Search

Objective The aim was to evaluate the effects of cocreated internet-based stepped care (iCAN-DO) on anxiety, depression, posttraumatic stress, and health-related quality of life (HRQoL) in individuals with cancer and self-reported anxiety and/or depression symptoms, compared with standard care. Methods Clinically recruited individuals with breast, colorectal, or prostate cancer underwent online screening with the Hospital Anxiety and Depression Scale (HADS). Those with anxiety and/or depression symptoms (>7 on any of the HADS subscales) were randomized to iCAN-DO or standard care. iCAN-DO comprised psychoeducation and self-care strategies (step 1) and internet-based cognitive behavioral therapy (iCBT, step 2). Data were collected before randomization and at 1, 4, 7, and 10 months and analyzed with intention-to-treat regression analysis and randomization tests. Results Online screening identified 245 (27%) of 909 individuals who reported anxiety and/or depression symptoms. They were randomized to iCAN-DO (n = 124) or standard care (n = 121). Of them 49% completed the 10-month assessment, and in the iCAN-DO group 85% accessed step 1 and 13% underwent iCBT. iCAN-DO decreased the levels of symptoms of depression (−0.54, 95% confidence interval: −1.08 to −0.01, P < .05) and the proportion of individuals with symptoms of depression (P < .01) at 10 months, compared with standard care, according to HADS. There were no significant effects on anxiety, posttraumatic stress, or HRQoL. Conclusion Internet-based stepped care improves symptoms of depression in individuals with cancer. Further studies are needed to gain knowledge on how to optimize and implement internet-based support in oncology care.

BackgroundAlthough the importance and advantages of measurement-based care in mental healthcare are well established, implementation in daily practice is complex and far from optimal.AimsTo accelerate the implementation of outcome measurement in routine clinical practice, a government-sponsored National Quality Improvement Collaborative was initiated in Dutch-specialised mental healthcare.MethodTo investigate the effects of this initiative, we combined a matched-pair parallel group design (21 teams) with a cluster randomised controlled trial (RCT) (6 teams). At the beginning and end, the primary outcome ‘actual use and perceived clinical utility of outcome measurement’ was assessed.ResultsIn both designs, intervention teams demonstrated a significant higher level of implementation of outcome measurement than control teams. Overall effects were large (parallel group d=0.99; RCT d=1.25).ConclusionsThe National Collaborative successfully improved the use of outcome measurement in routine clinical practice.

BackgroundPsychosis seminars enable service users, their carers and mental health professionals to meet outside of a formal care setting, increase understanding of mental illness and help establish a dialogue.AimsTo explore feasibility of psychosis seminars in the UK and the experiences of participants.MethodSeven meetings attended by 25 people were held over a 3-month period. An open-ended questionnaire was returned by ten participants. Responses were subjected to content analysis.ResultsBenefits experienced were having an open forum for talking freely about mental health issues in a neutral space, learning from others about psychosis and hearing different views. Suggested adjustments were clarifying expectations of participants at the beginning, strengthening facilitation and increasing attendance.ConclusionsPsychosis seminars may help to establish a dialogue among users, carers and professionals and seem feasible in the UK, although adjustment to delivery can help their implementation.

Purpose To evaluate the effect of electronic and paper-based standardized nursing care plans (SNCPs) use on quality of nurses' documentation. Methods Using quasi-experimental design, two wards were grouped into electronic and paper-based wards. Nurses were trained to use electronic- and paper-based SNCPs for care-planning and documentation. Data was collected before, 3, and 6 months postintervention and analyzed with SPSS version 20. Findings There was improvement in documentation quality in the two wards after introducing SNCPs with higher quality scores in the electronic ward postintervention. Conclusion Providing SNCPs in electronic and paper formats is critical to improving nursing documentation. Implication for nursing practice Adequate training and support for nurses are needed for successful implementation of SNCPs in electronic health records (EHRs) in developing nations.

SummaryStandardizing nursing handoffs at shift change is recommended to improve communication, with electronic tools as the primary approach. However, nurses continue to rely on personally created paper-based cognitive artifacts - their “paper brains” - to support handoffs, indicating a deficiency in available electronic versions.The purpose of this qualitative study was to develop a deep understanding of nurses’ paper-based cognitive artifacts in the context of a cancer specialty hospital.After completing 73 hours of hospital unit field observations, 13 medical oncology nurses were purposively sampled, shadowed for a single shift and interviewed using a semi-structured technique. An interpretive descriptive study design guided analysis of the data corpus of field notes, transcribed interviews, images of nurses’ paper-based cognitive artifacts, and analytic memos.Findings suggest nurses’ paper brains are personal, dynamic, living objects that undergo a life cycle during each shift and evolve over the course of a nurse’s career. The life cycle has four phases: Creation, Application, Reproduction, and Destruction. Evolution in a nurse’s individually styled, paper brain is triggered by a change in the nurse’s environment that reshapes cognitive needs. If a paper brain no longer provides cognitive support in the new environment, it is modified into (adapted) or abandoned (made extinct) for a different format that will provide the necessary support.The “hidden lives” - the life cycle and evolution - of paper brains have implications for the design of successful electronic tools to support nursing practice, including handoff. Nurses’ paper brains provide cognitive support beyond the context of handoff. Information retrieval during handoff is undoubtedly an important function of nurses’ paper brains, but tools designed to standardize handoff communication without accounting for cognitive needs during all phases of the paper brain life cycle or the ability to evolve with changes to those cognitive needs will be underutilized.Citation: Blaz JW, Doig AK, Cloyes KG, Staggers N. The hidden lives of nurses’ cognitive artifacts.

Objective: There are concerns that structured electronic documentation systems can limit expressivity and encourage long and unreadable notes. We assessed the impact of an electronic clinical documentation system on the quality of admission notes for patients admitted to a general medical unit.Methods: This was a prospective randomized crossover study comparing handwritten paper notes to electronic notes on different patients by the same author, generated using a semistructured electronic admission documentation system over a 2-month period in 2014. The setting was a 4-team, 80-bed general internal medicine clinical teaching unit at a large urban academic hospital. The quality of clinical documentation was assessed using the QNOTE instrument (best possible score = 100), and word counts were assessed for free-text sections of notes.Results: Twenty-one electronic-paper note pairs (42 notes) written by 21 authors were randomly drawn from a pool of 303 eligible notes. Overall note quality was significantly higher in electronic vs paper notes (mean 90 vs 69, P Conclusions: An electronic admission documentation system improved both the quality of free-text content and the overall quality of admission notes. Authors wrote more in the free-text sections of electronic documents as compared to paper versions.

The nursing care plan plays an essential role in supporting care provision in Australian aged care. The implementation of electronic systems in aged care homes was anticipated to improve documentation quality. Standardized nursing terminologies, developed to improve communication and advance the nursing profession, are not required in aged care practice. The language used by nurses in the nursing care plan and the effect of the electronic system on documentation quality in residential aged care need to be investigated.To describe documentation practice for the nursing care plan in Australian residential aged care homes and to compare the quantity and quality of documentation in paper-based and electronic nursing care plans.A nursing documentation audit was conducted in seven residential aged care homes in Australia. One hundred and eleven paper-based and 194 electronic nursing care plans, conveniently selected, were reviewed. The quantity of documentation in a care plan was determined by the number of phrases describing a resident problem and the number of goals and interventions. The quality of documentation was measured using 16 relevant questions in an instrument developed for the study.There was a tendency to omit 'nursing problem' or 'nursing diagnosis' in the nursing process by changing these terms (used in the paper-based care plan) to 'observation' in the electronic version. The electronic nursing care plan documented more signs and symptoms of resident problems and evaluation of care than the paper-based format (48.30 vs. 47.34 out of 60, P0.01), but had a lower total mean quality score. The electronic care plan contained fewer problem or diagnosis statements, contributing factors and resident outcomes than the paper-based system (P0.01). Both types of nursing care plan were weak in documenting measurable and concrete resident outcomes.The overall quality of documentation content for the nursing process was no better in the electronic system than in the paper-based system. Omission of the nursing problem or diagnosis from the nursing process may reflect a range of factors behind the practice that need to be understood. Further work is also needed on qualitative aspects of the nurse care plan, nurses' attitudes towards standardized terminologies and the effect of different documentation practice on care quality and resident outcomes.

Objectives: Multi-institutional research increases the generalizability of research findings. However, little is known about characteristics of collaborations across institutions in health sciences education research. Using a systematic review process, the authors describe characteristics of published, peer-reviewed multi-institutional health sciences education research to inform educators who are considering such projects.Methods: Two medical librarians searched MEDLINE, the Education Resources Information Center (ERIC), EMBASE, and CINAHL databases for English-language studies published between 2004 and 2013 using keyword terms related to multi-institutional systems and health sciences education. Teams of two authors reviewed each study and resolved coding discrepancies through consensus. Collected data points included funding, research network involvement, author characteristics, learner characteristics, and research methods. Data were analyzed using descriptive statistics.Results: One hundred eighteen of 310 articles met inclusion criteria. Sixty-three (53%) studies received external and/or internal financial support (87% listed external funding, 37% listed internal funding). Forty-five funded studies involved graduate medical education programs. Twenty (17%) studies involved a research or education network. Eighty-five (89%) publications listed an author with a master’s degree or doctoral degree. Ninety-two (78%) studies were descriptive, whereas 26 studies (22%) were experimental. The reported study outcomes were changes in student attitude (38%; n=44), knowledge (26%; n=31), or skill assessment (23%; n=27), as well as patient outcomes (9%; n=11).Conclusions: Multi-institutional descriptive studies reporting knowledge or attitude outcomes are highly published. Our findings indicate that funding resources are not essential to successfully undertake multi-institutional projects. Funded studies were more likely to originate from graduate medical or nursing programs.

Objective To assess the state of readiness for the adoption of paperless labeling among a nationally representative sample of pharmacies, including chain pharmacies, independent retail pharmacies, hospitals, and other rural or urban dispensing sites. Methods Both quantitative and qualitative analyses were used to analyze responses to a cross-sectional survey disseminated to American Pharmacists Association pharmacists nationwide. The survey assessed factors related to pharmacists' attitudinal readiness (ie, perceptions of impact) and pharmacies' structural readiness (eg, availability of electronic resources, internet access) for the paperless labeling initiative. Results We received a total of 436 survey responses (6% response rate) from pharmacists representing 44 US states and territories. Across the spectrum of settings we studied, pharmacists had work access to computers, printers, fax machines and access to the internet or intranet. Approximately 79% of respondents believed that the initiative would improve the adequacy of drug information available in their work site and 95% believed it would either not change (33%) or would improve (62%) communication to patients. Overall, respondents' comments supported advancing the initiative; however, some comments revealed reservations regarding corporate or pharmacy buy-in, success of implementation, and ease of adoption. Conclusions This is the first nationwide study to report about pharmacists' perspectives on paperless labeling. In general, pharmacists believe they are ready and that their pharmacies are well equipped for the transition to paperless labeling. Further exploration of perspectives from product label manufacturers and corporate pharmacy offices is needed to understand fully what will be necessary to complete this transition.

Ethical and legal requirements for healthcare providers in the United States, stipulate that patients sign a consent form prior to undergoing medical treatment or participating in a research study. Currently, the majority of the hospitals obtain these consents using paper-based forms, which makes patient preference data cumbersome to store, search and retrieve. To address these issues, Health Sciences of South Carolina (HSSC), a collaborative of academic medical institutions and research universities in South Carolina, is developing an electronic consenting system, the Research Permissions Management System (RPMS). This article reports the findings of a study conducted to investigate the efficacy of the two proposed interfaces for this system - an iPad-based and touchscreen-based by comparing them to the paper-based and Topaz-based systems currently in use.This study involved 50 participants: 10 hospital admission staff and 40 patients. The four systems were compared with respect to the time taken to complete the consenting process, the number of errors made by the patients, the workload experienced by the hospital staff and the subjective ratings of both patients and staff on post-test questionnaires.The results from the empirical study indicated no significant differences in the time taken to complete the tasks. More importantly, the participants found the new systems more usable than the conventional methods with the registration staff experiencing the least workload in the iPad and touchscreen-based conditions and the patients experiencing more privacy and control during the consenting process with the proposed electronic systems. In addition, they indicated better comprehension and awareness of what they were signing using the new interfaces.The results indicate the two methods proposed for capturing patient consents are at least as effective as the conventional methods, and superior in several important respects. While more research is needed, these findings suggest the viability of cautious adoption of electronic consenting systems, especially because these new systems appear to address the challenge of identifying the participants required for the complex research being conducted as the result of advances in the biomedical sciences.

Background: Peer review of university classroom teaching can increase the quality of teaching but is not universally practiced in Australian universities. Aim: To report an evaluation of paired peer-review process using both paper and web based teaching evaluation tools. Methods: Twenty university teachers in one metropolitan Australian School of Nursing and Midwifery were randomly paired and then randomly assigned to a paper based or web-based peer review tool. Each teacher reviewed each other's classroom teaching as part of a peer review program. The participants then completed an 18 question survey evaluating the peer review tool and paired evaluation process. Responses were analyzed using frequencies and percentages. Results: Regardless of the tool used, participants found this process of peer review positive (75%), collegial (78%), supportive (61%) and non-threatening (71%). Participants reported that the peer review will improve their own classroom delivery (61%), teaching evaluation (61%) and planning (53%). The web-based tool was found to be easier to use and allowed more space than the paper-based tool. Conclusion: Implementation of a web-based paired peer review system can be a positive method of peer review of university classroom teaching. Pairing of teachers to review each other's classroom teaching is a promising strategy and has the potential to improve teaching in teaching universities. Refereed/Peer-reviewed

SummaryWith the adoption of Computerized Patient Order Entry (CPOE), many physicians – particularly consultants and those who are affiliated with multiple hospital systems – are faced with the challenge of learning to navigate and commit to memory the details of multiple EHRs and CPOE software modules. These physicians may resist CPOE adoption, and their refusal to use CPOE presents a risk to patient safety when paper and electronic orders co-exist, as paper orders generated in an electronic ordering environment can be missed or acted upon after delay, are frequently illegible, and bypass the Clinical Decision Support (CDS) that is part of the evidence-based value of CPOE.We defined a category of CPOE Low Frequency Users (LFUs) – physicians issuing a total of less than 10 orders per month – and found that 50.4% of all physicians issuing orders in 3 urban/suburban hospitals were LFUs and actively issuing orders across all shifts and days of the week. Data are presented for 2013 on the number of LFUs by month, day of week, shift and facility, over 2.3 million orders issued.A menu of 6 options to assist LFUs in the use of CPOE, from which hospital leaders could select, was instituted so that paper orders could be increasingly eliminated. The options, along with their cost implications, are described, as is the initial option selected by hospital leaders. In practice, however, a mixed pattern involving several LFU support options emerged. We review data on how the option mix selected may have impacted CPOE adoption and physician use rates at the facilities. The challenge of engaging LFU physicians in CPOE adoption may be common in moderately sized hospitals, and these options can be deployed by other systems in advancing CPOE pervasiveness of use and the eventual elimination of paper orders.

Introduction: There have been several concerns about the quality of documentation in electronic health records (EHRs) when compared to paper charts. This study compares the accuracy of physical examination findings documentation between the two in initial progress notes. Methodology: Initial progress notes from patients with 5 specific diagnoses with invariable physical findings admitted to Beaumont Hospital, Royal Oak, between August 2011 and July 2013 were randomly selected for this study. A total of 500 progress notes were retrospectively reviewed. The paper chart arm consisted of progress notes completed prior to the transition to an EHR on July 1, 2012. The remaining charts were placed in the EHR arm. The primary endpoints were accuracy, inaccuracy, and omission of information. Secondary endpoints were time of initiation of progress note, word count, number of systems documented, and accuracy based on level of training. Results: The rate of inaccurate documentation was significantly higher in the EHRs compared to the paper charts (24.4% vs 4.4%). However, expected physical examination findings were more likely to be omitted in the paper notes compared to EHRs (41.2% vs 17.6%). Resident physicians had a smaller number of inaccuracies (5.3% vs 17.3%) and omissions (16.8% vs 33.9%) compared to attending physicians. Conclusions: During the initial phase of implementation of an EHR, inaccuracies were more common in progress notes in the EHR compared to the paper charts. Residents had a lower rate of inaccuracies and omissions compared to attending physicians. Further research is needed to identify training methods and incentives that can reduce inaccuracies in EHRs during initial implementation.

One of the most significant changes in modern healthcare delivery has been the evolution of the paper record to the electronic health record (EHR). In this paper we argue that the primary change has been a shift in the focus of documentation from monitoring individual patient progress to recording data pertinent to Institutional Priorities (IPs). The specific IPs to which we refer include: finance/reimbursement; risk management/legal considerations; quality improvement/safety initiatives; meeting regulatory and accreditation standards; and patient care delivery/evidence based practice. Following a brief history of the transition from the paper record to the EHR, the authors discuss unintended or contested consequences resulting from this change. These changes primarily reflect changes in the organization and amount of clinician work and clinician-patient relationships. The paper is not a research report but was informed by an institutional ethnography the aim of which was to understand how the EHR impacted clinicians and administrators in a large, urban hospital in the United States. The paper was also informed by other sources, including the philosophies of Jacques Ellul, Don Idhe, and Langdon Winner.

Hand washing is a primary means of infection control. The Centers for Disease Control and Prevention (CDC), the Association for Professionals in Infection Control and Epidemiology, and the World Health Organization all cite handwashing with soap and water as important in preventing the spread of infectious diseases.1-3 The CDC states that “keeping hands clean is one of the most important steps we can take to avoid getting sick and spreading germs to others.”3 Numerous studies have demonstrated that handwashing in the school setting reduces infectious diseases, particularly respiratory and gastrointestinal infections.4-7 Handwashing reduces absenteeism among students and staff.4,7 However, many barriers to handwashing in the school environment have been described that can reduce compliance with handwashing. These barriers include insufficient time for students to wash, lack of education and promotion around hand hygiene, and insufficient handwashing facilities.4,8 Maintaining adequate handwashing supplies in student bathrooms is made difficult by lack of money, limited staff time, student vandalism, and misguided efforts by school staff to prevent messes in bathrooms. One large school district in New Mexico began environmental inspections in the fall of 2006 to address issues of hygiene and safety and to make improvements when indicated in their schools. They reported initial inspection findings from 91 schools in September 2006. Within those schools inspected, 25% of student bathrooms lacked soap and 38% lacked paper towels or hand dryers.9 A pilot study was conducted to measure the availability of handwashing supplies for students in public schools in New Mexico. The study further aimed to determine whether scheduled school nurse inspections of handwashing supplies in school bathrooms, with reporting of findings to appropriate school officials, would result in improved availability of handwashing supplies for students.

Objective Healthcare institutions worldwide are moving to electronic health records (EHRs). These transitions are particularly numerous in the US where healthcare systems are purchasing and implementing commercial EHRs to fulfill federal requirements. Despite the central role of EHRs to workflow, the cognitive impact of these transitions on the workforce has not been widely studied. This study assesses the changes in cognitive workload among pediatric nurses during data entry and retrieval tasks during transition from a hybrid electronic and paper information system to a commercial EHR. Materials and methods Baseline demographics and computer attitude and skills scores were obtained from 74 pediatric nurses in two wards. They also completed an established and validated instrument, the NASA-TLX, that is designed to measure cognitive workload; this instrument was used to evaluate cognitive workload of data entry and retrieval. The NASA-TLX was administered at baseline (pre-implementation), 1, 5 and 10 shifts and 4 months post-implementation of the new EHR. Results Most nurse participants experienced significant increases of cognitive workload at 1 and 5 shifts after “go-live”. These increases abated at differing rates predicted by participants’ computer attitudes scores (p = 0.01). Conclusions There is substantially increased cognitive workload for nurses during the early phases (1–5 shifts) of EHR transitions. Health systems should anticipate variability across workers adapting to “meaningful use” EHRs. “One-size-fits-all” training strategies may not be suitable and longer periods of technical support may be necessary for some workers.

The study aimed to conduct a literature review as a step of the development of a new questionnaire about the nursing workers' perception of job factors that may lead to musculoskeletal symptoms. An information synthesis was achieved by collecting data from studies that fitted the search criteria. The results showed that despite the existence of several job factors related to musculoskeletal symptoms, no specific questionnaire that evaluates this relationship was found. Therefore, this literature review presents important topics for developing the first questionnaire to analyze work activities that may contribute to pain and discomfort among nursing personnel.

This study examines a paper hand-held record and a shared electronic health record in an Australian tertiary hospital healthcare maternity setting and the role that both types of records play in facilitating integrated care among healthcare providers. A qualitative research design was used where five focus groups were conducted in two phases with 69 hospital healthcare providers. In total, 32 interviews were also carried out with general practitioners. Transcripts were analysed using qualitative content analysis. Three key themes were identified: (1) selective use of records; (2) records as communication of care; and (3) negativity about the use of records. This study demonstrates that healthcare providers do not effectively share information using either a paper hand-held record or a shared electronic health record. Considering a national commitment to e-health innovation, a multi-professional input, organisational support and continuing education are identified as crucial to realising the potential of a maternity shared electronic health record to facilitate integrated care.

Objectives—To describe the use, perceived eVectiveness, and predicted future use of organisational strategies for influencing clinicians’ behaviour in the approach of NHS trusts to clinical governance, and to ascertain the perceived benefits of clinical governance and the barriers to change. Design and setting—Whole population postal survey conducted between March and June 1999. Subjects—Clinical governance leads of 86 NHS trusts across the South West and West Midlands regions. Method—A combination of open questions to assess the use of strategies to influence clinician behaviour and the barriers to clinical governance. Closed (yes/ no) and Likert type ratings were used to assess the use, perceived eVectiveness, and future use of 13 strategies and the predicted outcomes of clinical governance. Results—All trusts use one or more of 13 strategies categorised as educational, facilitative, performance management, and organisational change methods. Most popular were educational programmes (96%) and protocols and guidelines (97%). The least popular was performance management such as use of financial incentives (29%). Examples of successful existing practice to date showed a preference for initiatives that described the use of protocols and guidelines, and use of benchmarking data. Strategies most frequently rated as eVective were facilitative methods such as the facilitation of best practice in clinical teams (79%), the use of pilot projects (73%), and protocols and guidelines (52%). The least often cited as eVective were educational programmes (42%) and training clinicians in information management (20%); 8% found none of the 13 strategies to be eVective. Predicted future use showed that all the trusts which completed this section intended to use at least one of the 13 strategies. The most popular strategies were educational and facilitative. Scatterplots show that there is a consistent relationship between use and planned future use. This was less apparent for the relationship between planned use and perceived eVectiveness. Barriers to change included lack of resources, mainly of money and staV time, and the need to address cultural issues, plus infrastructure support. The anticipated outcomes of clinical governance show that most trusts expect to influence clinician behaviour by improving patient outcomes (78%), but only 53% expect it to result in better use of resources, improved patient satisfaction (36%), and reduced complaints (10%). Conclusions—Clinical governance leads of trusts report using a range of strategies for influencing clinician behaviour and plan to use a similar range in the future. The choice of methods seems to be related to past experience of local use, despite equivocal judgements of their perceived eVectiveness in the trusts. Most expect to achieve a positive impact on patient outcomes as a result. It is concluded that trusts should establish methods of learning what strategies are eVective from their own data and from external comparison. (Quality in Health Care 2001;10:76‐82)

Aim—To identify and describe current methods of making health related research evidence accessible to general practice staV in the Northern and Yorkshire Region. Method—A postal survey questionnaire of general practice staV in the Northern and Yorkshire Region. Results—At least one completed questionnaire was obtained from 70% of the general practices surveyed, and the individual response rate to the survey was 45%. Just under 60% of all respondents reported having no access to the NHS internet and just under 50% also reported having no access to the internet. All respondents in this survey reported greater access to paper based information than to electronic databases. However, this research provides evidence of diVerential access to information resources between diVerent professions in general practice with GPs clearly having easier access than other professions to both paper based resources and electronic databases. 70% of all respondents said that they would need to be trained to use either a computer, the internet, or to search databases if the opportunity for easy access to any of these information services was available. Conclusions—At the time of this survey, general practices seemed to be struggling to set up the infrastructure and develop the skills that are necessary to make best use of available research evidence. In addition, there is a need for further investigation into the reasons why diVerent professions working in the same practice setting have diVerential access to information resources available in primary care. (Quality in Health Care 2001;10:83‐89)

Background —Consumer involvement in clinical guidelines has long been advocated although there are few empirical accounts of attempts to do so. It is therefore not surprising that there is a lack of clarity about how and when to involve consumers and what to expect from them within the process of guideline development. Methods —The North of England evidence based guideline development programme has used four different methods of consumer involvement. Results —When individual patients were included in a guideline development group they contributed infrequently and had problems with the use of technical language. Although they contributed most in discussions of patient education, their contributions were not subsequently acted on. In a “one off” meeting with a group of patients there were again reported problems with medical terminology and the group were most interested in sections on patient education and self management. However, their understanding of the use of scientific evidence in order to contribute to a more cost effective health care remained unclear. In a workshop it was possible to explain the technical elements of guideline development to patients who could then engage with such a process and make relevant suggestions as a consequence. However, this was relatively resource intensive. A patient advocate within a guideline development group felt confidence to speak, was used to having discussions with health professionals, and was familiar with the medical terminology. Conclusions —Consumers should be involved in all stages of guideline development. While this is possible, it is not straightforward. There is no one right way to accomplish this and there is a clear need for further work on how best to achieve it.

Background —No published quantitative instrument exists to measure maternal satisfaction with the quality of different models of labour care in the UK. Methods —A quantitative psychometric multidimensional maternal satisfaction questionnaire, the Women's Views of Birth Labour Satisfaction Questionnaire (WOMBLSQ), was developed using principal components analysis with varimax rotation of successive versions. Internal reliability and content and construct validity were assessed. Results —Of 300 women sent the first version (WOMBLSQ1), 120 (40%) replied; of 300 sent WOMBLSQ2, 188 (62.7%) replied; of 500 women sent WOMBLSQ3, 319 (63.8%) replied; and of 2400 women sent WOMBLSQ4, 1683 (70.1%) replied. The latter two versions consisted of 10 dimensions in addition to general satisfaction. These were (Cronbach's alpha): professional support in labour (0.91), expectations of labour (0.90), home assessment in early labour (0.90), holding the baby (0.87), support from husband/partner (0.83), pain relief in labour (0.83), pain relief immediately after labour (0.65), knowing labour carers (0.82), labour environment (0.80), and control in labour (0.62). There were moderate correlations (range 0.16–0.73) between individual dimensions and the general satisfaction scale (0.75). Scores on individual dimensions were significantly related to a range of clinical and demographic variables. Conclusion —This multidimensional labour satisfaction instrument has good validity and internal reliability. It could be used to assess care in labour across different models of maternity care, or as a prelude to in depth exploration of specific areas of concern. Its external reliability and transferability to care outside the South West region needs further evaluation, particularly in terms of ethnicity and social class.

Student peer assessment (SPA) has been used intermittently in medical education for more than four decades, particularly in connection with skills training. SPA generally has not been rigorously tested, so medical educators have limited evidence about SPA effectiveness.Seventy-one first-year medical students were stratified by previous test scores into problem-based learning tutorial groups, and then these assigned groups were randomized further into intervention and control groups. All students received evidence-based medicine (EBM) training. Only the intervention group members received SPA training, practice with assessment rubrics, and then application of anonymous SPA to assignments submitted by other members of the intervention group.Students in the intervention group had higher mean scores on the formative test with a potential maximum score of 49 points than did students in the control group, 45.7 and 43.5, respectively (P = 0.06).SPA training and the application of these skills by the intervention group resulted in higher scores on formative tests compared to those in the control group, a difference approaching statistical significance. The extra effort expended by librarians, other personnel, and medical students must be factored into the decision to use SPA in any specific educational context.SPA has not been rigorously tested, particularly in medical education. Future, similarly rigorous studies could further validate use of SPA so that librarians can optimally make use of limited contact time for information skills training in medical school curricula.

Purpose To describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment. Methods This was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated. Results Varying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms). Conclusions Electronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective.

Background: In health care, the use of physical parameters to monitor physical disease progress is common. In mental health care, the periodic measurement of a client's functioning during treatment, or routine outcome monitoring, has recently become important. Online delivery of questionnaires has the potential to reduce clinicians' resistance to the implementation of routine outcome monitoring. Online delivery enables clinicians to receive results on a questionnaire in a graphic directly after data entry. This gives them insight into the progress of a client at a single glance. Objective: To explore clinicians' perspectives on a routine outcome monitoring procedure where questionnaires and feedback on scores were delivered online. Questionnaires could also be filled out on paper and then entered into the online system by a research assistant. Methods: In 2009 we sent an online survey, consisting of five yes-or-no questions and six open-ended questions, to all clinicians in the 14 mental health care organizations working with the routine outcome monitoring system in the Netherlands. Of the 172 clinicians contacted, 80 (47%) opened the link and 70 of these 80 (88%) clinicians completed the survey. Results: Clinicians seldom used the graphical feedback from the Web-based system, which indicates that direct feedback on scores did not enhance the implementation of routine outcome monitoring. Integration into the electronic patient record and more training on interpretation and implementation of feedback in daily practice were seen as the primary points for further improvement. It was mainly the availability of a research assistant that made the routine outcome monitoring procedure feasible. Conclusions: Without a research assistant and training in the interpretation of outcomes, software programs alone cannot ensure effective implementation of monitoring activities in everyday practice. © Marjolein A Veerbeek, Richard C Oude Voshaar, Anne Margriet Pot.

To describe the paper-based and electronic formats of resident admission forms used in several aged care facilities in Australia and to compare the extent to which resident admission information was documented in paper-based and the electronic health records.Retrospective auditing and comparison of the documentation quality of paper-based and electronic resident admission forms were conducted. A checklist of admission data was qualitatively derived from different formats of the admission forms collected. Three measures were used to assess the quality of documentation of the admission forms, including completeness rate, comprehensiveness rate and frequency of documented data element. The associations between the number of items and their completeness and comprehensiveness rates were estimated at a general level and at each information category level.Various paper-based and electronic formats of admission forms were collected, reflecting varying practice among the participant facilities. The overall completeness and comprehensiveness rates of the admission forms were poor, but were higher in the electronic health records than in the paper-based records (60% versus 56% and 40% versus 29% respectively, p0.01). There were differences in the overall completeness and comprehensiveness rates between the different formats of admission forms (p0.01). At each information category level, varying degrees of difference in the completeness and comprehensiveness rates were found between different form formats and between the paper-based and the electronic records. A negative association between the completeness rate and the number of items in a form was found at each information category level (p0.01), i.e., more data items designed in a form, the less likely that the items would be completely filled. However, the associations between the comprehensiveness rates and the number of items were highly positive at both overall and individual information category levels (p0.01), suggesting more items designed in a form, more information would be captured.Better quality of documentation in resident admission forms was identified in the electronic documentation systems than in previous paper-based systems, but still needs to be further improved in practice. The quality of documentation of resident admission data should be further analysed in relation to its specific content.

Although the potential benefits of computer-based records have been identified in different areas of the healthcare environment, in many settings paper-based records and computer-based records are still used in parallel. In this article, emergency department (ED) staff perspectives about the use of paper- or computer-based records are presented. This was a qualitative study in which data were collected using in-depth semi-structured interviews with the ED staff. The interviews were transcribed verbatim and data were analysed using framework analysis. In total, 34 interviews were undertaken. The study identified a number of factors which might encourage or discourage the use of paper-based and computer-based records in the ED. Users also expressed their concerns and expectations. Although there is a tendency towards computerizing healthcare settings, user acceptance of technology should not be underestimated. To improve user acceptance, users’ concerns should be investigated and addressed appropriately.

Summary Objective: The purpose of this study was to investigate the effects of hybrid environments (i.e. where part of the patient record is paper-based and part of it is electronic) upon aspects of novice nurse information seeking (i.e. amount of information accessed, choice of key information sources, type of information and use of information seeking tactics). Methods: A within group, laboratory, experimental study was conducted using two simulated environments (i.e. a paper environment and a hybrid environment). Thirty-five novice nurses participated in the study. Results: Findings revealed significant differences between the paper and hybrid environments in terms of their effects upon aspects of novice nurse information seeking. Subjects accessed: 1) less information in the hybrid environment than the paper environment, 2) more non-electronic sources of information were accessed by novice nurses in the hybrid environment, and 3) novice nurses used more passive information seeking tactics in the hybrid environment than the paper environment. Qualitative findings from the cued recall data revealed subjects experienced increased cognitive load in the hybrid environment. Conclusions: Hybrid environments may affect aspects of novice nurse information seeking. Future research should explore the effects of hybrid environments upon the information seeking of other types of health professionals (e.g. physicians, physiotherapists) with differing levels of expertise (i.e. novice, intermediate and expert).

Health professionals need competencies in improvement skills if they are to contribute usefully to improving patient care. Medical education programmes in the USA have not systematically taught improvement skills to residents (registrars in the UK). The Accreditation Council for Graduate Medical Education (ACGME) has recently developed and begun to deploy a competency based model for accreditation that may encourage the development of improvement skills by the 100 000 residents in accredited programmes. Six competencies have been identified for all physicians, independent of specialty, and measurement tools for these competencies have been described. This model may be applicable to other healthcare professions. This paper explores patterns that inhibit efforts to change practice and proposes an educational model to provide changes in management skills based on trainees' analysis of their own work.

PURPOSE We compared the completeness of data collection using paper forms and using electronic forms loaded on handheld computers in an offi ce-based patient interview survey conducted within the American Academy of Family Phy- sicians National Research Network. METHODS We asked 19 medical assistants and nurses in family practices to administer a survey about pneumococcal immunizations to 60 older adults each, 30 using paper forms and 30 using electronic forms on handheld computers. By random assignment, the interviewers used either the paper or electronic form fi rst. Using multilevel analyses adjusted for patient characteristics and clustering of forms by practice, we analyzed the completeness of the data. RESULTS A total of 1,003 of the expected 1,140 forms were returned to the data center. The overall return rate was better for paper forms (537 of 570, 94%) than for electronic forms (466 of 570, 82%) because of technical diffi culties experienced with electronic data collection and stolen or lost handheld comput- ers. Errors of omission on the returned forms, however, were more common using paper forms. Of the returned forms, only 3% of those gathered electroni- cally had errors of omission, compared with 35% of those gathered on paper. Similarly, only 0.04% of total survey items were missing on the electronic forms, compared with 3.5% of the survey items using paper forms. CONCLUSIONS Although handheld computers produced more complete data than the paper method for the returned forms, they were not superior because of the large amount of missing data due to technical diffi culties with the hand- held computers or loss or theft. Other hardware solutions, such as tablet comput- ers or cell phones linked via a wireless network directly to a Web site, may be better electronic solutions for the future.

PURPOSE In 2004, a commentary by Merenstein was published in JAMA describing how he was sued for engaging a patient in shared decision making for prostate cancer screening. The article sparked considerable debate on the impact of litigation on medical care. A natural experiment (a study assessing shared decision making under way at the practice that was sued) enabled us to evaluate whether physicians changed their prostate cancer screening behavior after the lawsuit. METHODS As part of a randomized controlled trial conducted between January 2002 and November 2004, patients and physicians completed exit questionnaires about prostate cancer screening discussions after health maintenance examinations. We compared responses before, during, and after physicians became aware of the lawsuit. RESULTS A total of 432 of 497 patients completed questionnaires (180 before the practice became aware of the lawsuit, 87 as knowledge of the case diffused through the practice, and 165 after publication of Merenstein’s commentary). Comparing patients’ responses over the 3 time periods, there were no changes in the average locus of decision-making control, time spent discussing screening, number of screening topics discussed, knowledge scores, or decisional conflict. The frequency with which physicians reported performing prostate-specific antigen testing increased (before vs after: 84% vs 90%; P = .03), and physicians were more likely to report that they, rather than the patients, had made the screening decision (before vs after: 3.3% vs 11.1%; P = .003). CONCLUSIONS The physicians in closest proximity to this well-known legal case continued to engage patients in shared decision making and to let patients decide whether to be screened. Prostate-specific antigen testing increased during this period.

Background: There are significant variations in the short term patterns of care and outcome after a first stroke in Europe. Objective: To estimate the variation in stroke care and outcome up to 1 year after a stroke in selected European centres. Methods: Hospital based stroke registers were established in 11 hospitals in seven western and central European countries to collect demographic, clinical, and resource use data at the time of first ever stroke during 1993–4. At 3 and 12 months, details of survival, activities of daily living score, and use of services were recorded. Univariate comparisons between centres were made using the χ2 test and stepwise regression was used to identify associations between centre, case mix, therapy provision, and outcomes. Results: Of the 4048 patients registered, 23% were lost to follow up and 38% had died at 1 year. The proportions of survivors who felt they needed assistance at 12 months ranged from 35% in Italy to 77% in UK2. There were comparatively high amounts of therapy provided up to 1 year in UK3, France and Germany 1, mainly at home. At 1 year, social services were still providing support in UK1, UK5 and France, with some support in Germany 1 and family support was provided in France. In multivariate analysis, after adjustment for case mix and receipt of rehabilitation, non-UK centres had improved activities of daily living (p

Objectives: The purpose of this study was to describe the process used to decide which patients are admitted to the intensive care unit (ICU) at a hospital with special focus on access for neurosurgery patients, and evaluate it using “accountability for reasonableness”. Methods: Qualitative case study methodology was used. Data were collected from documents, interviews with key informants, and observations. The data were subjected to thematic analysis and evaluated using the four conditions of “accountability for reasonableness” (relevance, publicity, appeals, enforcement) to identify good practices and opportunities for improvement. Results: ICU admissions were based on the referring physician’s assessment of the medical need of the patient for an ICU bed. Non-medical criteria (for example, family wishes) also influenced admission decisions. Although there was an ICU bed allocation policy, patient need always superceded the bed allocation policy. ICU admission guidelines were not used. Admission decisions and reasons were disseminated to the ICU charge nurse, the bed coordinator, the ICU resident, the intensivist, and the requesting physician/surgeon by word of mouth and by written documentation in the patient’s chart, but not to the patient or family. Appeals occurred informally, through negotiations between clinicians. Enforcement of relevance, publicity, and appeals was felt to be either non-existent or deficient. Conclusions: Conducting a case study of priority setting decisions for patients requiring ICU beds, with a special focus on neurosurgical patients, and applying the ethical framework “accountability for reasonableness” can help critical care units improve the fairness of their priority setting.

Comprehensive care for people with disabling neurological disease—finding the best approach Comprehensive care for people with disabling neurological illnesses is widely acknowledged to require input from many specialisms. The foundation of such multifaceted care should be a detailed assessment of physical and psychosocial function and health needs, ideally by experienced individuals able to work in a transdisciplinary way and possessing excellent communication skills. Such individuals would be capable of both identifying a clinical problem, such as impaired heel strike, and determining the most appropriate treatment, such as stretches from the physiotherapist, botulinum toxin from the physician or orthopaedic release. Clearly clinicians with the wide training and experience for such …

BackgroundThe appropriate medical treatment test (ATT), included in the Mental Health Act (MHA) (1983, as amended 2007), aims to ensure that detention only occurs when treatment with the purpose of alleviating a mental disorder is available.AimsAs part of the Assessing the Impact of the Mental Health Act (AMEND) project, this qualitative study aimed to assess professionals' understanding of the ATT, and its impact on clinical practice.MethodForty-one professionals from a variety of mental health subspecialties were interviewed. Interviews were coded related to project aims, and themes were generated in an inductive process.ResultsWe found that clinicians are often wholly relied upon for the ATT. Considered treatment varied depending on the patient's age rather than diagnosis. The ATT has had little impact on clinical practice.ConclusionsOur findings suggest the need to review training and support for professionals involved in MHA assessments, with better-defined roles. This may enable professionals to implement the ATT as its designers intended.

Background During the 2009 H1N1 immunization campaign, electronic and hybrid (comprising both electronic and paper components) systems were employed to collect client-level vaccination data in clinics across Canada. Because different systems were used across the country, the 2009 immunization campaign offered an opportunity to study the usability of the various data collection methods. Methods A convenience sample of clinic staff working in public health agencies and hospitals in 9 provinces/territories across Canada completed a questionnaire in which they indicated their level of agreement with seven statements regarding the usability of the data collection system employed at their vaccination clinic. Questions included overall ease of use, effectiveness of the method utilized, efficiency at completing tasks, comfort using the method, ability to recover from mistakes, ease of learning the method and overall satisfaction with the method. A 5-point Likert-type scale was used to measure responses. Results Most respondents (96%) were employed in sites run by public health. Respondents included 186 nurses and 114 administrative staff, among whom 90% and 47%, respectively, used a paper-based method for data collection. Approximately half the respondents had a year or less of experience with immunization-related tasks during seasonal influenza campaigns. Over 90% of all frontline staff found their data collection method easy to use, perceived it to be effective in helping them complete their tasks, felt quick and comfortable using the method, and found the method easy to learn, regardless of whether a hybrid or electronic system was used. Conclusions This study demonstrates that there may be a greater willingness of frontline immunization staff to adapt to new technologies than previously perceived by decision-makers. The public health community should recognize that usability may not be a barrier to implementing electronic methods for collecting individual-level immunization data.