Validating international CanMEDS-based standards defining education and safe practice of nurse anesthetists.

AIM: To investigate whether the CanMEDS-based International Federation of Nurse Anesthetists' Standards could adequately define the scope of practice and reliably be used to train and evaluate Swiss nurse anesthetists (NAs). BACKGROUND: Although nurse anesthetists represent a majority of the global workforce in anesthesia, policies that define the scope of practice are frequently non-existent. In low- and middle-income countries, the lack of anesthesia providers with adequate training is a major challenge. INTRODUCTION: Despite stringent training requirements, the scope of practice of Swiss nurse anesthetists is actually not defined. Therefore, we surveyed and assessed whether nurse anesthetists felt that the professional competencies outlined in this framework were aligned with their clinical practice. METHODS: A cross-sectional survey investigated Swiss nurse anesthetists' relevance ratings of 76 competencies of the International Federation of Nurse Anesthetists according to their professional practice. Cronbach's alpha coefficients were used to determine the internal consistency of the competencies, as well as factor analyses to assess construct validity of these competencies integrated into the CanMEDS roles model. RESULTS: Participants rated the Standards overall as very relevant with high reliability. Factor analyses provided evidence of construct validity of these. DISCUSSION: The International Federation of Nurse Anesthetists' Standards of Practice provide a highly relevant framework and a valuable set of competencies for the scope of practice of Swiss nurse anesthetists, which enabled translation from global guides to local national standards. CONCLUSION AND IMPLICATION FOR NURSING AND HEALTH POLICY: Adopted by low- and middle-income countries or countries where national standards are non-existent, this survey could introduce national and local policies at minimally acceptable standards of care for nurse anesthetists worldwide. The above standards have the potential to align education, outcomes and assessment of nurse anesthetists with the needs of national healthcare systems.

Standardised clients as assessors in a veterinary communication OSCE: a reliability and validity study.

In human medicine, standardised patients (SP) have been shown to reliably and accurately assess learners' communication performance in high-stakes certification Objective Structured Clinical Examinations (OSCE), offering a feasible way to reduce the need for recruitment, time commitment and coordination of faculty assessors. In this study, we evaluated the use of standardised clients (SC) as a viable option for assessing veterinary students' communication performance. We designed a four-station, two-track communication skills OSCE. SC assessors used an adapted nine-item Liverpool Undergraduate Communication Assessment Scale (LUCAS). Faculty used a 21-item checklist derived from the Calgary-Cambridge Guide (CCG) and a five-point global rating scale. Participants were second year veterinary students (n=96). For the four stations, intrastation reliability (α) ranged from 0.63 to 0.82 for the LUCAS, and 0.73 to 0.87 for the CCG. The interstation reliability coefficients were 0.85 for the LUCAS and 0.89 for the CGG. The calculated Generalisability (G) coefficients were 0.62 for the LUCAS and 0.60 for the CGG. Supporting construct validity, SC and faculty assessors showed a significant correlation between the LUCAS and CCG total percent scores (r=0.45, P<0.001), and likewise between the LUCAS and global rating scores (r=0.49, P<0.001).Study results support that SC assessors offer a reliable and valid approach for assessing veterinary communication OSCE.

The impact of a hybrid online and classroom-based course on palliative care competencies of family medicine residents.

The University of Calgary offers a palliative care course that involves both classroom- and web-based learning for rural-based family medicine residents. This study assessed the impact of the course on palliative care-related competencies for two classes: 2004 and 2005. Instruments were developed to evaluate pre- versus post-course changes in knowledge (15-item quiz), attitudes (12-item survey), self-perceived comfort levels (19-item survey) and skills (3 long Objective Structured Clinical Examination stations (OSCEs), with accompanying standardised score sheets). In all, 16 and 20 residents participated in the 2004 and 2005 classes, respectively. Internal reliability values were acceptable to very good (Knowledge Quiz, Kuder-Richardson 20 = 0.5; Attitude Scale, alpha = 0.68-0.78; OSCE score sheets, alpha = 0.63-0.89; Self-Perceived Comfort Survey, alpha = 0.89-0.92). Inter-rater reliability values of the OSCE score sheets were alpha = 0.87 to 0.92. There was a significant improvement in the pre- versus post-course performances in OSCE 2 for 2004 and 2005 (P = 0.01; P = 0.01; d = 1.42 and 1.94, respectively). Despite statistically insignificant changes in the other OSCEs, acceptable to large effect sizes were noted (d = 0.4-1.34) for OSCE 1 in 2004 and OSCEs 3 in 2004 and 2005. Knowledge improved significantly pre-versus post-course in 2004 and 2005 (t = 4.44 and 8.99; d = 2.29 and 2.24, respectively). Significant improvements and large effect sizes were noted in the comfort scales, but a ceiling effect was noted in the communication subscale. This hybrid course resulted in significant improvements across four domains, knowledge, attitudes, self-perceived comfort scale, and skills, in 2 consecutive classes.

A meta-analysis of the published research on the effects of child sexual abuse.

A meta-analysis of the published research on the effects of child sexual abuse (CSA) was undertaken for 6 outcomes: posttraumatic stress disorder (PTSD), depression, suicide, sexual promiscuity, victim-perpetrator cycle, and poor academic performance. Thirty-seven studies published between 1981 and 1995 involving 25,367 people were included. Many of the studies were published in 1994 (24; 65%), and most were done in the United States (22; 59%). All six dependent variables were coded, and effect sizes (d) were computed for each outcome. Average unweighted and weighted ds for each of the respective outcome variables were .50 and .40 for PTSD, .63 and .44 for depression, .64 and .44 for suicide, .59 and .29 for sexual promiscuity, .41 and .16 for victim-perpetrator cycle, and .24 and .19 for academic performance. A file drawer analysis indicated that 277 studies with null ds would be required to negate the present findings. The analyses provide clear evidence confirming the link between CSA and subsequent negative short- and long-term effects on development. There were no statistically significant differences on ds when various potentially mediating variables such as gender, socioeconomic status, type of abuse, age when abused, relationship to perpetrator, and number of abuse incidents were assessed. The results of the present meta-analysis support the multifaceted model of traumatization rather than a specific sexual abuse syndrome of CSA.

Assessment of physician performance in Alberta: the physician achievement review.

The College of Physicians and Surgeons of Alberta, in collaboration with the Universities of Calgary and Alberta, has developed a program to routinely assess the performance of physicians, intended primarily for quality improvement in medical practice. The Physician Achievement Review (PAR) provides a multidimensional view of performance through structured feedback to physicians. The program will also provide a new mechanism for identifying physicians for whom more detailed assessment of practice performance or medical competence may be needed. Questionnaires were created to assess an array of performance attributes, and then appropriate assessors were designated--the physician himself or herself (self-evaluation), patients, medical peers, consultants and referring physicians, and non-physician coworkers. A pilot study with 308 physician volunteers was used to evaluate the psychometric and statistical properties of the questionnaires and to develop operating policies. The pilot surveys showed good statistical validity and technical reliability of the PAR questionnaires. For only 28 (9.1%) of the physicians were the PAR results more than one standard deviation from the peer group means for 3 or more of the 5 major domains of assessment (self, patients, peers, consultants and coworkers). In post-survey feedback, two-thirds of the physicians indicated that they were considering or had implemented changes to their medical practice on the basis of their PAR data. The estimated operating cost of the PAR program is approximately $200 per physician. In February 1999, on the basis of the operating experience and the results of the pilot survey, the College of Physicians and Surgeons of Alberta implemented this innovative program, in which all Alberta physicians will be required to participate every 5 years.

Changing physicians' practices: the effect of individual feedback.

OBJECTIVE: To determine whether physicians who received feedback from six peers, six referring/referral physicians, six co-workers, and 25 patients about 55 aspects of their medical practices (e.g., able to reach doctor by phone after office hours) would make changes to their practices based on that feedback. METHOD: In an earlier study, 308 physicians were given feedback about 106 aspects of their practices in the form of mean Likert-scale ratings that (1) the peers made on 26 aspects; (2) the referring/referral physicians made on 23 aspects; (3) the co-workers made on 17 aspects; and (4) the patients made on 40 aspects. Three months later 255 of these physicians responded when asked to indicate whether they had contemplated or initiated changes, or whether no change had been necessary, regarding 31 practice aspects, each of which was a summary of one or more of 55 of the original 106 aspects on which they had received ratings. These 55 were considered the aspects most amenable to change over a short period. The physicians were also asked about the educational interventions that they felt would help them make changes. Multivariate analysis of variance was used to see whether the types of changes reported for the specific aspects of practice were associated with the feedback ratings received for those aspects. RESULTS: An examination of the responses showed that 83% of the 255 physicians reported having contemplated a change, and 66% reported having initiated a change for at least one aspect of practice. Changes were contemplated most frequently for aspects of practice associated with clinical skills and resource use. Changes were initiated most frequently for aspects of practice associated with communication with patients and support of patients. Physicians who contemplated or initiated changes had lower (i.e., more negative) mean ratings than did physicians who reported that no change was necessary, which suggests that the physicians did use their feedback ratings to decide about changes, although their qualitative comments indicated other sources as well. Printed material was chosen most often as a method of receiving continuing medical education related to making changes in the practice areas examined.

Cuing effect of "all of the above" on the reliability and validity of multiple-choice test items.

It is generally acknowledged that alternatives such as none of the above and all of the above should be used sparingly in multiple-choice (MC) items. But the effect that all of the above has on the reliability and validity of an MC item is unclear. This study compared the results of a single-response (SRa) item format that included all of the above as the correct response to a multiple-response (MR) item format that required examinees to select all of the available alternatives for a correct response. A crossover design was used to compare the effect of formats on student performance while item content, scoring method, and student ability levels remained constant. Results indicated that the SRa format greatly distorted examinee performance by elevating their scores because examinees who recognized two or more alternatives as being correct were cued to select all of the above. In addition, the SRa format significantly reduced the reliability and concurrent validity of examinee scores. In summary, the MR format was found to be superior. Based upon new empirical evidence, this study recommends that whenever an educator wishes to evaluate student understanding of an issue that has multiple facts, the SRa format should be avoided and the MR format should be used instead.

An evaluation of competing structural models of adolescents' concerns: chi-squared, fit indices, and parsimony.

In 1993 Adwere-Boamah and Curtis replicated a 1988 study by Violato and Holden of a four-factor model of adolescents' concerns. Employing confirmatory factor analysis, they concluded that the model did not fit the data well. In a reanalysis, it is suggested in the present paper that on the contrary, the results support the original model.

Factors which differentiate sexually abused from nonabused males: an exploratory study.

In the present study, 200 male university students between the ages of 18 and 27 years (mean = 21.4 yr.) completed a questionnaire designed to record data about childhood sexual abuse. The rate of disclosure of sexual abuse was 14%. Analysis indicated that the 28 abused subjects had experienced earlier separation from parents and a generally more unstable environment than the nonabused subjects. Implications for research are discussed.

A factor analysis of the ways of coping questionnaire based on data from saddening experiences.

Data from 149 subjects coping with saddening life events were collected over a ten-week period (745 life events). A factor analysis indicated that the Ways of Coping Questionnaire Avoidance items lost their unidimensionality and loaded on two distinct factors (i.e., one factor tapping cognitive avoidance and one tapping physiological symptomatology). Moreover, items from the Self-control scale lost their coherence and did not load meaningfully on any factor.

Item difficulty and discrimination as a function of stem completeness.

The effects on item difficulty and discrimination of stem completeness (complete stem or incomplete stem) for multiple-choice items were studied experimentally. Subjects (166 junior education students) were classified into three achievement groups (low, medium, high) and one of two forms of a multiple-choice test was randomly assigned to each subject. A two-way factorial design (completeness x achievement) was used as the experimental model. Analysis indicated that stem completeness had no effect on either item discrimination or difficulty and there was no interaction effect with achievement. It was concluded that multiple-choice items may be very robust in measuring knowledge in a subject area irrespective of variations in stem construction.

Images of adolescence in English literature: the middle ages to the modern period.

It is argued that modern images of adolescence are also reflected in English literary tradition. Thus, relevant works of the major authors, Chaucer, More, Locke, Shakespeare, Bayly, Milton, Prior, Wordsworth, Coleridge, Hazlitt, and Dickens, are analyzed for their imagery of youth and adolescence. It is concluded that, with minor exceptions, the way that youth are depicted in these works remains remarkably stable over time. The main theme of adolescence throughout these works is that it is a time of turbulence, excess, and passion. This is in consonance with the modern-day view of adolescence as a time of storm and stress.

A confirmatory factor analysis of a four-factor model of adolescent concerns.

Based on considerable previous research, a four-factor model of adolescent concerns was proposed. Data on concerns were collected from 439 adolescents together with demographic data. A hierarchy of concerns was established based on mean ratings, and sex and age differences were reported. The data were factor analyzed into four principal components and were tested for the goodness of fit to the proposed model using linear structural relationships (LISREL) techniques by the method of maximum likelihood. The data fit the model very well (goodness of fit index=.958). The implications of these findings for further research and theories of adolescent development are discussed generally.