clinical workforce : an exploratory study

The Monash Mini Case Record (MCR), based on Norcinis mini CEX, is an observed interaction between a student and a real patient in an authentic clinical setting. The assessor rates the students competence in history taking or physical examination and clinical reasoning on eight point scales. Professional / ethical behaviour within the encounter is evaluated on a four point scale. The assessor also grades the complexity of the case as low, medium or high. On completion of the student patient interaction, or her performance, and the assessor provides verbal and written feedback. Students complete both formative and summative MCRs across the academic year.

Barriers and enablers to clinical fieldwork education in rural public and private allied health practice

There is a need to maximise rural clinical fieldwork placement to build health workforce capacity. This study investigated allied health professionals' (AHPs) experience of supervising students as part of work-integrated learning in public and private rural health settings. An anonymous postal questionnaire with 30 questions was used to collect quantitative and qualitative data about the barriers and enablers that AHPs encounter when supervising students in their clinical setting. A total of 113 public and private AHPs from Southwest Victoria, Australia, returned the questionnaire. The AHPs were trained in the disciplines of occupational therapy, physiotherapy, speech pathology, dietetics, podiatry or psychology. The majority of respondents (75%) had previously supervised students. Most respondents had only provided fieldwork education in the public sector. Allied health professionals working in public and private sectors had positive experiences with clinical fieldwork education and often had increased job satisfaction while supervising students. They experienced similar enablers to involvement in clinical fieldwork education programs, however the barriers they encountered were different. The findings highlight the differing issues between rural public and private settings that need to be addressed for successful clinical fieldwork education and work-integrated learning. Strategies to address the identified barriers need to be specific to the work conditions of each setting.

Bridging the gap : from simulation to clinical practice

There has been a shift from the initial learning of skills on patients in the clinical setting to initial learning in a simulated environment, using part-task models, with the risk of a task focus to the learning. We contend that quality learning in both the simulated and the clinical environment is crucial to enhance the transferability of skills to the clinical setting.

Development, implementation and evaluation of a clinical research engagement and leadership capacity building program in a large Australian health care service

BACKGROUND: Health professionals need to be integrated more effectively in clinical research to ensure that research addresses clinical needs and provides practical solutions at the coal face of care. In light of limited evidence on how best to achieve this, evaluation of strategies to introduce, adapt and sustain evidence-based practices across different populations and settings is required. This project aims to address this gap through the co-design, development, implementation, evaluation, refinement and ultimately scale-up of a clinical research engagement and leadership capacity building program in a clinical setting with little to no co-ordinated approach to clinical research engagement and education.

METHODS/DESIGN: The protocol is based on principles of research capacity building and on a six-step framework, which have previously led to successful implementation and long-term sustainability. A mixed methods study design will be used. Methods will include: (1) a review of the literature about strategies that engage health professionals in research through capacity building and/or education in research methods; (2) a review of existing local research education and support elements; (3) a needs assessment in the local clinical setting, including an online cross-sectional survey and semi-structured interviews; (4) co-design and development of an educational and support program; (5) implementation of the program in the clinical environment; and (6) pre- and post-implementation evaluation and ultimately program scale-up. The evaluation focuses on research activity and knowledge, attitudes and preferences about clinical research, evidence-based practice and leadership and post implementation, about their satisfaction with the program. The investigators will evaluate the feasibility and effect of the program according to capacity building measures and will revise where appropriate prior to scale-up.

DISCUSSION: It is anticipated that this clinical research engagement and leadership capacity building program will enable and enhance clinically relevant research to be led and conducted by health professionals in the health setting. This approach will also encourage identification of areas of clinical uncertainty and need that can be addressed through clinical research within the health setting.