Exploring educational interventions to facilitate health professional students' professionally safe online presence.

OBJECTIVE: To establish the most effective approach and type of educational intervention for health professional students, to enable them to maintain a professionally safe online presence. METHOD: This was a qualitative, multinational, multi-institutional, multiprofessional study. Practical considerations (availability of participants) led us to use a combination of focus groups and individual interviews, strengthening our findings by triangulating our method of data collection. The study gathered data from 57 nursing, medical and paramedical students across four sites in three countries (Aotearoa/New Zealand, Australia and Wales). A content analysis was conducted to clarify how and why students used Facebook and what strategies they thought might be useful to ensure professional usage. A series of emergent codes were examined and a thematic analysis undertaken from which key themes were crystallized. RESULTS: The results illuminated the ways in which students use social networking sites (SNS). The three key themes to emerge from the data analysis were negotiating identities, distancing and risks. Students expressed the wish to have material about professional safety on SNS taught to them by authoritative figures to explain "the rules" as well as by peers to assist with practicalities. Our interactive research method demonstrated the transformative capacity of the students working in groups. CONCLUSIONS: Our study supports the need for an educational intervention to assist health professional students to navigate SNS safely and in a manner appropriate to their future roles as health professionals. Because health professional students develop their professional identity throughout their training, we suggest that the most appropriate intervention incorporate small group interactive sessions from those in authority, and from peers, combined with group work that facilitates and enhances the students' development of a professional identity.

Empathy among undergraduate medical students: A multi-centre cross-sectional comparison of students beginning and approaching the end of their course.

BACKGROUND: Although a core element in patient care the trajectory of empathy during undergraduate medical education remains unclear. Empathy is generally regarded as comprising an affective capacity: the ability to be sensitive to and concerned for, another and a cognitive capacity: the ability to understand and appreciate the other person's perspective. The authors investigated whether final year undergraduate students recorded lower levels of empathy than their first year counterparts, and whether male and female students differed in this respect. METHODS: Between September 2013 and June 2014 an online questionnaire survey was administered to 15 UK, and 2 international medical schools. Participating schools provided both 5-6 year standard courses and 4 year accelerated graduate entry courses. The survey incorporated the Jefferson Scale of Empathy-Student Version (JSE-S) and Davis's Interpersonal Reactivity Index (IRI), both widely used to measure medical student empathy. Participation was voluntary. Chi squared tests were used to test for differences in biographical characteristics of student groups. Multiple linear regression analyses, in which predictor variables were year of course (first/final); sex; type of course and broad socio-economic group were used to compare empathy scores. RESULTS: Five medical schools (4 in the UK, 1 in New Zealand) achieved average response rates of 55 % (n = 652) among students starting their course and 48 % (n = 487) among final year students. These schools formed the High Response Rate Group. The remaining 12 medical schools recorded lower response rates of 24.0 % and 15.2 % among first and final year students respectively. These schools formed the Lower Response Rate Group. For both male and female students in both groups of schools no significant differences in any empathy scores were found between students starting and approaching the end of their course. Gender was found to significantly predict empathy scores, with females scoring higher than males. CONCLUSIONS: Participant male and female medical students approaching the end of their undergraduate education, did not record lower levels of empathy, compared to those at the beginning of their course. Questions remain concerning the trajectory of empathy after qualification and how best to support it through the pressures of starting out in medical practice.

How well do medical students rate and communicate clinical empathy?

BACKGROUND: This article presents findings from a prospective, longitudinal cohort educational study investigating empathy communication in clinical consultations. It reports on changes in students' self-report empathy during medical undergraduate training, investigates how well peers can assess student competence in motivational interviewing/brief interventions (MI/BI) skills and explores the relationship between students' self-report empathy and peer- or tutor-assessments of competence. METHODS: 72 medical students completed the Jefferson Scale of Physician Empathy at three time points: at the beginning of their fifth year medical training (Time 1), after a specific MI/BI training session during their fifth year medical training (Time 2) and 1 year later during a revision session in year 6. Competence in BI/MI consultation was assessed using the validated tool Behaviour Change Counselling Index. RESULTS: A significant decline in medical students' empathy scores was observed from year 5 to year 6, consistent with international findings. Peer assessments and tutor ratings of competence in MI/BI skills performance were moderately correlated, but peer assessments were negatively correlated with medical students' self-rated empathy. Senior medical students who self-rated as more empathic received lower competence evaluations of MI/BI skills from their peers. Interventions to further investigate teaching and learning of empathy are discussed.

A template approach to quality improvement activity: a primary care example.

INTRODUCTION: This paper demonstrates the use of a Quality Framework and Implementation Template to review processes for improving the quality and safety of opiate prescribing for chronic non-malignant pain (CNMP). Escalating use of prescription opiates for chronic pain is of national and international concern, with major implications for personal and public health as well as for patient safety and health service quality and safety. OBJECTIVES: This paper uses opiate prescribing for CNMP as a worked example to illustrate use of the Quality Framework for self-directed quality improvement in smaller specialist medical or community-based practices. METHODS: An Implementation Template, comprising a series of focussed questions derived from the Quality Framework, was applied to one specific quality improvement activity arising from clinical practice (opiate prescribing for CNMP). This helped the practice team understand current systems and processes, identify actual and potential problems, and find possible solutions to institute interventions for change. CONCLUSION: The template approach to quality activity is very applicable within smaller specialist or community health service settings, enabling such health services to focus on their own quality improvement activities and address topics of importance to the practice in a systematic and productive manner.

Challenges to alcohol and other drug discussions in the general practice consultation.

BACKGROUND: There is a widely held expectation that GPs will routinely use opportunities to provide opportunistic screening and brief intervention for alcohol and other drug (AOD) abuse, a major cause of preventable death and morbidity. AIM: To explore how opportunities arise for AOD discussion in GP consultations and how that advice is delivered. DESIGN: Analysis of video-recorded primary care consultations. SETTING: New Zealand General Practice. METHODS: Interactional content analysis of AOD consultations between 15 GP's and 56 patients identified by keyword search from a bank of digital video consultation recordings. RESULTS: AOD-related words were found in almost one-third (56/171) of the GP consultation transcripts (22 female and 34 male patients). The AOD dialogue varied from brief mention to pertinent advice. Tobacco and alcohol discussion featured more often than misuse of anxiolytics, night sedation, analgesics and caffeine, with only one direct enquiry about other (unspecified) recreational drug use. Discussion was associated with interactional delicacy on the part of both doctor and patient, manifested by verbal and non-verbal discomfort, use of closed statements, understatement, wry humour and sudden topic change. CONCLUSIONS: Mindful prioritization of competing demands, time pressures, topic delicacy and the acuteness of the presenting complaint can impede use of AOD discussion opportunities. Guidelines and tools for routine screening and brief intervention in primary care do not accommodate this reality. Possible responses to enhance AOD conversations within general practice settings are discussed.

The MacGyver effect: alive and well in health services research?

BACKGROUND: In a manner similar to the television action hero MacGyver, health services researchers need to respond to the pressure of unpredictable demands and constrained time frames. The results are often both innovative and functional, with the creation of outputs that could not have been anticipated in the initial planning and design of the research. DISCUSSION: In the conduct of health services research many challenges to robust research processes are generated as a result of the interface between academic research, health policy and implementation agendas. Within a complex and rapidly evolving environment the task of the health services researcher is, therefore, to juggle sometimes contradictory pressures to produce valid results. SUMMARY: This paper identifies the MacGyver-type dilemmas which arise in health services research, wherein innovation may be called for, to maintain the intended scientific method and rigour. These 'MacGyver drivers' are framed as opposing issues from the perspective of both academic and public policy communities. The ideas expressed in this paper are illustrated by four examples from research projects positioned at the interface between public policy strategy and academia.

"Being-in-role": A teaching innovation to enhance empathic communication skills in medical students.

BACKGROUND: The communication of empathy is key in physician-patient interactions. We introduced drama training in "How to act-in-role" to medical students and evaluated the effect of this. METHODS: A quasi-experimental design was employed, with 72 students in the control and 77 students in the intervention group. The students' empathy scores were obtained using the Jefferson Scale of Physician Empathy (JSPE) during the introductory course. Both groups received tutorials in motivational interviewing and brief intervention skills. The students in the intervention group also received training in "How to act-in-role". The JSPE was repeated for both groups. The students subsequently undertook observed structured clinical examinations (OSCE). Both tutors and students evaluated the student's OSCE performance as well as their motivational interviewing skills using the Behavior Change Counseling Index (BECCI). RESULTS: Our findings show that while the students in both groups did not significantly differ in baseline empathy scores, the intervention group reported significantly higher empathy scores post-intervention. The intervention group also received significantly higher tutor ratings for their motivational interviewing (BECCI score) and overall OSCE performances. In conclusion, the teaching innovation "How to act-in-role" was effective not only in increasing medical students' self-reported empathy but also their competence in consultation skills.

Management and monitoring of anticoagulation for children undergoing cardiopulmonary bypass in cardiac surgery.

Cardiopulmonary bypass (CPB) creates a pro-coagulant state by causing platelet activation and inflammation leading to thrombin generation and platelet dysfunction. It is associated with severe derangements in normal homeostasis resulting in both thrombotic and hemorrhagic complications. This derangement is greater in children with congenital heart disease than in adults because of the immaturity of the coagulation system, hemodilution of coagulation factors, hyperreactive platelets, and in some patients, physiologic changes associated with cyanosis. During CPB, an appropriate amount of heparin is given with the goal of minimizing the risk of thrombosis and platelet activation and at the same time reducing the risk of bleeding from over anticoagulation. In young children, this balance is more difficult to achieve because of inherent characteristics of the hemostatic system in these patients. Historically, protocols for heparin dosing and monitoring in children have been adapted from adult protocols without re-validation for children. Extreme hemodilution of coagulation factors and platelets in young children affects the accuracy of anticoagulation monitoring in children. The activated clotting time does not correlate with plasma levels of heparin. In addition, recent studies suggest that children need larger doses of heparin than adults, because they have lower antithrombin levels, and they metabolize heparin more rapidly. Preliminary studies demonstrated that the use of individualized heparin and protamine monitoring and management in children is associated with reduced platelet activation and dysfunction and improved clinical outcomes. However, this review article clearly establishes that further studies are necessary to obtain evidence-based protocols for the proper management of anticoagulation of children undergoing cardiopulmonary bypass.

Evaluation of iodine levels in the Riverina population.

OBJECTIVE: To assess the iodine status in a random group of adults in a rural region. DESIGN: A cross-sectional study; urinary iodine concentrations (UIC) were correlated with results of a questionnaire that collected demographic information. SETTING: Primary care. PARTICIPANTS: A total of 173 adults from the Riverina region provided a morning midstream urine sample and completed a questionnaire. There were no exclusion criteria. MAIN OUTCOME MEASURES: Iodine status was based upon mean UIC (MUIC) values and categorised according to World Health Organisation criterion. Subgroups were classified according to sex, age, town, salt usage, vitamin/supplement usage, pregnant or breast-feeding status and diet. RESULTS: The MUIC for the study population was 79 microg L(-1); 29% were iodine-replete, 52% had mild deficiency and 18.5% were moderately to severely deficient. Use of iodised salt produced a non-clinically significant increase in MUIC of 81 microg L(-1)compared with 71 microg L(-1)(P = 0.1907). Daily vitamin supplementation led to iodine sufficiency with a MUIC of 111 microg L(-1)(P = 0.0011). Participants aged 50-59 years had a significantly lower MUIC than participants aged 18-39 years (67 versus 89 microg L(-1), respectively, P = 0.0106). Further, the MUIC decreased with age from 18 to 59 years (P = 0.0208). CONCLUSIONS: A mild iodine deficiency was found in this sample of the Riverina population, consistent with other Australian studies. Salt iodisation might not be an effective strategy to correct iodine deficiencies within Australia.

Falls Assessment Clinical Trial (FACT): design, interventions, recruitment strategies and participant characteristics.

BACKGROUND: Guidelines recommend multifactorial intervention programmes to prevent falls in older adults but there are few randomised controlled trials in a real life health care setting. We describe the rationale, intervention, study design, recruitment strategies and baseline characteristics of participants in a randomised controlled trial of a multifactorial falls prevention programme in primary health care. METHODS: Participants are patients from 19 primary care practices in Hutt Valley, New Zealand aged 75 years and over who have fallen in the past year and live independently. Two recruitment strategies were used - waiting room screening and practice mail-out. Intervention participants receive a community based nurse assessment of falls and fracture risk factors, home hazards, referral to appropriate community interventions, and strength and balance exercise programme. Control participants receive usual care and social visits. Outcome measures include number of falls and injuries over 12 months, balance, strength, falls efficacy, activities of daily living, quality of life, and physical activity levels. RESULTS: 312 participants were recruited (69% women). Of those who had fallen, 58% of people screened in the practice waiting rooms and 40% when screened by practice letter were willing to participate. Characteristics of participants recruited using the two methods are similar (p > 0.05). Mean age of all participants was 81 years (SD 5). On average participants have 7 medical conditions, take 5.5 medications (29% on psychotropics) with a median of 2 falls (interquartile range 1, 3) in the previous year. CONCLUSION: The two recruitment strategies and the community based intervention delivery were feasible and successful, identifying a high risk group with multiple falls. Recruitment in the waiting room gave higher response rates but was less efficient than practice mail-out. Testing the effectiveness of an evidence based intervention in a 'real life' setting is important.

Challenging some assumptions about empathy.

BACKGROUND: In New Zealand little nursing or medical curricula time, if any, is specifically devoted to the enhancement of empathy. If being empathic is important in the context of patient care, it is a quality that is already present in students or is learned by students during their practicum in the company of experienced clinicians. This study aimed to compare self-reported empathy ratings between different groups of medical students and one cohort of nursing students who were either exposed or not exposed to explicit empathy training or learning in clinical settings in the presence of patients. METHODS: The Jefferson Scale of Physician Empathy (JSPE) was completed before and after groups of medical and nursing students had been exposed to various extended periods of practicum. Some medical student cohorts undertook brief empathy training, whereas others had no exposure. The nursing student cohort had no formal, explicit empathy training. RESULTS: Irrespective of profession, length of practicum or exposure to specific empathy training, there were no significant differences in the self-reported JSPE scores across the seven different cohorts of students. Empathy is a quality that is already present in students or is learned by students during their practicum DISCUSSION: If empathy is caught rather than taught, then brief efforts to enhance empathy may be futile. To optimise the inherent empathic qualities of aspirant health professionals, explicit consideration should be given to how empathy is influenced by the practicum experience.

Dietary flavanols and procyanidin oligomers from cocoa (Theobroma cacao) inhibit platelet function.

BACKGROUND: Flavonoids may be partly responsible for some health benefits, including antiinflammatory action and a decreased tendency for the blood to clot. An acute dose of flavanols and oligomeric procyanidins from cocoa powder inhibits platelet activation and function over 6 h in humans. OBJECTIVE: This study sought to evaluate whether 28 d of supplementation with cocoa flavanols and related procyanidin oligomers would modulate human platelet reactivity and primary hemostasis and reduce oxidative markers in vivo. DESIGN: Thirty-two healthy subjects were assigned to consume active (234 mg cocoa flavanols and procyanidins/d) or placebo (< or = 6 mg cocoa flavanols and procyanidins/d) tablets in a blinded parallel-designed study. Platelet function was determined by measuring platelet aggregation, ATP release, and expression of activation-dependent platelet antigens by using flow cytometry. Plasma was analyzed for oxidation markers and antioxidant status. RESULTS: Plasma concentrations of epicatechin and catechin in the active group increased by 81% and 28%, respectively, during the intervention period. The active group had significantly lower P selectin expression and significantly lower ADP-induced aggregation and collagen-induced aggregation than did the placebo group. Plasma ascorbic acid concentrations were significantly higher in the active than in the placebo group (P < 0.05), whereas plasma oxidation markers and antioxidant status did not change in either group. CONCLUSIONS: Cocoa flavanol and procyanidin supplementation for 28 d significantly increased plasma epicatechin and catechin concentrations and significantly decreased platelet function. These data support the results of acute studies that used higher doses of cocoa flavanols and procyanidins.

Fragile sites and bladder cancer.

Continued reports of associations between environmentally induced chromosomal fragile sites and cancer prompted us to undertake a review of current literature to examine whether there might be a relationship between fragile sites and chromosomal alterations reported for bladder cancer. It was found that more than half (56%; odds ratio [OR] = 4.70) of chromosomal rearrangements reported for bladder cancer were located at 77 (65%) of the 118 recognized fragile sites (OR = 6.88). Furthermore, 55% of the fragile sites implicated coincided with one or more genes that have been associated with human cancer (such as oncogenes, tumor suppressor, relonc, transloc, disorder, apoptotic, and angiogenic genes). The most common fragile sites involved were FRA1D, FRA1F, FRA8C, FRA9D, FRA9E, and FRA11C. This correlation suggests that there may be profiles of genetic damage via fragile site expression that lead to the development of at least a proportion of bladder cancers.

Organophosphate-based pesticides and genetic damage implicated in bladder cancer.

Organophosphate-based pesticides have been associated with pathology and chromosomal damage in humans. There are also epidemiologic links with cancer. The few screening tests for low-level occupational exposure are of doubtful sensitivity; this investigation evaluated four methods. Blood samples were studied from 10 farmers before and after occupational exposure to organophosphate-based pesticides and five unexposed controls. The standard cholinesterase test was insensitive to the exposure (P=0.815). However, a significant increase in Howell-Jolly bodies within erythrocytes was observed (P=0.001). Cytogenetic studies on routine and aphidicolin-induced blood cultures revealed that following organophosphate exposure the total number of gaps and breaks on human chromosomes was significantly increased (P=0.004 and P=0.0006, respectively). We concluded that Howell-Jolly body and fragile site analysis were sensitive indicators of nuclear damage resulting from low-level occupational exposure to organophosphate. Such nuclear damage could be implicated in carcinogenesis. The development of bladder cancer is one such example.

The detection of Chlamydia pneumoniae in atherosclerotic plaques of Australian subjects.

AIM: To determine whether the common respiratory pathogen, Chlamydia pneumoniae, was associated with atherosclerotic plaques in Australian subjects. METHODS: A total of 29 coronary atherosclerotic lesions and 18 normal coronary arterial samples were tested for the presence of C. pneumoniae by PCR and immunofluorescence methods. RESULTS: Chlamydia pneumoniae was detected in 15 of the atheromatous lesions as well as in three of the normal tissues; the immunofluorescence assay was more sensitive (P=0.028) than PCR (P=0.26). CONCLUSIONS: These findings contradict previous Australian studies which did not detect C. pneumoniae in atherosclerotic plaques, thereby discounting the speculation that its absence was likely due to geographical variation. The detection of the bacterium in some of the normal tissues suggests that C. pneumoniae infection might be an initial trigger of atherosclerotic development.

Mystery shopping in health service evaluation.

BACKGROUND: Over the last 5 years, primary care telephone triage systems have been introduced in the United Kingdom, United States, Australia, and most recently in New Zealand. Evaluation of the clinical safety of such systems poses a challenge for health planners and researchers. AIM: To evaluate the use of simulated patients in the assessment of aspects of clinical safety in a pilot New Zealand primary care telephone triage service. DESIGN OF STUDY: 'Mystery shopping', an evaluation strategy commonly used in market research, was adapted by using simulated patients for telephone triage service evaluation. SETTING: New Zealand. METHODS: Four scripted clinical scenarios were developed by academic general practitioners, validated in student teaching situations, and then used by simulated patients to make 101 telephone calls. The scenarios were designed to necessitate a referral to a medical practitioner for further investigation. The documentation kept by the callers was compared with the call records from the telephone triage company, and both were analysed for capture and handling of the clinical safety features of each scenario. In cases where the endpoint was not a medical assessment, possible reasons for this were explored. RESULTS: Records were retrieved for 85 telephone calls. Considerable triage variability was discovered. There were discrepancies between expected and actual triage outcomes with 51% of analysed calls resulting in a self-care recommendation. A number of reasons were identified both for the triage variability and the unpredicted outcomes. Audiotaping of consultations would have enhanced the credibility of the evaluation but it would have carried ethical constraints. CONCLUSION: Simulated patients can be used to evaluate the limitations of health services and to identify areas that could be addressed to improve patient safety. Evaluation of patient satisfaction with services is not sufficient alone to evaluate safety.

Addressing patient alcohol use: a view from general practice.

INTRODUCTION: General practitioners (GPs) have the potential to promote alcohol harm minimisation via discussion of alcohol use with patients, but knowledge of GPs' current practice and attitudes on this matter is limited. Our aim was to assess GPs' current practice and attitudes towards discussing alcohol use with their patients. METHODS: This qualitative study involved semi-structured, face-to-face interviews with 19 GPs by a group of medical students in primary care practices in Wellington, New Zealand. FINDINGS: Despite agreement amongst GPs about the importance of their role in alcohol harm minimisation, alcohol was not often raised in patient consultations. GPs' usual practice included referral to drug and alcohol services and advice. GPs were also aware of national drinking guidelines and alcohol screening tools, but in practice these were rarely utilised. Key barriers to discussing alcohol use included its societal 'taboo' nature, time constraints, and perceptions of patient dishonesty. CONCLUSION: In this study there is a fundamental mismatch between the health community's expectations of GPs to discuss alcohol with patients and the reality. Potential solutions to the most commonly identified barriers include screening outside the GP consultation, incorporating screening tools into existing software used by GPs, exploring with GPs the social stigma associated with alcohol misuse, and framing alcohol misuse as a health issue. As it is unclear if these approaches will change GP practice, there remains scope for the development and pilot testing of potential solutions identified in this research, together with an assessment of their efficacy in reducing hazardous alcohol consumption.

Exploring resilience in families living with addiction.

INTRODUCTION: Information about the impact of addiction on New Zealand (NZ) families is scarce. A good understanding of the nature and extent of family problems is essential to help families become more resilient and minimise the consequences. This study aimed to explore experiences of NZ families living with addiction, identify impacts on non-addicted family members, their coping strategies and barriers to help seeking. METHODS: Literature and key stakeholder interviews informed the development of an interview schedule for 29 family participants recruited through health and social services. Interviews were recorded for analysis of central themes and critical elements that underpin those. Key stakeholders and informal informants were again consulted to discuss findings and interpretation. FINDINGS: Addiction has widespread effects on NZ families. The coping strategies described by the participants in this project lacked the positive connotations of resilience, namely positive adaptation under significant adversity. CONCLUSION: Family impacts of addiction are complex, and similar family problems arise regardless of the substance(s) involved. This small exploratory study indicates that the implications for NZ families deserve further investigation. Future research is also required to further characterise the impact of behavioural addictions on families, addiction in particular ethnic groupings and the implications of the findings for clinical practice, other social and health services, and for public health and social policy.

A special type of 'hard-to-reach' patient: experiences of pregnant women on methadone.

INTRODUCTION: Opiate addicts in New Zealand are a heterogeneous, hard-to-reach group with illicit drug activity as their common characteristic. This project investigated the experience of a specific hard-to-reach group: pregnant women with opiate dependency, focussing on their interactions with helping services and social networks. The aim was to explore the interactions of pregnant women on methadone with helping services and social support, with the objective to make recommendations to improve service to this 'hard-to-reach' group. METHOD: Questions for staff and client interview schedules were constructed, informed by a literature search. Seven methadone clinic staff were interviewed and a questionnaire was distributed to 10 antenatal clinic staff known to have previously managed pregnant women on methadone. Five methadone clients were interviewed at the clinic and interviews taped for transcription with consent. FINDINGS: High risk pregnancies warrant a multidisciplinary approach, but in the hard-to-reach this ideal can itself be out of reach. Although primary care is better placed than secondary care to coordinate maternity and community support services, few opiate-dependent people have a regular general practitioner and may have perceived or actual barriers to access to care. Perceived stigma deterred these women from engaging. Women also fear that services will judge and report them, worrying about the health of their child and the powers of child protection services. CONCLUSION: A fresh consideration of the functionality of services to the hard-to-reach may be beneficial. A nursing concept of 'face-work' throws some light on the misperception of well-intentione services by the hard-to-reach.