Accuracy, precision and diagnostic accuracy of oral thermometry in pediatric patients.

PURPOSE: To determine the accuracy and precision of oral thermometry in pediatric patients, along with its sensitivity and specificity for detecting fever and hypothermia, with rectal thermometry as reference standard. DESIGN AND METHODS: This method-comparison study enrolled patients aged between 6 and 17 years, admitted to the surgical ward during a 21-month period. KD-2150 and IVAC Temp Plus II were used for oral and rectal temperature measurements respectively. Fever and hypothermia were defined as core temperature ≥38.0 °C and ≤ 35.9 °C respectively. Accuracy and precision of oral thermometry were determined by the Bland-Altman method. Sensitivity, specificity, positive and negative predictive value, and correct classification of oral temperature cutoffs for detecting fever and hypothermia were calculated. RESULTS: Based on power analysis, 100 pediatric patients were enrolled. The mean difference between oral and rectal temperatures was -0.34 °C, with 95 % limits of agreement ranging between -0.52 and -0.16. Sensitivity and specificity of oral thermometry for detecting fever were 0.50 and 1.0 respectively; its sensitivity and specificity for detecting hypothermia were 1.0 and 0.88 respectively. The oral temperature value of 37.6 °C provided excellent sensitivity for detecting fever, while the value of 35.7 °C provided optimal sensitivity and specificity for detecting hypothermia. CONCLUSIONS: Oral thermometry had low sensitivity for detecting fever and suboptimal specificity for detecting hypothermia; thus, temperature values <38.0 °C and <36.0 °C cannot exclude fever and confirm hypothermia respectively with high certainty. PRACTICE IMPLICATIONS: Diagnostic accuracy of oral thermometry can be improved by the use of oral temperature thresholds <38.0 °C for detecting fever and <35.9 °C for detecting hypothermia.

Diagnostic accuracy of oral thermometry for fever detection in adult patients: literature review and meta-analysis.

AIMS AND OBJECTIVES: To synthesise the evidence on the accuracy and precision of oral thermometry in adult patients, as well as on its sensitivity and specificity for fever detection. BACKGROUND: Oral thermometry has long been used in various clinical settings thanks to its rapid, safe and convenient measurements, which are easy to obtain and minimally prone to operator errors. DESIGN: Literature review and meta-analysis that adhered to the PRISMA statement. METHODS: By using key terms, literature searches were conducted in CINAHL, PubMed, Web of Science, Scopus and Cochrane Library. Method-comparison studies, which were published from January 1990 to December 2020 in English-language, peer-reviewed journals, compared oral temperature measurements with invasive thermometry ones, and were conducted on patients ≥18 years, were included. Methodological quality of selected studies was evaluated with QUADAS-2. RESULTS: Sixteen articles were selected for inclusion. Risk of bias was assessed as low in most of them. Quantitative synthesis indicated that pooled mean oral temperature was lower than core temperature by .07℃, with 95% limits of agreement ranging between -.22℃ and .08℃. Pooled sensitivity and specificity for fever detection (defined as core temperature ≥38℃ in most studies) were .53 (95% confidence interval, .39-.66) and .98 (95% confidence interval, .97-.99), respectively. Sensitivity analysis indicated larger temperature underestimation in case rectal temperature was used as reference standard. CONCLUSION: Despite its satisfactory accuracy, precision and specificity, oral thermometry has low sensitivity for fever detection, which entails a high number of false-negative readings and uncertainty for excluding fever in patients found to be non-febrile. RELEVANCE TO CLINICAL PRACTICE: Oral thermometry cannot be recommended for replacing invasive thermometry methods in hospitalised adult patients, considering the high incidence of fever in them and possible negative effects of missing fever for patient diagnosis and outcomes.

Nurse understaffing is associated with adverse events in postanaesthesia care unit patients.

AIMS AND OBJECTIVES: To investigate the associations between nurse staffing and the incidence and severity of hypoxaemia, arterial hypotension and bradycardia of postoperative patients during their postanaesthesia care unit stay. BACKGROUND: Nurse understaffing has been associated with adverse patient outcomes in a variety of hospital settings. In the postanaesthesia care unit, nursing shortage is common and can be related to compromised prevention, detection and treatment of adverse events. DESIGN: Observational, single-centre, prospective study that adhered to Strengthening the Reporting of Observational studies in Epidemiology checklist (see Supporting information Appendix S1); 2,207 patients admitted to the postanaesthesia care unit of a tertiary care hospital over a 5-month period were enrolled. METHODS: Incidence of hypoxaemia (arterial oxygen saturation <95%), arterial hypotension (systolic blood pressure <90 mmHg) and bradycardia (heart rate <50 beats per minute), along with episode severity, was recorded. Patients were classified into three groups as follows: sufficient staffing, low and high understaffing. Risk for hypoxaemia, arterial hypotension and bradycardia was adjusted according to patient, anaesthesia and operation characteristics. RESULTS: The incidence of hypoxaemia was significantly higher in the high understaffing group patients, while the incidence of arterial hypotension was significantly higher in both low and high understaffing group patients, compared to sufficient staffing group ones. In the high understaffing group patients, hypoxaemia and arterial hypotension episodes were of significantly higher severity. CONCLUSIONS: These associations between hypoxaemia and arterial hypotension and postanaesthesia care unit understaffing indicate that care quality and patient safety can be compromised in case patient acuity is not matched with sufficient nursing resources. RELEVANCE TO CLINICAL PRACTICE: Higher incidence of hypoxaemia and arterial hypotension advocates for the prevention of imbalances between patient number and care demands and the number of available nurses.

Temporal Artery Thermometry in Pediatric Patients: Systematic Review and Meta-Analysis.

PROBLEM: Non-invasive thermometry methods have been used as substitutes for intra-corporeal ones in order to decrease patient discomfort and risk for complications, yet the evaluation of their performance is necessary. Our aim was to synthesize the evidence on the accuracy and precision of temporal artery (TA) thermometry, as well as on its sensitivity and specificity for fever detection. ELIGIBILITY CRITERIA: This systematic review and meta-analysis included method-comparison studies, which compared TA temperature measurements with invasive thermometry ones, were published between 2000 and 2018, and were conducted on patients aged <18 years. SAMPLE: Thirty articles were selected for inclusion in the final analysis after screening those identified by searches in CINAHL, PubMed, Web of Science, Cochrane Library, EMBASE and Scopus. RESULTS: Quantitative synthesis indicated that pooled mean TA temperature was lower than core temperature by 0.01 °C (95% limits of agreement, -0.06 °C to 0.03 °C). Average summary sensitivity and specificity for fever detection were 0.72 (95% confidence interval, 0.66-0.79) and 0.91 (95% confidence interval, 0.86-0.93) respectively. Subgroup analysis indicated a trend toward larger temperature underestimation in febrile patients and in ages ≤4 years. CONCLUSIONS: Despite its satisfactory accuracy, precision and specificity, TA thermometry has low sensitivity when used in pediatric patients, which does not allow satisfactory fever detection. IMPLICATIONS: TA thermometry cannot be recommended for replacing rectal temperature measurement methods in children, due to its high proportion of false negative readings during screening for fever.

Inadvertent hypothermia and mortality in critically ill adults: Systematic review and meta-analysis.

OBJECTIVE: Considering that inadvertent hypothermia (IH) is common in Intensive Care Unit (ICU) patients and can be followed by severe complications, this systematic review identified, appraised and synthesised the published literature about the association between IH and mortality in adults admitted to the ICU. DATA SOURCES: By using key terms, literature searches were conducted in Pubmed, CINAHL, Cochrane Library, Web of Science and EMBASE. REVIEW METHODS: According to PRISMA guidelines, articles published between 1980-2016 in English-language, peer-reviewed journals were considered. IH was defined as core temperature of <36.5°C or lower, present on ICU admission or manifested during ICU stay. Outcome measure included ICU, hospital or 28-day mortality. Selected cohort studies were evaluated with the Newcastle-Ottawa Scale. Extracted data were summarised in tables and synthesised qualitatively and quantitatively, with adjusted odds ratios (ORs) for mortality being combined in meta-analyses. RESULTS: Eighteen observational studies met inclusion criteria. All of them had high methodological quality. In twelve out of fifteen studies, unadjusted mortality was significantly higher in hypothermic patients compared to non-hypothermic ones. Likewise, in thirteen out of sixteen studies, IH or lowest core temperature was independently associated with significantly higher mortality. High severity and long duration of IH were also associated with higher mortality. Mortality was significantly higher in patients with core temperature <36.0°C (pooled OR 2.093, 95% CI 1.704-2.570), and in those with core temperature <35.0°C (pooled OR 2.945, 95% CI 2.166-4.004). CONCLUSIONS: These findings indicate that IH predicts mortality in critically ill adults and pose suspicion that this may contribute to adverse patient outcome.

Agreement of infrared temporal artery thermometry with other thermometry methods in adults: systematic review.

AIMS AND OBJECTIVES: To critically review and synthesise the evidence on the agreement of temporal artery thermometry with invasive and noninvasive thermometry methods in hospitalised adults. BACKGROUND: Noninvasive thermometry methods aim at combining patient comfort and ease of use with satisfactory accuracy of temperature measurements. Infrared temporal artery thermometry is based on the detection of heat radiated from this artery in the forehead and temporal region. DESIGN: Systematic literature review. METHODS: A literature search was conducted in Pubmed, CINAHL, Cochrane Library, Web of Science and Embase. Data were extracted from twenty method-comparison studies published between 2002-2015. Methodological quality of selected studies was evaluated. RESULTS: Temperature measurements of temporal artery were compared with pulmonary artery, urinary bladder, oesophageal or nasopharyngeal ones in eight studies for the whole temperature range. Accuracy and precision of temporal artery thermometry exceeded recommended levels of 0·3°C in three and six studies respectively. Likewise, in nine studies that compared temporal artery temperature measurements with oral and ear-based ones, satisfactory agreement and variability was reported in five and none of them respectively. With regard to fever and hypothermia, although specificity of temporal artery thermometers for detecting these disorders was satisfactory, their sensitivity was low. CONCLUSIONS: Existing evidence does not support that temporal artery thermometry can replace common invasive and noninvasive thermometry methods in adult patients. RELEVANCE TO CLINICAL PRACTICE: Health care professionals are recommended to avoid the use of infrared temporal artery temporal artery thermometry in adults, or be cautious about the accuracy and precision of its readings, until improved devices are developed.

Perioperative Adverse Respiratory Events in Overweight/Obese Children: Systematic Review.

Childhood obesity is associated with numerous respiratory disorders, which may be aggravated when general anesthesia is administered. This systematic review aimed to investigate and synthesize the published literature on the associations between childhood obesity and perioperative adverse respiratory events (PAREs). By using key terms, observational studies published between 1990 and 2014 in English-language journals indexed by Cumulative Index for Nursing and Allied Health Literature, PubMed, Web of Science, Cochrane Database, and EMBASE were searched for reports of relevant associations. Nine articles were considered eligible for inclusion. In all studies, significant univariate and multivariate associations were reported between obesity and increased risk for PAREs in pediatric patients, mainly for hypoxemia, upper airway obstruction, and difficult mask ventilation. Appropriate strategies for preventing PAREs in obese children need to be followed by health care professionals. Multicenter studies are also recommended for ensuring high generalizability of reported associations and elucidating underlying mechanisms that link obesity to PAREs.

Development and psychometric evaluation of an instrument for the assessment of nurses' knowledge on capnography.

BACKGROUND: Despite the expansion of capnography use, instruments for evaluating healthcare professionals' knowledge about capnography are missing from international literature. OBJECTIVES: To develop and validate an instrument for evaluating nurses' knowledge about capnography, named the "Nurses' Knowledge about Capnography Test" (NKCT). METHOD: A literature review was performed to formulate instrument items. Thirty-six items were initially developed, which covered principles of capnography function, conditions affecting end-tidal CO2 pressure and capnography waveform, and indications for capnography use. Six items were deleted after content validity and intra-rater reliability evaluation. The final 30-item instrument was completed by 103 anesthesiology department nurses employed in six hospitals of Greece, to test its internal consistency, item difficulty and discrimination, and construct validity. RESULTS: Kuder-Richardson 20 coefficient was 0.79. Ten items were found to be of high difficulty, while item discrimination was low for two of them. Instrument scores were found significantly higher among participants with higher educational level and longer experience in capnography use. CONCLUSION: NKCT is a psychometrically comprehensive instrument for evaluating nurses' knowledge about capnography, which is recommended to be re-validated beyond the anesthesiology department and be used for the assessment of educational programs on capnography.

Predictors of nurses' knowledge and attitudes toward postoperative pain in Greece.

Undertreatment of postoperative pain can aggravate patient outcomes and is associated with attending nurses' knowledge deficits or negative attitudes toward pain. The aim of this study was to investigate knowledge and attitudes toward postoperative pain of surgical department nurses and to identify predictors of their knowledge and attitudes. This was a descriptive, cross-sectional survey that took place in the departments of general surgery, orthopedics, neurosurgery, ear-nose-throat surgery, and obstetrics/gynecology at five Greek hospitals. Participants were a convenience sample of registered and assistant nurses. Nurses were asked to complete a three-section questionnaire, which included demographics, a Knowledge and Attitudes Survey Regarding Pain (KASRP) tool modified for postoperative pain, and seven questions capturing personal characteristics, working conditions, and feelings about work. One hundred eighty-two questionnaires were completed. Average scores were 45.35% for modified KASRP tool; 28.57% for pain assessment; 55.44% for general pain management; and 47.13% for use of analgesics. Four of the five most commonly missed items referred to use of analgesics. More previous personal experience of postoperative pain (p = .002) and being a registered nurse (p = .015) predicted higher modified KASRP tool score. Participation in continuing education programs and department of employment were also associated with differences in the modified tool score. The knowledge deficits and negative attitudes of the nurses toward postoperative pain highlight the role of pregraduate and continuing education, appropriately specialized for each surgical department, in the development of empathy toward patients in pain and of clinical competency regarding pain assessment and administration of analgesics.

Residual neuromuscular blockade and postoperative critical respiratory events: literature review.

AIMS AND OBJECTIVES: To investigate and synthesise published literature on the associations between residual neuromuscular blockade and critical respiratory events of postoperative adult patients in the postanaesthesia care unit. BACKGROUND: Residual neuromuscular blockade continues to be common among patients transferred to the postanaesthesia care unit after general anaesthesia, while negative effects of residual neuromuscular blockade on respiratory function have been demonstrated in laboratory volunteers. DESIGN: Literature review. METHODS: Using key terms, a search was conducted in Cumulative Index for Nursing and Allied Health Literature, PubMed, Web of Science, Cochrane Database and EMBASE (January 1990-May 2013) for clinical trials or observational studies on the associations between residual neuromuscular blockade and critical respiratory events, published in English-language journals. RESULTS: Nine articles met the inclusion criteria. Residual neuromuscular blockade definition threshold differed between studies. Among critical respiratory events, only hypoxaemia was investigated in all included studies. Residual neuromuscular blockade was significantly associated with increased incidence of hypoxaemia during postanaesthesia care unit stay in most studies, while associations with the rest of the critical respiratory events were inconclusive. CONCLUSIONS: Although limited, existing research has provided evidence that patients with residual neuromuscular blockade are at high risk of early postoperative hypoxaemia. Further studies are needed to investigate independent associations between residual neuromuscular blockade and critical respiratory events, along with causality of these associations. The clinical importance of residual neuromuscular blockade for groups at high risk of critical respiratory events should also be investigated. RELEVANCE TO CLINICAL PRACTICE: Healthcare professionals have to be aware of the increased risk of hypoxaemia in patients with residual neuromuscular blockade. Efforts to decrease residual neuromuscular blockade incidence, combined with identification and appropriate evaluation of patients with residual neuromuscular blockade during postanaesthesia care unit stay, are recommended.

Nursing personnel's attitudes towards fever and antipyresis of adult patients: cross-sectional survey.

AIMS AND OBJECTIVES: To investigate the attitudes of nurses caring for hospitalised adult patients towards fever and antipyresis and to identify the predictors of these attitudes. BACKGROUND: Fever is a host defence mechanism, whose harmful effects are limited to specific patients. Findings about antipyretic treatment have further challenged the need for routine or aggressive fever suppression. Unfortunately, nurses continue to be fever phobic, while their attitudes towards fever and antipyresis considerably affect antipyretic practice. DESIGN: Prospective, cross-sectional, multicentre survey. METHODS: A convenience sample of registered and assistant nurses employed in surgical/medical wards and intensive care units of nine Greek hospitals was enrolled. The developed questionnaire included 10 multiple-choice, knowledge-evaluating items about fever and antipyresis, 10 Likert-type attitude-evaluating items towards fever and 10 towards antipyresis. Multiple linear regression analysis was used to identify the predictors of attitudes towards fever and antipyresis. RESULTS: The attitudes of the 458 participants were found to be relatively positive towards both fever and antipyresis. Lower fever/antipyresis knowledge score predicted both negative attitude towards fever (p = 0·001) and positive attitude towards antipyresis (p < 0·001), while longer professional experience predicted positive attitude towards antipyresis (p = 0·002). CONCLUSIONS: Advancing nurses' evidence-based knowledge about fever and antipyresis is expected to limit their tendency to overtreat fever and favour fever care based on the assessment of actual patient demands. RELEVANCE TO CLINICAL PRACTICE: These findings highlight the need for continuing education programmes to eliminate fever phobia and improve nurses' competency for individualised fever care.

Knowledge of pulse oximetry: comparison among intensive care, anesthesiology and emergency nurses.

AIMS AND OBJECTIVES: To evaluate pulse oximetry knowledge of nurses employed in the Intensive Care Unit (ICU), Anesthesiology Department (AD) and Emergency Department (ED) and to compare knowledge among these departments/units. BACKGROUND: Although pulse oximetry has been widely used in clinical practice, previous studies have reported knowledge deficits among nurses, which may adversely affect patient outcomes. DESIGN: Prospective, cross-sectional, multicentre study. METHODS: All nurses employed in the ICU, AD and ED of six hospitals were asked to complete in private a 21-item, knowledge-evaluating questionnaire, which was evaluated for content-related validity and reliability. RESULTS: Two hundred and seven questionnaires were completed (a response rate of 74·5%). Mean pulse oximetry knowledge score was 12·8 ± 3·2, with ICU nurses having significantly higher scores than ED nurses (p = 0·001) and those with more than 10 years of experience having significantly higher scores than less experienced ones (p = 0·015). Correct responses did not exceed 50% for six questionnaire items, five of which covered principles of pulse oximetry function. ICU nurses had significantly more correct responses in five items compared to ED nurses, and in two of them compared to AD nurses. CONCLUSIONS: Longer professional experience and being employed in the ICU were associated with higher pulse oximetry knowledge of Greek nurses. Considering knowledge deficits and differences among nurses, pulse oximetry knowledge seems to mainly develop through clinical experience. RELEVANCE TO CLINICAL PRACTICE: These findings highlight the need for pregraduate education to follow clinical advances, and especially for the implementation of high-quality, continuing education programmes to provide systematic learning and support professional development of nurses.

Knowledge is power: studying critical incidents in intensive care.

Despite their difficult definition and taxonomy, it is imperative to study critical incidents in intensive care, since they may be followed by adverse events and compromised patient safety. Identifying recurring patterns and factors contributing to critical incidents constitutes a prerequisite for developing effective preventive strategies. Self-reporting methodology, although widely used for studying critical incidents, has been criticized in terms of reliability and may considerably underestimate both overall frequency and specific types of them. Promotion of non-blaming culture, analysis of critical incident reports and development of clinical recommendations are expected to minimize critical incidents in the future.

Delayed Admission to the Intensive Care Unit and Mortality of Critically Ill Adults: Systematic Review and Meta-analysis.

Delayed admission of patients to the intensive care unit (ICU) is increasing worldwide and can be followed by adverse outcomes when critical care treatment is not provided timely. This systematic review and meta-analysis appraised and synthesized the published literature about the association between delayed ICU admission and mortality of adult patients. Articles published from inception up to August 2021 in English-language, peer-reviewed journals indexed in CINAHL, PubMed, Scopus, Cochrane Library, and Web of Science were searched by using key terms. Delayed ICU admission constituted the intervention, while mortality for any predefined time period was the outcome. Risk for bias was evaluated with the Newcastle-Ottawa Scale and additional criteria. Study findings were synthesized qualitatively, while the odds ratios (ORs) for mortality with 95% confidence intervals (CIs) were combined quantitatively. Thirty-four observational studies met inclusion criteria. Risk for bias was low in most studies. Unadjusted mortality was reported in 33 studies and was significantly higher in the delayed ICU admission group in 23 studies. Adjusted mortality was reported in 18 studies, and delayed ICU admission was independently associated with significantly higher mortality in 13 studies. Overall, pooled OR for mortality in case of delayed ICU admission was 1.61 (95% CI 1.44-1.81). Interstudy heterogeneity was high (I 2 = 66.96%). According to subgroup analysis, OR for mortality was remarkably higher in postoperative patients (OR, 2.44, 95% CI 1.49-4.01). These findings indicate that delayed ICU admission is significantly associated with mortality of critically ill adults and highlight the importance of providing timely critical care in non-ICU settings.

Reasons for academic dishonesty during examinations among nursing students: Cross-sectional survey.

BACKGROUND: Understanding why nursing students engage in academic dishonesty is crucial, since cheating is becoming more common and can be followed by unethical professional practice. OBJECTIVES: To develop and validate a questionnaire for investigating nursing students' perceptions about the reasons for academic dishonesty during examinations, along with identifying the most important of these reasons. DESIGN: Cross-sectional survey with the use of a convenience sample. PARTICIPANTS AND SETTING: 660 undergraduate students of a nursing department in Greece. METHODS: Questionnaire items were developed based on literature review and student interviews, evaluation of their content validity and intra-rater reliability. The participants completed the questionnaire electronically, which included items referring to behaviors of and reasons for academic dishonesty during examinations. Based on their responses, factor analysis was used to determine structural validity of the items that referred to the reasons for academic dishonesty. RESULTS: High prevalence of academic dishonesty behaviors during examinations was confirmed. Reasons for academic dishonesty were grouped into three factors, which included 17 items in total. Highly-rated items mainly referred to non-realistic demands of and unfair student treatment by academic personnel, absence of severe consequences for cheating, the way examinations are performed, and the importance of achieving high grades. Female, junior and high degree grade students had significantly higher percentages of highly-rated responses in some items. CONCLUSIONS: These findings offered knowledge about the reasons that students perceive to mostly favor cheating, whose identification can guide preventive strategies.

Gender bias favors female nursing students in the written examination evaluation: Crossover study.

BACKGROUND: Gender discrimination against male nursing students has been reported and attributed to the female-dominated tradition of nursing profession. OBJECTIVES: To investigate gender bias in the written examination evaluation of undergraduate nursing students. DESIGN: One-group crossover study with two phases. SETTING AND PARTICIPANTS: Four male and four female examiners provided 400 previously graded examination scripts (50 each) of nursing students. METHODS: Participating examiners were asked to re-grade scripts after any information about student identity was covered to allow blind marking. Script degrees after non-blind and blind marking were compared within male and within female students, as well as between male and female students. RESULTS: Significantly more female students' degrees shifted downwards and less of them shifted upwards compared with male students' degrees after blind marking, while mean degree of female students was significantly lower. Among male examiners, significantly more female students' degrees shifted downwards and less of them shifted upwards compared with male students' degrees after blind marking, while mean degree of male students was significantly higher. Among female examiners, mean degree of both male and female students was significantly lower after blind marking. No central tendency bias was detected. CONCLUSIONS: Gender bias in favor of females was detected in the written examination evaluation of nursing students. This unequal treatment may prevent retention of males in nursing studies and profession.

Nursing students' attitudes toward statistics: Effect of a biostatistics course and association with examination performance.

BACKGROUND: Although statistical knowledge and skills are necessary for promoting evidence-based practice, health sciences students have expressed anxiety about statistics courses, which may hinder their learning of statistical concepts. OBJECTIVES: To evaluate the effects of a biostatistics course on nursing students' attitudes toward statistics and to explore the association between these attitudes and their performance in the course examination. DESIGN: One-group quasi-experimental pre-test/post-test design. SETTING AND PARTICIPANTS: Undergraduate nursing students of the fifth or higher semester of studies, who attended a biostatistics course. METHODS: Participants were asked to complete the pre-test and post-test forms of The Survey of Attitudes Toward Statistics (SATS)-36 scale at the beginning and end of the course respectively. Pre-test and post-test scale scores were compared, while correlations between post-test scores and participants' examination performance were estimated. RESULTS: Among 156 participants, post-test scores of the overall SATS-36 scale and of the Affect, Cognitive Competence, Interest and Effort components were significantly higher than pre-test ones, indicating that the course was followed by more positive attitudes toward statistics. Among 104 students who participated in the examination, higher post-test scores of the overall SATS-36 scale and of the Affect, Difficulty, Interest and Effort components were significantly but weakly correlated with higher examination performance. CONCLUSIONS: Students' attitudes toward statistics can be improved through appropriate biostatistics courses, while positive attitudes contribute to higher course achievements and possibly to improved statistical skills in later professional life.