Inter-rater reliability of assessments regarding the quality of drug treatment, and drug-related hospital admissions.

AIMS: To investigate inter-rater agreement on the quality of drug treatment, and the relationship between the drug treatment and hospital admission. METHODS: Three specialist physicians and two resident physicians determined, independently and in consensus, the quality of drug treatment from an overall medical perspective, and its association with admission, in 30 randomly selected patients (50% female, median age 72 years) admitted to Sahlgrenska University Hospital, Sweden, in April 2018. The inter-rater agreement was evaluated with Gwet's agreement coefficient (AC1 ). RESULTS: In all, 200 (95%) out of 210 drugs at admission and 238 (97%) out of 245 drugs at discharge were assessed as reasonable drug treatment by all assessors. Conversely, none of the drugs at admission, and two at discharge, were assessed as unreasonable drug treatment by all assessors (AC1 : 0.88 and 0.94 [all], 0.86 and 0.95 [specialists], 0.92 and 0.92 [residents], respectively). The assessments regarding the association between the drug treatment and the hospital admission (not related or main/contributory reason) were consistent between the assessors for 16 out of 30 patients (AC1 : 0.67 [all], 0.74 [specialists], 0.54 [residents]). In none of the three cases where the hospital admission was considered possibly attributable to a prescribing error did the assessors make consistent assessments. CONCLUSIONS: As the inter-rater agreement ranged between weak and almost perfect, the reliability of assessments of drug treatment quality, as well as adverse consequences, appears to be a methodological concern. To yield acceptably reliable results regarding both drug treatment aspects at issue, specialist physicians should be involved.

The Satisfaction with Daily Occupations (SDO-13) Scale: Psychometric Properties among Clients in Primary Care in Sweden.

This article describes the results to expand and develop the use of the Satisfaction with Daily Occupations (SDO-13) Scale. Data were collected in primary care before (I) and after intervention (II) among clients with stress-related disorders and musculoskeletal pain. The Cronbach's alpha values of the SDO-13 Scale were 0.80 and 0.88. Convergent validity was assessed against global occupational satisfaction and general health, resulting in rs = -0.65 (p < 0.001) and rs = -0.46 (p < 0.001). The SDO-13 Scale could not discriminate between the primary care sample and a psychiatric sample (p = 0.15), whereas number of current occupations could (p < 0.001). The SDO-13 was not sensitive to change (p = 0.92). Future studies need to explore criterion and construct validity based on more dissimilar samples and more standardized interventions. Applications of these results to practice are discussed.

Interdisciplinary pain rehabilitation for immigrants with chronic pain who need language interpretation.

OBJECTIVE: To investigate outcomes in patients with chronic pain after participation in an interdisciplinary pain rehabilitation programme with language interpreters, and to investigate the outcomes in women and men separately. DESIGN: Prospective multi-centre cohort study. PATIENTS: Ninety-five patients in Sweden with chronic pain who have insufficient knowledge of the Swedish language. METHODS: Duration and intensity of pain, anxiety and depression, health-related quality of life and fear of movement were evaluated before and after the programme. Patients were compared with a reference group comprising Swedish-speaking patients participating in an ordinary interdisciplinary pain rehabilitation programme. RESULTS: Before the interdisciplinary pain rehabilitation programme with language interpreters, all variables except pain duration differed significantly to the detriment of the studied group. The studied group showed significant improvements after the interdisciplinary pain rehabilitation programme with language interpreters, with regards to pain intensity, depression and fear of movement. The reference group improved significantly for all variables. The women in the studied group showed significant improvements for the same variables as the whole group, while the men in the studied group did not improve in any of the variables. CONCLUSION: This study indicates that patients with chronic pain, and especially women, who have insufficient knowledge of Swedish seem to benefit from participating in an interdisciplinary pain rehabilitation programme with language interpreters. The result may be of value for the further development of rehabilitation programmes with language interpreters.

Fetal monitoring with computerized ST analysis during labor: a systematic review and meta-analysis.

BACKGROUND: Computerized ST analysis of fetal electrocardiography (ECG) combined with cardiotochography (CTG) has been introduced for intrapartum monitoring and is the prevailing method when ST analysis (STAN®) is used. OBJECTIVE: To assess the evidence that computerized ST analysis during labor reduces the incidence of fetal metabolic acidosis, hypoxic ischemic encephalopathy, cesarean section, instrumental vaginal delivery or the number of instances where fetal scalp blood sampling is used as compared with CTG only. METHODS: Search of PubMed, Cochrane Library, EMBASE, Web of Science, CINAHL and CRD databases. SELECTION CRITERIA: CTG only compared with CTG + computerized ST analysis. DATA COLLECTION AND ANALYSIS: Studies were assessed using pre-designed templates. Meta-analyses of included randomized controlled trials were performed using a random effects model. RESULTS: Risk ratio for cord metabolic acidosis with STAN® was 0.96 [95% confidence interval (CI) 0.49-1.88]. Risk ratio for cesarean sections or instrumental vaginal deliveries for fetal distress was 0.93 (95%CI 0.80-1.08) and for fetal scalp blood sampling 0.55 (95%CI 0.40-0.76). Encephalopathy cases were not assessed due to their low incidence. CONCLUSIONS: There is not enough scientific evidence to conclude that computerized ST analysis reduces the incidence of metabolic acidosis. Cesarean sections and instrumental vaginal deliveries due to fetal distress or other indications are the same, regardless of method, but STAN® reduces the number of instances which require scalp blood sampling.

Healthcare professionals' experiences and perspectives of team-based interdisciplinary pain rehabilitation with immigrants requiring an interpreter. A qualitative study.

PURPOSE: There is a lack of knowledge about interprofessional rehabilitation for culturally diverse patients with chronic pain. This study explores experiences of healthcare professionals developing and working with rehabilitation with patients in need of an interpreter and their experience of working with interpreters. METHODS: Twelve healthcare professionals at two Swedish specialist rehabilitation centres were interviewed. Grounded theory principles were used for the data collection and analysis. RESULTS: The main category "Demanding and Meaningful Work" represents three concurrently interacting categories: "Frustration" includes the informants' doubts regarding the benefits of the rehabilitation, lack of care for patients and cultural dissonance between professionals and patients. "Challenges" describes problems in the rehabilitation work due to the need for interpreted mediated communication, the complexity in health status and social aspects among the patients. "Solutions" represents practical working methods and personal approaches developed by the informants for managing frustrations and challenges. CONCLUSIONS: The informants' frustration and challenges when working with a new group of patients, vulnerable and different in their preconceptions, led to new solutions in working methods and approaches. When starting a pain rehabilitation programme for culturally diverse patients, it is important to consider the rehabilitation team's need for additional time and support.IMPLICATIONS FOR REHABILITATIONHealthcare professionals who encounter immigrants with chronic pain need resources to develop their own skills in order to handle complex ethical questions as the patients represent a vulnerable patient group with many low status identitiesIn order to adapt rehabilitation programmes to patient groups with different languages and pre-understandings of chronic pain, there is a need for a team with specific qualities, i.e., close cooperation, an innovative atmosphere, time and also support from expertsFor appropriate language interpretation it is important to have a professional interpreter and a healthcare professional who are aware of and adopt the rules, possibilities and restrictions of interpretationThe rehabilitation of patients in need of language interpretation needs more time and organisation compared to the rehabilitation of patients who speak the national language.

Evaluation of feedback methods for improved detection of hindlimb lameness in horses among riding instructors and trainers.

Lameness, a wellknown issue in sport horses, impedes performance and impairs welfare. Early detection of lameness is essential for horses to receive needed treatment, but detection of hindlimb lameness is challenging. Riding instructors and trainers observe horses in motion in their daily work and could contribute to more efficient lameness detection. In this cross-sectional and prospective study, we evaluated the ability of riding instructors and trainers to assess hindlimb lameness. We also evaluated different feedback methods for improved lameness detection. For the cross-sectional part, n = 64 riding instructors and trainers of varying level and n = 23 high-level trainers were shown 13 videos of trotting horses, lameness degree: 0-3.5 (test 1) and tasked with classifying the horses as sound, left hindlimb lame, or right hindlimb lame. For the prospective part, the riding instructors and trainers of varying levels were randomly allocated to three different groups (a, b, c) and given 14 days of feedback-based, computer-aided training in identifying hindlimb lameness, where they assessed 13 videos (of which three were repeated from test 1) of horses trotting in a straight line. Participants in groups a-c received different feedback after each video (group a: correct answer and re-viewing of video at full and 65% speed; group b: correct answer, re-viewing of video at full and 65% speed, narrator providing explanations; group c: correct answer and re-viewing of video at full speed). After computer-aided training, the participants were again subjected to the video test (test 2). Participants also provided background information regarding level of training etcetera. Effects of participants' background on results were analyzed using analysis of variance, and effects of the different feedback methods were analyzed using generalized estimation equations. On test 1, 44% (group a), 48% (b), 46% (c), and 47% (high-level trainers) of horses were correctly classified. Group a participants significantly improved their test score, both with (p < 0.0001) and without (p = 0.0086) inclusion of repeated videos. For group c, significant improvement was only seen with inclusion of repeated videos (p = 0.041). For group b, no significant improvement was seen (p = 0.51). Although test 2 scores were low, computer-aided training may be useful for improving hindlimb lameness detection.

Randomized healthservices study of human papillomavirus-based management of low-grade cytological abnormalities.

Human papillomavirus (HPV)-based management of women with borderline atypical squamous cells of undetermined significance (ASCUS) or mildly abnormal cervical intraepithelial neoplasia (CINI) cervical cytology has been extensively studied in the research setting. We wished to assess safety and health care resource use of a real-life health care policy using HPV triaging. All 15 outpatient clinics involved in the organized population-based screening program in Stockholm, Sweden screening program were randomized to either continue with prior policy (colposcopy of all women with ASCUS/CINI) or to implement a policy with HPV triaging and colposcopy only of HPV-positive women. The trial enrolled the 3,319 women who were diagnosed with ASCUS (n = 1,335) or CINI (n = 1,984) in Stockholm during 17th March 2003 to 16th January 2006. Detection of high-grade cervical lesions (CINII+) and health care cost consumption was studied by registry linkages. The proportion of histopathology-verified CINII+ was similar for the two policies (395 of 1,752 women (22.5%; 95% Confidence interval [CI]: 20.6-24.6%) had CINII+ diagnosed with HPV triaging policy, 318 of 1,567 women (20.3%; 95%CI: 18.3-22.4%) had CINII+ with colposcopy policy). Sixty-four percent of women with ASCUS and 77% of women with CINI were HPV positive. HPV-positivity was age-dependent, with 81% of women below 35 years of age and 44% of women above 45 years of age testing HPV-positive. HPV triaging was cost-effective only above 35 years of age. In conclusion, a real-life randomized healthservices study of HPV triaging of women with ASCUS/CINI demonstrated similar detection of CINII+ as colposcopy of all women.

Variability in patient characteristics and service provision of interdisciplinary pain rehabilitation: A study using the Swedish national quality registry for pain rehabilitation.

OBJECTIVE: To describe the organization, content and dosage of interdisciplinary pain rehabilitation, and the differences in degree of severity of problems of patients admitted to clinical units reporting to a Swedish national quality pain registry, grouped according to unit size and possible affiliation with a university hospital. METHODS: Reports from 31 out of 39 clinical units in Sweden, on inclusion processes, organization, content and dosage of interdisciplinary pain rehabilitation, and patient-reported data from a Swedish national quality pain registry at assessment for interdisciplinary pain rehabilitation were analysed. RESULTS: the number of patients treated annually at each unit ranged from 3 to 340. In 17 units, teams comprised 5 professionals. Dosage of interdisciplinary pain rehabilitation ranged from 20-180 h per patient in total. Patients at the university-hospital units scored the highest levels of symptoms and lowest levels of health-related quality of life. Units used similar sets of inclusion criteria, and several treatments, such as education, self-training and psychological interventions, were used by most units. CONCLUSION: When interpreting outcome data from registries, aspects other than rehabilitation outcomes must be considered. The interpretation of outcomes from quality registries would be facilitated if data, in addition to assessments and patient-reported outcomes, also includes standardized descriptions of the reporting clinical units.

Medical interns' view of their undergraduate medical education in Uppsala: an alumnus study with clear attitude differences between women and men.

BACKGROUND: An alumni study of graduates from the medical school in Uppsala, was performed to give input into an ongoing reform process. AIMS: This study aimed to investigate how medical interns view their undergraduate medical education and the extent to which they felt that the curriculum prepared them for their current positions. METHODS: A web-based questionnaire was sent out via mail in 2005 to all past graduates who had qualified in Uppsala in 2003. RESULTS: Replies were obtained from 69 of 102 students (68%). The most apparent suggested change of the education was increased integration of preclinical and clinical teaching. Correlations were found between student satisfaction with the medical school and perceived teacher attitude, encouragement to reflect, and the graduates' perception of having sufficient practical abilities. Significant gender differences were found regarding perceived clinical ability and concerning feedback and encouragement from the teachers. CONCLUSIONS: Our results suggest more direct feedback from the teachers and more integration between basic sciences and clinical education. Female and male students may have different needs. A key question is therefore to encourage teachers to learn about gender since female and male students should equally experience respectful encounters with teachers and doctors acting as role models.

Return to work after interdisciplinary pain rehabilitation: One- and two-year follow-up based on the Swedish Quality Registry for Pain rehabilitation.

OBJECTIVES: To investigate: (i) changes in sick-leave benefits from 1 year prior to multimodal rehabilitation to 1 and 2 years after rehabilitation; (ii) sex differences in sick leave; and (iii) the impact of policy changes on sick leave. METHODS: All patients undergoing multimodal rehabilitation registered in a national pain database for 2007-11 (n = 7,297) were linked to the Swedish Social Insurance Agency database. Sick leave was analysed in 3-month periods: T0: 1 year before rehabilitation; T1: before start; T2: 1 year after; and T3: 2 years after rehabilitation. Four sick-leave benefit categories were constructed: no sick leave, part-time sick leave, full-time sick leave, and full-time permanent sick leave. The individual change in sick-leave category at each time-period was analysed. RESULTS: Sick-leave benefits increased from T0 to T1 (p < 0.001) and decreased from T1 to T3 (p < 0.001). Reductions were significant for both men and women from T1 to T3, but men had less sick-leave benefits at T2 and T3. Positive changes in sick-leave benefits at T2 and T3 were found both prior to and after policy changes, with less sick-leave benefits after policy changes at all time-points. CONCLUSION: Multimodal rehabilitation may positively influence sick-leave benefits for patients with chronic pain, regardless of their sick-leave situation, sex or policy changes.

Acceptance: a factor to consider in persistent pain after neck trauma.

BACKGROUND AND AIMS: Studies on the interaction between acceptance and pain-related processes after neck trauma are to our knowledge sparse and such treatment strategies are rarely incorporated in management and treatment of posttraumatic neck pain. Thus, the aim of the present study is to investigate how acceptance relates to persistent pain in patients after neck trauma, when controlling for the influence of other psychological factors, trauma characteristics and demographic variables. METHODS: Consecutive patients with persistent pain and disability after neck trauma (n = 565) were assessed by a multi-professional team at a specialized pain rehabilitation clinic. Separate regression analyses were conducted with three outcomes: pain distribution, pain interference, and pain severity. Predictors were age, sex, education, time since trauma, type of trauma, anxiety, depression, and acceptance. RESULTS: Acceptance was the only factor associated with all outcomes, and patients with lower acceptance displayed more widespread pain and greater interference and severity of pain. The results also showed that higher depression was associated with worse pain interference and severity, whilst anxiety only mattered significantly for pain severity and not for pain interference. Female sex was related to more widespread pain and greater pain interference. CONCLUSIONS: Overall acceptance stood out as the most important factor for the different outcomes and lower acceptance was associated with more widespread pain distribution and greater pain interference and severity. IMPLICATIONS: The findings of this study add to a growing body of literature confirming that the development of chronicity after neck trauma should be understood as a multidimensional process, best described by a biopsychosocial model. The results also suggest that psychological factors and especially acceptance might be important processes with implications for enhanced recovery after neck trauma.

Chronic pain patients can be classified into four groups: Clustering-based discriminant analysis of psychometric data from 4665 patients referred to a multidisciplinary pain centre (a SQRP study).

OBJECTIVE: To subgroup chronic pain patients using psychometric data and regress the variables most responsible for subgroup discrimination. DESIGN: Cross-sectional, registry-based study. SETTING AND SUBJECTS: Chronic pain patients assessed at a multidisciplinary pain centre between 2008 and 2015. METHODS: Data from the Swedish quality registry for pain rehabilitation (SQRP) were retrieved and analysed by principal component analysis, hierarchical clustering analysis, and partial least squares-discriminant analysis. RESULTS: Four subgroups were identified. Group 1 was characterized by low "psychological strain", the best relative situation concerning pain characteristics (intensity and spreading), the lowest frequency of fibromyalgia, as well as by a slightly older age. Group 2 was characterized by high "psychological strain" and by the most negative situation with respect to pain characteristics (intensity and spreading). Group 3 was characterized by high "social distress", the longest pain durations, and a statistically higher frequency of females. The frequency of three neuropathic pain conditions was generally lower in this group. Group 4 was characterized by high psychological strain, low "social distress", and high pain intensity. CONCLUSIONS: The identification of these four clusters of chronic pain patients could be useful for the development of personalized rehabilitation programs. For example, the identification of a subgroup characterized mainly by high perceived "social distress" raises the question of how to best design interventions for such patients. Differentiating between clinically important subgroups and comparing how these subgroups respond to interventions is arguably an important area for further research.

Psychosocial coping profiles after pain rehabilitation: associations with occupational performance and patient characteristics.

Purpose The aims of the present study were to assess: (i) changes in coping by use of Multidimensional Pain Inventory profiles from baseline to follow-up, (ii) associations between Adaptive Coper (AC) profiles at follow-up and improvements in occupational performance (by Canadian Occupational Performance Measure COPM) and (iii) ability to predict AC profiles at follow-up by participants' baseline characteristics. Method Data at baseline, discharge and follow-up from 525 participants in a pain rehabilitation program were analyzed with multivariate statistics. Results AC profiles increased and Dysfunctional (DYS) profiles decreased at follow-up. Clinically relevant improvements on COPM were associated with having an AC profile at follow-up. Being Nordic born, having longer education, an AC profile and higher baseline scores on satisfaction with performance predicted an AC profile at follow-up. Conclusions Pain rehabilitation seems to result in sustainable and favourable coping strategies at follow-up, and improved occupational performance is associated with favourable coping at follow-up. Outcomes need to be measured independently of improved coping strategies and improvements of participant's individual goals such as difficulties to perform their most meaningful occupations. Patients at risk for unfavourable coping strategies may need modified interventions. Implications for Rehabilitation More participants reported a beneficial coping, MPI profile, in a long-term perspective after a pain rehabilitation program. Improvements on occupational performance prioritized as meaningful by each of the participants are related to adequate coping strategies at follow-up. The associations between improved occupational performance and beneficial coping profiles need to be better understood. Patients with worse initial occupational performance may need modified pain rehabilitation interventions to improve their coping strategies.

Regulated delivery of glial cell line-derived neurotrophic factor into rat striatum, using a tetracycline-dependent lentiviral vector.

In this study, a tetracycline-regulated lentiviral vector system, based on the tetracycline-dependent transactivator rtTA2(S)-M2, was developed for controlled expression of glial cell line-derived neurotrophic factor (GDNF) in the rat brain. Expression of the marker gene green fluorescent protein (GFP) and GDNF was tightly regulated in a dose-dependent manner in neural cell lines in vitro. Injection of high-titer lentiviral vectors into the rat striatum resulted in a 7-fold induction of GDNF tissue levels (1060 pg/mg tissue), when doxycycline (a tetracycline analog) was added to the drinking water. However, low levels of GDNF (150 pg/mg tissue) were also detected in animals that did not receive doxycycline, indicating a significant background leakage from the vector system in vivo. The level of basal expression was markedly reduced when a 10-fold lower dose of the tetracycline-regulated GDNF vector was injected into the striatum (3-11 pg/mg tissue), and doxycycline-induced GDNF tissue levels obtained in these animals were about 190 pg/mg tissue. Doxycycline-induced expression of GDNF resulted in a significant downregulation of the tyrosine hydroxylase (TH) protein in the intact striatum. Removal of doxycycline from the drinking water rapidly (within 3 days) turned off transgenic GDNF mRNA expression and GDNF protein levels in the tissue were completely reduced by 2 weeks, demonstrating the dynamics of the system in vivo. Accordingly, TH protein expression returned to normal by 2-8 weeks after removal of doxycycline, indicating that GDNF-induced downregulation of TH is a reversible event.

Thyroid gland function in ovariectomized ewes exposed to phytoestrogens.

Phytoestrogens are by definition plant-derived substances that are able to activate the mammalian oestrogen receptors. We examined the possible effects of phytoestrogens on the secretion of thyroid hormones as well as on the immunoreactivity to oestrogen receptor alpha (ER alpha) in the thyroid glands of ovariectomized ewes. Eight ovariectomized ewes were fed 3.5 kg of 100% red clover silage for 14 days. Blood samples were collected before and on day 14 of exposure to phytoestrogens. After 5 months, four of the ewes were re-exposed to red clover silage as described above and the other four served as controls. Blood samples were collected as above. All ewes were slaughtered at the end of the experiment and the thyroid glands were weighed and examined for macroscopical changes. Tissue samples were taken for immunohistochemistry and image analysis. Ewes exposed to red clover silage had significantly higher plasma concentrations of total T(3) and free T(3) than ewes fed hay. The cross-section area of thyroid follicles tended to be larger in ewes fed red clover silage than in the control animals. ER alpha immunoreactivity was stronger in thyroid glands from ewes exposed to phytoestrogens than in ewes fed hay. In conclusion, daily ingestion of 81-95 mg phytoestrogens per kg body weight for 14 days stimulated secretion of thyroid hormones and tended to increase follicle size and ER alpha immunoreactivity of thyroid glands of ovariectomized ewes.

Evaluation of changes in occupational performance among patients in a pain management program.

OBJECTIVES: The aims of this study were to evaluate changes in occupational performance among chronic pain patients after a pain management program and to explore relationships between these changes and demographic and clinical factors, psychosocial functioning and psychological well-being. SUBJECTS: 188 consecutive patients were included. METHODS: Changes were registered by using Canadian Occupational Performance Measure, Multidimensional Pain Inventory and Psychological General Well-Being Index. RESULTS: There were statistically significant positive changes in occupational performance. Patients with sickness compensation had significantly higher changes in occupational performance than those without sickness compensation. The patients with a profile group as interpersonally distressed had statistically significant higher change scores on occupational performance than the adaptive coper group. Furthermore, increases in changes on general activity level, general health, and vitality and decreases in pain severity were associated with positive changes on perceived occupational performance and performance satisfaction. CONCLUSION: Changes in occupational performance, psychological well-being and psychosocial functioning seem all to be of relevance in the evaluation of pain management programs. Psychosocial profiles and sickness compensation has relevance for directions on changes in occupational performance, whereas other demographic and clinical factors do not.

Occupational performance and factors associated with outcomes in patients participating in a musculoskeletal pain rehabilitation programme.

OBJECTIVES: To assess outcomes after a pain rehabilitation programme in terms of occupational performance and satisfaction with occupational performance, and to investigate whether socio-demographic factors and pain-related factors were associated with outcomes at follow-up. METHODS: A pre- and post-test study of 555 participants with musculoskeletal pain who completed a pain rehabilitation programme. The Canadian Occupational Performance Measure (COPM) was used as the primary outcome measure. Socio-demographic and pain-related factors were collected using background questionnaires, the Disability Rating Index (DRI) and the Multidimensional Pain Inventory (MPI). Data were analysed using multivariate logistic regression analyses. RESULTS: Statistically significant improvements were seen on occupational performance and satisfaction with occupational performance at the 1-year follow-up. Female gender, less severe disability, less life interference and more life control predicted improvements 1 year after the programme. High initial scores on occupational performance and satisfaction with performance predicted reduced possibilities for improvements in these respects. CONCLUSION: A pain rehabilitation programme can, for a majority of participants, affect occupational performance and satisfaction with performance. Men and those with more severe pain-related consequences may need additional or modified rehabilitation interventions in order to improve their occupational performance and satisfaction with occupational performance.

Nursing preceptors' experiences of two clinical education models.

Preceptors play an important role in the process of developing students' knowledge and skills. There is an ongoing search for the best learning and teaching models in clinical education. Little is known about preceptors' perspectives on different models. The aim of the study was to describe nursing preceptors' experiences of two clinical models of clinical education: peer learning and traditional supervision. A descriptive design and qualitative approach was used. Eighteen preceptors from surgical and medical departments at two hospitals were interviewed, ten representing peer learning (student work in pairs) and eight traditional supervision (one student follows a nurse during a shift). The findings showed that preceptors using peer learning created room for students to assume responsibility for their own learning, challenged students' knowledge by refraining from stepping in and encouraged critical thinking. Using traditional supervision, the preceptors' individual ambitions influenced the preceptorship and their own knowledge was empathized as being important to impart. They demonstrated, observed and gradually relinquished responsibility to the students. The choice of clinical education model is important. Peer learning seemed to create learning environments that integrate clinical and academic skills. Investigation of pedagogical models in clinical education should be of major concern to managers and preceptors.