Studies on Reliability and Measurement Error of Measurements in Medicine - From Design to Statistics Explained for Medical Researchers.

Reliability and measurement error are measurement properties that quantify the influence of specific sources of variation, such as raters, type of machine, or time, on the score of the individual measurement. Several designs can be chosen to assess reliability and measurement error of a measurement. Differences in design are due to specific choices about which sources of variation are varied over the repeated measurements in stable patients, which potential sources of variation are kept stable (ie, restricted), and about whether or not the entire measurement instrument (or measurement protocol) was repeated or only part of it. We explain how these choices determine how intraclass correlation coefficients and standard errors of measurement formulas are built for different designs by using Venn diagrams. Strategies for improving the measurement are explained, and recommendations for reporting the essentials of these studies are described. We hope that this paper will facilitate the understanding and improve the design, analysis, and reporting of future studies on reliability and measurement error of measurements.

Factors Influencing Professional Identity Construction in Fourth-Year Pharmacy Students.

Objectives. To explore the key factors that influence professional identity construction in fourth-year pharmacy students enrolled in a Doctor of Pharmacy program.Methods. A single-site instrumental case study of current fourth-year pharmacy students from the Leslie Dan Faculty of Pharmacy, University of Toronto, was used. Thirteen students participated in semistructured interviews. Poststructural social identity theories were used to analyze the data and identify themes that influence identity construction in pharmacy students.Results. Data analysis identified five overarching themes that influence pharmacy student professional identity construction: path to pharmacy, curriculum, environment, preceptors, and patient interactions. The Leslie Dan Faculty of Pharmacy curriculum prioritized the health care provider identity, which influenced the students desire to "become" clinicians. Based on their internalized health care provider identity, they rejected preceptors and practice environments that negatively impacted their ability to embody this identity.Conclusion. The findings of this study suggest that pharmacy students align themselves strongly with health care provider identities at the cost of other potentially relevant identities. Pharmacy education programs may benefit from curricular reforms that incorporate and legitimize multiple pharmacist identities to ensure a strong pharmacy workforce for the future.

Utility of a multimodal computer-based assessment format for assessment with a higher degree of reliability and validity.

Multiple choice questions (MCQs) suffer from cueing, item quality and factual knowledge testing. This study presents a novel multimodal test containing alternative item types in a computer-based assessment (CBA) format, designated as Proxy-CBA. The Proxy-CBA was compared to a standard MCQ-CBA, regarding validity, reliability, standard error of measurement, and cognitive load, using a quasi-experimental crossover design. Biomedical students were randomized into two groups to sit a 65-item formative exam starting with the MCQ-CBA followed by the Proxy-CBA (group 1, n = 38), or the reverse (group 2, n = 35). Subsequently, a questionnaire on perceived cognitive load was taken, answered by 71 participants. Both CBA formats were analyzed according to parameters of the Classical Test Theory and the Rasch model. Compared to the MCQ-CBA, the Proxy-CBA had lower raw scores (p < 0.001, η2 = 0.276), higher reliability estimates (p < 0.001, η2 = 0.498), lower SEM estimates (p < 0.001, η2 = 0.807), and lower theta ability scores (p < 0.001, η2 = 0.288). The questionnaire revealed no significant differences between both CBA tests regarding perceived cognitive load. Compared to the MCQ-CBA, the Proxy-CBA showed increased reliability and a higher degree of validity with similar cognitive load, suggesting its utility as an alternative assessment format.

Using Resident-Sensitive Quality Measures Derived From Electronic Health Record Data to Assess Residents' Performance in Pediatric Emergency Medicine.

PURPOSE: Traditional quality metrics do not adequately represent the clinical work done by residents and, thus, cannot be used to link residency training to health care quality. This study aimed to determine whether electronic health record (EHR) data can be used to meaningfully assess residents' clinical performance in pediatric emergency medicine using resident-sensitive quality measures (RSQMs). METHOD: EHR data for asthma and bronchiolitis RSQMs from Cincinnati Children's Hospital Medical Center, a quaternary children's hospital, between July 1, 2017, and June 30, 2019, were analyzed by ranking residents based on composite scores calculated using raw, unadjusted, and case-mix adjusted latent score models, with lower percentiles indicating a lower quality of care and performance. Reliability and associations between the scores produced by the 3 scoring models were compared. Resident and patient characteristics associated with performance in the highest and lowest tertiles and changes in residents' rank after case-mix adjustments were also identified. RESULTS: 274 residents and 1,891 individual encounters of bronchiolitis patients aged 0-1 as well as 270 residents and 1,752 individual encounters of asthmatic patients aged 2-21 were included in the analysis. The minimum reliability requirement to create a composite score was met for asthma data (α = 0.77), but not bronchiolitis (α = 0.17). The asthma composite scores showed high correlations ( r = 0.90-0.99) between raw, latent, and adjusted composite scores. After case-mix adjustments, residents' absolute percentile rank shifted on average 10 percentiles. Residents who dropped by 10 or more percentiles were likely to be more junior, saw fewer patients, cared for less acute and younger patients, or had patients with a longer emergency department stay. CONCLUSIONS: For some clinical areas, it is possible to use EHR data, adjusted for patient complexity, to meaningfully assess residents' clinical performance and identify opportunities for quality improvement.

The limited use of instructional design guidelines in healthcare simulation scenarios: an expert appraisal.

BACKGROUND: Systematic reviews on simulation training effectiveness have pointed to the need to adhere to evidence-based instructional design (ID) guidelines. ID guidelines derive from sound cognitive theories and aim to optimize complex learning (integration of knowledge, skills, and attitudes) and learning transfer (application of acquired knowledge and skills in the workplace). The purpose of this study was to explore adherence to ID guidelines in simulation training programs for dealing with postpartum hemorrhage (PPH), a high-risk situation and the leading cause of maternal mortality worldwide. METHODS: A total of 40 raters analyzed simulation training programs as described in 32 articles. The articles were divided into four subsets of seven articles and one subset of four articles. Each subset was judged by seven to ten raters on adherence to ID guidelines. The 5-point Likert score rating scale was based on Merrill's First Principles of Instruction and included items relating to key ID features categorized into five subscales: authenticity, activation of prior knowledge, demonstration, application, and integration/transfer. The authors searched for articles published in English between January 2007 and March 2017 in PubMed, Eric, and Google Scholar and calculated the mean Likert-scale score, per subscale, and interrater reliability (IRR). RESULTS: The mean Likert-scale scores calculated for all subscales were < 3.00. For the number of raters used to judge the papers in this study (varying between 7 and 10), the IRR was found to be excellent for the authenticity and integration/transfer subscales, good-to-excellent for the activation of prior knowledge and application subscales, and fair-to-good for the demonstration subscale. CONCLUSION: The results demonstrate a paucity of the description of adherence to evidence-based ID guidelines in current simulation trainings for a high-risk situation such as PPH.

Shaping the right conditions in programmatic assessment: how quality of narrative information affects the quality of high-stakes decision-making.

BACKGROUND: Programmatic assessment is increasingly being implemented within competency-based health professions education. In this approach a multitude of low-stakes assessment activities are aggregated into a holistic high-stakes decision on the student's performance. High-stakes decisions need to be of high quality. Part of this quality is whether an examiner perceives saturation of information when making a holistic decision. The purpose of this study was to explore the influence of narrative information in perceiving saturation of information during the interpretative process of high-stakes decision-making. METHODS: In this mixed-method intervention study the quality of the recorded narrative information was manipulated within multiple portfolios (i.e., feedback and reflection) to investigate its influence on 1) the perception of saturation of information and 2) the examiner's interpretative approach in making a high-stakes decision. Data were collected through surveys, screen recordings of the portfolio assessments, and semi-structured interviews. Descriptive statistics and template analysis were applied to analyze the data. RESULTS: The examiners perceived less frequently saturation of information in the portfolios with low quality of narrative feedback. Additionally, they mentioned consistency of information as a factor that influenced their perception of saturation of information. Even though in general they had their idiosyncratic approach to assessing a portfolio, variations were present caused by certain triggers, such as noticeable deviations in the student's performance and quality of narrative feedback. CONCLUSION: The perception of saturation of information seemed to be influenced by the quality of the narrative feedback and, to a lesser extent, by the quality of reflection. These results emphasize the importance of high-quality narrative feedback in making robust decisions within portfolios that are expected to be more difficult to assess. Furthermore, within these "difficult" portfolios, examiners adapted their interpretative process reacting on the intervention and other triggers by means of an iterative and responsive approach.

Supervisory dyads' communication and alignment regarding the use of workplace-based observations: a qualitative study in general practice residency.

BACKGROUND: In medical residency, performance observations are considered an important strategy to monitor competence development, provide feedback and warrant patient safety. The aim of this study was to gain insight into whether and how supervisor-resident dyads build a working repertoire regarding the use of observations, and how they discuss and align goals and approaches to observation in particular. METHODS: We used a qualitative, social constructivist approach to explore if and how supervisory dyads work towards alignment of goals and preferred approaches to performance observations. We conducted semi-structured interviews with supervisor-resident dyads, performing a template analysis of the data thus obtained. RESULTS: The supervisory dyads did not frequently communicate about the use of observations, except at the start of training and unless they were triggered by internal or external factors. Their working repertoire regarding the use of observations seemed to be primarily driven by patient safety goals and institutional assessment requirements rather than by providing developmental feedback. Although intended as formative, the institutional test was perceived as summative by supervisors and residents, and led to teaching to the test rather than educating for purposes of competence development. CONCLUSIONS: To unlock the full educational potential of performance observations, and to foster the development of an educational alliance, it is essential that supervisory dyads and the training institute communicate clearly about these observations and the role of assessment practices of- and for learning, in order to align their goals and respective approaches.

Ottawa 2020 consensus statement for programmatic assessment - 1. Agreement on the principles.

INTRODUCTION: In the Ottawa 2018 Consensus framework for good assessment, a set of criteria was presented for systems of assessment. Currently, programmatic assessment is being established in an increasing number of programmes. In this Ottawa 2020 consensus statement for programmatic assessment insights from practice and research are used to define the principles of programmatic assessment. METHODS: For fifteen programmes in health professions education affiliated with members of an expert group (n = 20), an inventory was completed for the perceived components, rationale, and importance of a programmatic assessment design. Input from attendees of a programmatic assessment workshop and symposium at the 2020 Ottawa conference was included. The outcome is discussed in concurrence with current theory and research. RESULTS AND DISCUSSION: Twelve principles are presented that are considered as important and recognisable facets of programmatic assessment. Overall these principles were used in the curriculum and assessment design, albeit with a range of approaches and rigor, suggesting that programmatic assessment is an achievable education and assessment model, embedded both in practice and research. Knowledge on and sharing how programmatic assessment is being operationalized may help support educators charting their own implementation journey of programmatic assessment in their respective programmes.

How pharmacists perceive their professional identity: a scoping review and discursive analysis.

OBJECTIVES: The objectives of this scoping review were to (a) explore how pharmacists perceive their professional roles and identities and (b) describe factors impacting which professional roles or identities pharmacists embody in different pharmacy practice settings. METHODS: A scoping review using a deductive approach was undertaken for this study. Systematic searches were conducted in five databases: Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, EBSCO Cumulative Index to Nursing and Allied Health and Scopus (Elsevier). Key words searched included pharmacist, identity, professional role and one variations of these. Results were double-blind screened for relevance by two authors. Data extraction was facilitated by the web-based software platform COVIDENCE. Foucauldian critical discourse analysis was used to deconstruct how pharmacists perceive their professional roles and identities. KEY FINDINGS: In total, 21 701 articles were retrieved in the search. Following de-duplication and screening, 23 studies from 11 different countries were included. Five major identity themes were identified: Clinician, Dispenser, Business Person, Patient Counsellor and Physician Supporter. The dispenser identity was the most widespread, but it was viewed by many pharmacists as undesirable. The clinician identity also had a strong presence but was viewed as an identity that pharmacists aspire to embody. CONCLUSIONS: This scoping review illustrates that pharmacists do not uniformly perceive themselves to be clinicians. A significant gap exists between the profession's desired identity and that embodied by practicing pharmacists. The resulting dissonance may be a contributing factor to the lack of wide-scale practice change that the profession has been seeking for decades.

When Feedback Backfires: Influences of Negative Discrepancies Between Physicians' Self and Assessors' Scores on Their Subsequent Multisource Feedback Ratings.

INTRODUCTION: With multisource feedback (MSF) physicians might overrate their own performance compared with scores received from assessors. However, there is limited insight into how perceived divergent feedback affects physicians' subsequent performance scores. METHODS: During 2012 to 2018, 103 physicians were evaluated twice by 684 peers, 242 residents, 999 coworkers, and themselves in three MSF performance domains. Mixed-effect models quantified associations between the outcome variable "score changes" between first and second MSF evaluations, and the explanatory variable "negative discrepancy score" (number of items that physicians rated themselves higher compared with their assessors' scores) at the first MSF evaluation. Whether associations differed across assessor groups and across a physician's years of experience as a doctor was analyzed too. RESULTS: Forty-nine percent of physicians improved their total MSF score at the second evaluation, as assessed by others. Number of negative discrepancies was negatively associated with score changes in domains "organization and (self)management" (b = -0.02; 95% confidence interval [CI], -0.03 to -0.02; SE = 0.004) and "patient-centeredness" (b = -0.03; 95% CI, -0.03 to -0.02; SE = 0.004). For "professional attitude," only negative associations between score changes and negative discrepancies existed for physicians with more than 6-year experience (b6-10yearsofexperience = -0.03; 95% CI, -0.05 to -0.003; SE = 0.01; b16-20yearsofexperience = -0.03; 95% CI, -0.06 to -0.004; SE = 0.01). DISCUSSION: The extent of performance improvement was less for physicians confronted with negative discrepancies. Performance scores actually declined when physicians overrated themselves on more than half of the feedback items. PA score changes of more experienced physicians confronted with negative discrepancies and were affected more adversely. These physicians might have discounted feedback due to having more confidence in own performance. Future work should investigate how MSF could improve physicians' performance taking into account physicians' confidence.

Effects of an in situ instructional design based postpartum hemorrhage simulation training on patient outcomes: an uncontrolled before-and-after study.

Objective: To compare postpartum hemorrhage (PPH) patient outcomes before and after an in situ instructional design based PPH simulation attended by obstetrics and gynecology (OBGYN) residents.Methods: This uncontrolled before-and-after study was conducted in Recife, Brazil including all 1388 women delivering from June to August 2012 and all 1357 delivering from June to August 2013. The 36 OBGYN residents were divided into13 teams of two or three participants and were trained through ID based PPH simulation training with the following eight steps: (1) prior knowledge activation, (2) video demonstration, (3) dual-coding PPH protocol discussion-an image association during the training, (4) training scenario # 1, (5) debriefing, (6) training scenario # 2 with immediate feedback, (7) training scenario # 3, and (8) debriefing with self-assessment. The training scenarios had an increasing level of complexity. The main goal of the training was the adequate management of PPH and situational awareness improvement-the ability to anticipate, recognize, and intercept unfolding error chains. The primary patient outcomes rates used for the before and after comparison were therapeutic uterotonics use within 24 h of birth and blood transfusion. Secondary outcomes were therapeutic oxytocin mean dosage IU within 24 h of birth, postpartum Hb < 6 g/dL, among others. Chi-square test was used for categorical variables comparison and independent t-test for continuous variables.Results: PPH rates were 100 (7.2% of 2012 deliveries) and 80 cases (5.9% of 2013 deliveries), respectively. Comparison of primary post- and pre-simulation outcomes revealed no significant differences. However, in the comparison for therapeutic oxytocin mean dosage IU within 24 h of birth, there was an increase found after the simulation (15.98 ± 7.4 versus 25.1 ± 12.3; p < .001). For all other outcome measures, there were no statistical differences.Conclusions: In situ ID based PPH simulation leads to an increase in the mean dosage of oxytocin after training, in selected cases. This may indicate better situational awareness when managing women with PPH.

Driving lesson or driving test? : A metaphor to help faculty separate feedback from assessment.

Although there is consensus in the medical education world that feedback is an important and effective tool to support experiential workplace-based learning, learners tend to avoid the feedback associated with direct observation because they perceive it as a high-stakes evaluation with significant consequences for their future. The perceived dominance of the summative assessment paradigm throughout medical education reduces learners' willingness to seek feedback, and encourages supervisors to mix up feedback with provision of 'objective' grades or pass/fail marks. This eye-opener article argues that the provision and reception of effective feedback by clinical supervisors and their learners is dependent on both parties' awareness of the important distinction between feedback used in coaching towards growth and development (assessment for learning) and reaching a high-stakes judgement on the learner's competence and fitness for practice (assessment of learning). Using driving lessons and the driving test as a metaphor for feedback and assessment helps supervisors and learners to understand this crucial difference and to act upon it. It is the supervisor's responsibility to ensure that supervisor and learner achieve a clear mutual understanding of the purpose of each interaction (i.e. feedback or assessment). To allow supervisors to use the driving lesson-driving test metaphor for this purpose in their interactions with learners, it should be included in faculty development initiatives, along with a discussion of the key importance of separating feedback from assessment, to promote a feedback culture of growth and support programmatic assessment of competence.

The Incidence and Nature of Adverse Medical Device Events in Dutch Hospitals: A Retrospective Patient Record Review Study.

OBJECTIVES: Despite widespread use of medical devices and their increasing complexity, their contribution to unintended injury caused by healthcare (adverse events, AEs) remains relatively understudied. The aim of this study was to gain insight in the incidence and types of AEs involving medical devices (AMDEs). METHODS: Data from two patient record studies for the identification of AEs were used. Identification of AMDEs was part of these studies. Patient records of 6894 admissions of a random sample of 20 hospitals in 2011/2012 and 19 hospitals in 2015/2016 were reviewed for AMDEs by trained nurses and physicians. RESULTS: In 98.7% of the admissions, a medical device was used. Adverse events involving medical devices were present in 2.8% of the admissions, with 24% of the AMDEs being potentially preventable. Of all AEs, in 40%, medical devices were involved. Of all potentially preventable AEs, in 44%, medical devices were involved. Implants were most often involved in potentially preventable AMDEs. CONCLUSIONS: Medical devices are substantially involved in potentially preventable AEs in hospitals. Research into AMDEs is of great importance because of the increasing use and complexity of medical devices. Based on patient records, most improvements could be made for placement of implants and prevention of infections related to medical devices. Safety and safe use of medical devices should be a subject of attention and further research.

Composite Reliability of Workplace Based Assessment of International Medical Graduates.

This article was migrated. The article was marked as recommended. Introduction All developed countries depend on International Medical Graduates (IMGs) to complement their workforce. However, the assessment of their fitness to practice and acculturation into the new system can be challenging. To improve this, we introduced Workplace Based Assessment (WBA), using a programmatic philosophy. This paper reports the reliability of this new approach. Method Over the past 10 years, we have assessed over 250 IMGs, each cohort assessed over a 6-month period. We used Mini-Cex, Case Based Discussions (CBD) and Multi-Source Feedback (MSF) to assess them. We analysed the reliability of each tool and the composite reliability of 12 Mini-Cex, 5 CBDs and 12 MSF assessments in the tool kit. Results A reliability coefficient of 0.78 with a SEM of 0.19 was obtained for the sample of 236 IMGs. We found the MSF to be the most reliable tool. By adding one more MSF to the assessment on two occasions, we can reach a reliability of 0.8 and SEM of 0.18. Conclusions The current assessment methodology has acceptable reliability. By increasing the MSF, we can improve the reliability. The lessons from this study are generalisable to IMG assessment and other medical education programs.

Improving the Competency of Nurses.

To decrease infusion pump administration errors, time-consuming training is often initiated. The aims of this study were twofold: to develop minimum competency requirements for programming and operation of infusion pumps and to develop and validate a test for nurses based on those requirements. The test was completed by 226 nurses between May and December 2017. This study demonstrates that testing is a promising method to assess the competency of nurses in using medical devices. Moreover, test acceptability among nurses is high. Using competency requirements to develop a test offers the potential to tailor training needs and reduce training time.

A history of assessment in medical education.

The way quality of assessment has been perceived and assured has changed considerably in the recent 5 decades. Originally, assessment was mainly seen as a measurement problem with the aim to tell people apart, the competent from the not competent. Logically, reproducibility or reliability and construct validity were seen as necessary and sufficient for assessment quality and the role of human judgement was minimised. Later, assessment moved back into the authentic workplace with various workplace-based assessment (WBA) methods. Although originally approached from the same measurement framework, WBA and other assessments gradually became assessment processes that included or embraced human judgement but based on good support and assessment expertise. Currently, assessment is treated as a whole system problem in which competence is evaluated from an integrated rather than a reductionist perspective. Current research therefore focuses on how to support and improve human judgement, how to triangulate assessment information meaningfully and how to construct fairness, credibility and defensibility from a systems perspective. But, given the rapid changes in society, education and healthcare, yet another evolution in our thinking about good assessment is likely to lurk around the corner.

A Historical Discourse Analysis of Pharmacist Identity in Pharmacy Education.

Objective. To determine the discourses on professional identity in pharmacy education over the last century in North America and which one(s) currently dominate. Methods. A Foucauldian critical discourse analysis using archival resources from the American Journal of Pharmaceutical Education (AJPE) and commissioned education reports was used to expose the identity discourses in pharmacy education. Results. This study identified five prominent identity discourses in the pharmacy education literature: apothecary, dispenser, merchandiser, expert advisor, and health care provider. Each discourse constructs the pharmacist's professional identity in different ways and makes possible certain language, subjects, and objects. The health care provider discourse currently dominates the literature. However, an unexpected finding of this study was that the discourses identified did not shift clearly over time, but rather piled up, resulting in students being exposed to incompatible identities. Conclusion. This study illustrates that pharmacist identity constructs are not simple, self-evident, or progressive. In exposing students to incompatible identity discourses, pharmacy education may be unintentionally impacting the formation of a strong, unified healthcare provider identity, which may impact widespread practice change.

Supervisors' intention to observe clinical task performance: an exploratory study using the theory of planned behaviour during postgraduate medical training.

BACKGROUND: Direct observation of clinical task performance plays a pivotal role in competency-based medical education. Although formal guidelines require supervisors to engage in direct observations, research demonstrates that trainees are infrequently observed. Supervisors may not only experience practical and socio-cultural barriers to direct observations in healthcare settings, they may also question usefulness or have low perceived self-efficacy in performing direct observations. A better understanding of how these multiple factors interact to influence supervisors' intention to perform direct observations may help us to more effectively implement the aforementioned guidelines and increase the frequency of direct observations. METHODS: We conducted an exploratory quantitative study, using the Theory of Planned Behaviour (TPB) as our theoretical framework. In applying the TPB, we transfer a psychological theory to medical education to get insight in the influence of cognitive and emotional processes on intentions to use direct observations in workplace based learning and assessment. We developed an instrument to investigate supervisors intention to perform direct observations. The relationships between the TPB measures of our questionnaire were explored by computing bivariate correlations using Pearson's R tests. Hierarchical regression analysis was performed in order to assess the impact of the respective TPB measures as predictors on the intention to perform direct observations. RESULTS: In our study 82 GP supervisors completed our TPB questionnaire. We found that supervisors had a positive attitude towards direct observations. Our TPB model explained 45% of the variance in supervisors' intentions to perform them. Normative beliefs and past behaviour were significant determinants of this intention. CONCLUSION: Our study suggests that supervisors use their past experiences to form intentions to perform direct observations in a careful, thoughtful manner and, in doing so, also take the preferences of the learner and other stakeholders potentially engaged in direct observations into consideration. These findings have potential implications for research into work-based assessments and the development of training interventions to foster a shared mental model on the use of direct observations.