The lived experience of Competence by Design: Canadian resident physicians' perspectives.

PURPOSE: Canadian specialist residency programs are in the process of transitioning to a hybrid time and competence model, Competence by Design (CBD), developed by the Royal College of Physicians and Surgeons Canada. Although there is extensive literature around competency-based medical education (CBME), few studies have evaluated the experience of residents after CBME implementation. The purpose of this study was to obtain a rich perspective on the lived experience of residents. METHODS: We designed a qualitative study with inductive thematic analysis of semistructured interview data. The study population was residents in CBD postgraduate training programs in anesthesiology, internal medicine, or surgery (including all surgical subspecialties) at Dalhousie University (Halifax, NS, Canada). RESULTS: Residents identified the following benefits of their programs and CBD: supportive peers and clinical supervisors, a roadmap for residency, formalized feedback opportunities, and program evolution. Resident-identified drawbacks of CBD included: a lack of transparency around CBD, CBD not as advertised, a lack of buy-in, increased administrative burden, difficulties obtaining evidence for entrustable professional activities (EPAs); the onus for CBD on residents, inconsistent feedback, cumbersome technology, and significant psychological burden. Resident-suggested improvements were reducing the number of EPAs, streamlining EPA requirements, increasing transparency and communication with competence committees, providing incentives and continuous education for clinical supervisors, improving on existing electronic interfaces, and developing technology better suited to the needs of CBD. CONCLUSION: This study highlights that the significant administrative and psychological burden of CBD detracts from clinical learning and enthusiasm for residency. Future research could explore whether overcoming the identified challenges will improve residents' experiences.

RéSUMé: OBJECTIF: Les programmes canadiens de résidence spécialisée sont en train de passer à un modèle hybride de temps et de compétence, soit la compétence par conception (CPC); ce modèle a été élaboré par le Collège royal des médecins et chirurgiens du Canada. Bien qu'il existe une abondante documentation sur la formation médicale fondée sur les compétences (FMFC), peu d'études ont évalué l'expérience des résidentes et résidents après la mise en œuvre de la FMFC. Le but de cette étude était d'obtenir une perspective enrichie quant à l'expérience vécue par les résidents et résidentes. MéTHODE: Nous avons conçu une étude qualitative avec une analyse thématique inductive des données d'entretiens semi-structurés. La population étudiée était composée de résident·es des programmes de formation postdoctorale en anesthésiologie, en médecine interne ou en chirurgie (y compris toutes les surspécialités chirurgicales) à l'Université Dalhousie (Halifax, N.-É., Canada). RéSULTATS: Les personnes interrogées ont identifié les avantages suivants de leurs programmes et de la CPC : le soutien des pairs et des superviseur·es cliniques, une feuille de route pour la résidence, des possibilités de rétroaction officielles et l'évolution du programme. Parmi les inconvénients de la CPC identifiés par les résident·es, mentionnons : un manque de transparence autour de la CPC, une CPC ne correspondant pas à ce qui avait été annoncé, un manque d'adhésion, un fardeau administratif accru, des difficultés à obtenir des preuves de participation à des actes professionnels non supervisés (APNS); le fardeau de la CPC incombant aux résident·es, une rétroaction incohérente, une technologie lourde et un fardeau psychologique important. Les améliorations suggérées par les résident·es comprenaient la réduction du nombre d'APNS, la rationalisation des exigences des APNS, l'augmentation de la transparence et de la communication avec les comités de compétence, l'offre d'incitations et de formation continue aux superviseur·es cliniques, l'amélioration des interfaces électroniques existantes et le développement d'une technologie mieux adaptée aux besoins de la CPC. CONCLUSION: Cette étude souligne que le fardeau administratif et psychologique important de la CPC nuit à l'apprentissage clinique et à l'enthousiasme pour la résidence. Les recherches futures pourraient déterminer si le fait de surmonter les défis identifiés améliorerait l'expérience des résidentes et résidents.

Impact of a nurse engagement intervention on pain, agitation and delirium assessment in a community intensive care unit.

BACKGROUND: In 2013, the Society of Critical Care Medicine published a revised version of the ICU Pain, Agitation, and Delirium (PAD) guidelines. Immobility and sleep were subsequently added in 2018. Despite the well-established advantages of implementing these guidelines, adoption and adherence remain suboptimal. This is especially true in community settings, where PAD assessment is performed less often, and the implementation of PAD guidelines has not yet been studied. The purpose of this prospective interventional study is to evaluate the effect of a multifaceted nurse engagement intervention on PAD assessment in a community intensive care unit (ICU). METHODS: All patients admitted to our community ICU for over 24 hours were included. A 20-week baseline audit was performed, followed by the intervention, and a 20-week postintervention audit. The intervention consisted of a survey, focus groups and education sessions. Primary outcomes included rates of daily PAD assessment using validated tools. RESULTS: There were improvements in the number of patients with at least one assessment per day of pain (67.5% vs 59.3%, p=0.04), agitation (93.1% vs 78.7%, p<0.001) and delirium (54.2% vs 39.4%, p<0.001), and the number of patients with target Richmond Agitation-Sedation Scale ordered (63.1% vs 46.8%, p=0.002). There was a decrease in the rate of physical restraint use (10.0% vs 30.9%, p<0.001) and no change in self-extubation rate (0.9% vs 2.5%, p=0.2). CONCLUSION: The implementation of a multifaceted nurse engagement intervention has the potential to improve rates of PAD assessment in community ICUs. Screening rates in our ICU remain suboptimal despite these improvements. We plan to implement multidisciplinary interventions targeting physicians, nurses and families to close the observed care gap.

Pain, agitation and delirium assessment and management in a community medical-surgical ICU: results from a prospective observational study and nurse survey.

BACKGROUND: Delirium is a common manifestation in the intensive care unit (ICU) that is associated with increased mortality and morbidity. Guidelines suggested appropriate management of pain, agitation and delirium (PAD) is crucial in improving patient outcomes. However, the practice of PAD assessment and management in community hospitals is unclear and the mechanisms contributing to the potential care gap are unknown. OBJECTIVES: This quality improvement initiative aimed to review the practice of PAD assessment and management in a community medical-surgical ICU (MSICU) and to explore the community MSICU nurses' perceived comfort and satisfaction with PAD management in order to understand the mechanisms of the observed care gap and to inform subsequent quality improvement interventions. METHODS: We prospectively collected basic demographic data, clinical information and daily data on PAD process measures including PAD assessment and target Richmond Agitation-Sedation Scale (RASS) score ordered by intensivists on all patients admitted to a community MSICU for >24 hours over a 20-week period. All ICU nurses in the same community MSICU were invited to participate in an anonymous survey. RESULTS: We collected data on a total of 1101 patient-days (PD). 653 PD (59%), 861 PD (78%) and 439 PD (39%) had PAD assessment performed, respectively. Target RASS was ordered by the intensivists on 515 PD (47%). Our nurse survey revealed that 88%, 85% and 41% of nurses were comfortable with PAD assessment, respectively. CONCLUSIONS: Delirium assessment was not routinely performed. This is partly explained by the discomfort nurses felt towards conducting delirium assessment. Our results suggested that improvement in nurse comfort with delirium assessment and management is needed in the community MSICU setting.