An Objective Structured Clinical Examination Case for Opioid Management: Standardized Patient Ratings of Communication Skills as a Predictor of Systems-Based Practice Scores.

The Wayne State University Office of Graduate Medical Education (WSUGME) uses an objective structured clinical examination (OSCE) to assess its programs' contribution to enhancing residents' communication skills. In response to revisions in Michigan's opioid-prescribing mandates in 2017, WSUGME developed a pain management case in collaboration with faculty and the Wayne State University School of Medicine to educate residents about these mandates while gauging their skills in Systems-Based Practice (SBP), an Accreditation Council for Graduate Medical Education Core Competency. This study examined whether resident OSCE performance predicted year-end milestones scores in SBP1 (coordinates patient care within various health care delivery settings), SBP2 (works in interdisciplinary teams to enhance patient safety and improve patient care quality), and SBP3 (practices and advocates for cost-effective, responsible care). Participants included two cohorts of first- (PRG-1) and second-year (PRG-2) residents in 6 programs: one cohort from academic year 2018-2019 (n=33), the other from 2019-2020 (n=37). Before the OSCE, WSUGME emailed residents the new state prescription requirements. During the simulated encounter, standardized patients rated residents on a validated communication instrument, and WSUGME conducted a linear regression of patient ratings on resident SBP milestone scores. The ratings of communication skills of PRG-1 residents did not predict any of the year-end SBP milestones. However, ratings of communication skills of PRG-2 residents predicted SBP1 and SBP2, though not SBP3, milestones. The OSCE opioid case proved to be a valid measure of PRG-2 residents' competence gained across the first year but was less meaningful when applied to PRG-1 residents.

Building a Culture of Well-Being in Primary Care Resident Training Programs.

Background: Monitoring and improving resident physicians' well-being are crucial because clinical care burdens can cause burnout, depression, and suicide. Burnout negatively affects patient care. Promoting well-being requires cultural change best achieved through a merging of institutional top-down efforts with resident and faculty bottom-up efforts. Methods: The Wayne State University Office of Graduate Medical Education targeted three residency programs (52 residents) at one hospital site for wellness interventions as part of the Alliance of Independent Academic Medical Centers (AIAMC) National Initiative VI. Institution-led efforts included promotion of employee wellness resources, prioritization of wellness at administrative meetings, and program evaluation and assessment. Resident- and faculty-led efforts included the formation of wellness committees that organized events and activities and communicated with program evaluation committees to address wellness concerns. Impact was assessed using mixed methods: the quantitative Resident Wellness Scale, a modified form of the Medical School Learning Environment Survey, and a qualitative Resident Wellness Semi-Structured Interview. Results: Institutional efforts were successfully applied through multiple administrative channels. Resident-led efforts were less successful initially, but wellness committees led by faculty champions were formed within programs and strengthened the resident-led efforts. Quantitative measures indicated that well-being increased and then declined, perhaps attributable to cohort effects. Qualitative analysis revealed multiple dimensions of well-being. We discuss limitations of the work and future directions. Conclusion: Resident well-being requires cooperation and a combination of top-down institutional and bottom-up trainee efforts. Because resident well-being is a complex phenomenon, efforts to improve and sustain it must also be multidimensional and broadly applied.

Using a Direct Observation Tool (TOC-CEX) to Standardize Transitions of Care by Residents at a Community Hospital.

Background: High-quality transitions of care are crucial for patient safety in hospitals, yet few undergraduate curricula include transition-of-care training. In 2012, the Wayne State University Office of Graduate Medical Education (WSUGME) required its residency programs to use the SAIF-IR mnemonic (summary, active issues, if-then contingency planning, follow-up activities, interactive questioning, readback) to ensure accurate and uniform handoffs. Subsequent program evaluations indicated that resident awareness and adoption of the mnemonic at our primary clinical site, Ascension Providence Rochester Hospital (APRH), could be improved. According to our institution's 2016 Clinical Learning Environment Review (CLER), 88% of residents reported following a standardized transition of care handoff, and 53% reported that faculty rarely supervised their handoffs. A 2016 WSUGME internal survey also revealed low rates of awareness (7% to 10%) of the mandated mnemonic. WSUGME then created a direct observation tool, the Transitions of Care-Clinical Evaluation Exercise (TOC-CEX), for faculty to monitor resident skill in using the mnemonic and thus standardize transitions of care as a practice habit at APRH. Methods: Since 2014, WSUGME had relied on 2 methods for training residents in the required handoff mnemonic: (1) introduction to the SAIF-IR mnemonic during the WSUGME orientation for all interns and (2) simulations during an objective simulated handoff evaluation activity for all postgraduate year (PGY) 1s and PGY 2s. In 2017, WSUGME innovated a direct observation tool, the TOC-CEX, for adoption by faculty at APRH to assess resident knowledge of and monitor their skill in using the SAIF-IR mnemonic in 3 primary care programs. The total number of possible participants was 138, and the actual number of individuals in the sample was 95. A majority (86%) of the observations during the study period were of PGY 1 residents, and thus the analysis reflects the ratings of 99% of all interns but only 69% of all possible residents. Results: WSUGME found that faculty use of a direct observation instrument in the clinical learning environment during 2017-2019 increased awareness and adoption of the SAIF-IR mnemonic among residents. Using a z-test of equal proportions on resident responses on an internal WSUGME survey, we found a significant rise in the percentage reporting yes to the question "Does your program have a mechanism for monitoring handoffs?" (χ2 [3]=23.6, P<0.0001) and in the percentage identifying SAIF-IR in response to the question "Does your program endorse a specific mnemonic for organizing the contents of a verbal handoff?" (χ2 [3]=45.0, P<0.0001). The increase from 2016 to 2017 is the result of the implementation of the TOC-CEX in the interim (question 1: χ2 [1]=12.4, P<0.0005; question 2: χ2 [1]=10.1, P<0.0025). Conclusion: Our research found that use of the TOC-CEX to monitor resident handoffs resulted in improved awareness and adoption of the SAIF-IR mnemonic in the clinical learning environment. Program leadership reported that the practice was both feasible and well accepted by residents, faculty, and the APRH chief medical officer as the TOC-CEX became a customary component of APRH organizational culture and was perceived as central to quality patient care.

Exposure to multiple career pathways by biomedical doctoral students at a public research university.

The Broadening Experiences in Scientific Experiences (BEST) program at Wayne State University was designed to increase doctoral students' awareness of multiple employment sectors beyond academia, improve their knowledge of transferable skills required to succeed in any career path, provide opportunities to explore diverse career paths, and gain in-depth knowledge about those paths using experiential learning opportunities. We devised a three-phase program that ranged from providing students with a broad introduction to multiple career opportunities to immersive experiential learning in a specific career sector. Importantly, program content was developed and delivered by alumni and industry experts in five employment sectors-business/industry, communication, government, law/regulatory affairs, and undergraduate/PUI teaching-in partnership with WSU faculty. This article provides data on two notable outcomes: doctoral students participate equally in BEST activities regardless of gender, race, and citizenship status, and student participation in BEST activities did not correlate with lower GRE ratings, lower GPA, or increased time-to-degree. Further, a "halo" effect of the program is evidenced by participation of students from all disciplines, not just the biomedical sciences. Centralizing BEST activities within the Graduate School will allow faculty and individual programs to save resources and time.

The prevalence of employed nurses identified or enrolled in substance use monitoring programs.

BACKGROUND: For over 100 years, nurses' particular work conditions have been anecdotally associated with increases in substance abuse. Reasons include job-related stress and easy access to medications. Current research has suggested that prevalence of nurses with substance use problems is actually similar to, if not less than, that seen in the general population. However, given nurses' proximity to critical patient care, the potential threat to public health, as well as the current shortage of practitioners and problems related to retention, the lack of research on the effectiveness of the two existing treatment protocols (disciplinary and alternative-to-discipline [ATD]) is a pressing issue of concern to the nursing profession. OBJECTIVES: The aims of this study were to estimate the 1-year prevalence of employed nurses requiring an intervention for substance use problems in the United States and the 1-year prevalence of nurses enrolled in substance abuse monitoring programs and to compare the sum total of nurses identified in disciplinary and alternative programs with the general population. METHODS: This was a balanced stratified sampling design study. Measurements included the National Council of State Boards of Nursing 2010 Survey of Regulatory Boards Disciplinary Actions on Nurses, the 2009 annual reports of alternative programs, the 2008 National Sample Survey of Registered Nurses, and the 2009 National Survey on Drug Use and Health. RESULTS: The 2009 1-year prevalence of employed nurses identified with substance use problems in the United States and its territories was 17,085 or 0.51% of the employed nursing population. The 1-year prevalence of nurses newly enrolled in substance abuse monitoring programs in the United States and its territories was 12,060 or 0.36%. Although every National Council of State Boards of Nursing jurisdiction has a disciplinary monitoring program, only 73% (n = 43) of these jurisdictions have alternative programs. Despite this, on average, alternative programs had nearly 75% more new enrollees (9,715) when compared with disciplinary programs (2,345). The prevalence of nurses identified with a substance use problem requiring an intervention (and likely treatment) is lower than the prevalence of those who report receiving substance abuse treatment in the general population (0.51% vs. 1.0%). CONCLUSIONS: The ATD programs potentially have a greater impact on protecting the public than disciplinary programs because ATD programs identify and/or enroll more nurses with substance use problems, thereby initially removing more nurses with substance use problems from direct patient care.

Nurses recovering from substance use disorders: a review of policies and position statements.

The authors review policy initiatives and professional organization position statements that hospital and nursing administrators should be familiar with to respond effectively to public and policy-maker concerns about substance use in healthcare settings. Detecting and addressing substance use disorders proactively and systematically are essential for 2 reasons: to protect patient safety and to enable healthcare professionals to recognize problems early and intervene swiftly. The authors identify key points and gaps in existing policy statements.

Don't ask don't tell: substance abuse and addiction among nurses.

AIM: The purpose of this manuscript is to illustrate the challenges faced by nurses who abuse substances and to promote international dialogue about what practitioners, administrators, health care providers and students can do when they suspect someone in the profession is abusing substances, or they may themselves be suffering from addiction. BACKGROUND: Addiction among nurses has been recognised by professionals in the field for over 100 years, and current estimates place rates of substance misuse, abuse and addiction rates as high as 20% among practicing nurses. Unfortunately, fear of punishment and discipline may keep nurses or students from asking for help for themselves or from reporting a colleague or friend who is in need of help. DESIGN: Discursive paper. METHOD: This paper synthesises the results of three previous papers conducted on substance abuse policies in the nursing profession. In the first paper, the authors reviewed the history of addiction in nursing and compared disciplinary and alternative-to-discipline policies. The second focused on the development of an alternative-to-dismissal policy for substance abuse in a school of nursing and using telephone and email interviews, and the final paper reported findings of what types of policies seem to be working to retain and rehabilitate nurses who suffer from addiction in the USA. Lastly, this paper introduces international policy for nurses with addictions. CONCLUSIONS: Poor or ineffective policies that mandate punitive action endanger the public by making it difficult for impaired students or professionals to ask for help. Providing early intervention and assistance is essential in helping colleagues and students recover from an addictive disorder and providing a non-punitive atmosphere of support may well be a life-saving first step for nurses and those in their care. Many territories and countries throughout the world now offer confidential, non-punitive, assistance for nurses suffering from addictions. RELEVANCE TO CLINICAL PRACTICE: Recognition of a colleague's need of treatment is the important first step in the rehabilitation process. Early intervention and assistance are essential for helping colleagues and students to recover from an addictive disorder and providing a confidential, non-punitive atmosphere of support may well be a life-saving first step for nurses and those in their care.