Systematic Review and Critical Appraisal of Role Definition and Responsibility Within the Concussion Management Team for Secondary Schools.

ABSTRACT: BACKGROUND: Sports- and recreation-related concussions impact the cognitive function of secondary school students during the recovery process. They can cause symptoms such as headache, difficulty concentrating, and memory impairment, which pose a challenge for students during the return to learn (RTL) after injury. Concussion management teams (CMTs) assist the student in managing symptoms and develop an individualized RTL process; however, the ideal composition of professionals involved in the CMT has not been fully evaluated. METHODS: A systematic review was conducted to assess current research on CMTs in secondary schools. A search of the databases CINAHL, MEDLINE, and PsycINFO was conducted using the search terms "concussion management team" AND "school" OR "return to learn." RESULTS: Twenty-four articles were included for review. The CMT structure was highly variable in all studies. Identified themes from the literature were confusion of role definition and function, and communication gaps among interdisciplinary team members. Half of the articles viewed the school nurse as the leader in coordinating the CMT and RTL process. CONCLUSION: Evidence from this review suggests further consensus in this field is needed to clarify the school nurse's role and standardize the CMT structure.

Policy Analysis of Return to Learn After Sport and Recreational Related Concussion for Secondary Schools in New England: Relevance to School Nurses and Nursing Practice.

Return to learn (RTL) is the individualized process of coordinating cognitive care and reintegration for students into the academic setting after any sport and recreational-related concussion (SRRC). The guidelines for RTL are based on empirical evidence, however, implementation differs by institution. The purpose of the policy analysis is to evaluate RTL guidelines after SRRC of student-athletes in New England secondary school public school systems. A review of the six New England states' policies surrounding RTL was conducted. The Comprehensive Analysis of Physical Activity Framework was referenced to identify the analytic components of existing legislation and because of the relatively new implementation of RTL-specific policy, a novel policy analysis tool was utilized. States with RTL-specific language scored on average 7.9 to 11.1 points higher when compared to states without RTL-specific language. This difference was associated with disparities in access to RTL resources for residents according to their geographic location. Lobbying efforts should be targeted toward states without RTL-specific language to provide equal care and opportunities for student-athletes to receive RTL services. RTL policy provides a responsibility to assist students who have suffered from an SRRC and can serve to improve health outcomes and academic achievement.

A Scoping Review of Retrieval Practice (Test-Enhanced Learning) in Nursing Education.

AIM: The aim of this study was to determine the status of retrieval practice in original research of nursing education. BACKGROUND: The science of learning is an emerging interdisciplinary field that offers evidence-based strategies to improve learning. One of the most highly effective strategies is retrieval practice, which involves recalling previously learned information from long-term memory prior to additional study. METHOD: Searching PubMed, CINAHL, Scopus, Psych INFO, and ERIC, an interprofessional team followed a formal scoping review framework and utilized the PRISMA Extension for Scoping Reviews to report the findings. RESULTS: The review included 25 research studies, with all but one at the prelicensure level. Quantitative designs were most common, and outcomes reflected objective and subjective measures. If present, terms were varied and inconsistent with supporting research. Documentation of many characteristics was lacking. CONCLUSION: Retrieval practice is an increasingly common strategy being studied at the prelicensure level. Opportunities for improvement include consistent use of standard terminology, documentation of important characteristics, and more attention to subjective outcomes and to graduate and continuing education levels.

Implementation of Return to Learn Protocols for Student Athletes with Sport and Recreation Related Concussion: An Integrative Review of Perceptions, Challenges and Successes.

Concussion or mild traumatic brain injury (mTBI) is a common phenomenon in the United States, with up to 3.6 million sport-related mTBIs diagnosed annually. Return to learn protocols have been developed to facilitate the reintegration of students into school after mTBI, however, the implementation of return to learn protocols varies significantly across geographic regions and school districts. An integrative review of the literature was performed using Whittemore and Knalf's methodology. A search of published literature was conducted using the PRISMA checklist. Database searches were conducted from March 2,019 to October 2,021 using the terms "mild traumatic brain injury" and "return to learn." Twenty-eight publications were included. Three themes were derived from this review: lack of policy, poor staff education on concussion symptoms and stakeholder communication breakdown. The development of communication patterns and use of a return to learn protocol could facilitate a gradual return to full academic workload after concussion.

Science of Learning Strategy Series: Article 3, Interleaving.

ABSTRACT: Interleaving is an evidence-based, learning-science strategy that is relevant to the planning and implementation of continuing professional development (CPD). Mixing related but different areas of study forces the brain to reconcile the relationship between the areas while understanding each area well. By doing so, interleaving increases the likelihood of mastery and memory. Research from cognitive psychology and neuroscience provides the rationale for interleaving, and examples of its implementation in health profession education have begun to appear in the literature. If utilized appropriately, some common CPD interventions can leverage interleaving. Through increased understanding, CPD participants can benefit from interleaving by making more-informed educational choices, and CPD planners can benefit in efforts to improve educational activities.

Educational needs assessment identifying opportunities to improve sepsis care.

INTRODUCTION: In 2015, the Centers for Medicare and Medicaid Services developed a national quality bundle for the management of patients with severe sepsis and septic shock (SEP-1). Despite performance improvement measures, compliance remains low. This needs assessment is the first stage of a quality improvement initiative to improve SEP-1 compliance. Using a conceptual outcomes framework, this needs assessment analyses SEP-1 compliance data, knowledge, and competence to identify gaps in care and educational opportunities. METHODS: The needs assessment began with a review of national and statewide SEP-1 compliance data to identify a need for improvement. The needs assessment proceeded with a retrospective chart review to evaluate process measures and identify which providers would most likely benefit from educational interventions. A focus group provided perspective on the chart review findings. RESULTS: During the period of 1 April 2017-31 March 2018, national SEP-1 compliance was 51% and compliance at the studied institution was 19%. The chart review included 51 patients (66.7% severe sepsis, 33.3% septic shock). Frequently missed SEP-1 measures included administration of intravenous fluids (0% severe sepsis, 58.8% septic shock), repeat lactate levels (52.6% severe sepsis, 60% septic shock), documentation of volume and tissue perfusion assessment (58.8%), vasopressor administration (73.3%) and administration of broad-spectrum antibiotics (76.5%, severe sepsis). Focus group perceptions identified themes related to gaps in declarative and dispositional knowledge. CONCLUSIONS: This educational needs assessment highlights gaps in SEP-1 clinician performance, competence and knowledge. A multifaceted education programme is the next step for this performance improvement project. Education should include a series of meetings, activities, and workshops that include declarative knowledge, procedural knowledge and dispositional knowledge. Simulation activities can provide an opportunity for providers to demonstrate competence. Point-of-care prompts and performance measurement and feedback of patient care data can support clinician performance. This needs assessment underscores the need for a multifaceted approach to clinician education and performance to improve SEP-1 compliance.

Scoping Review of Distributed Practice in Nursing Education.

AIM: The aim of this study was to describe the status of distributed practice in research of nursing education. BACKGROUND: The science of learning has compiled evidence-based strategies that should be integral to nursing education. One long-standing strategy, distributed practice, involves spacing, placing cognitive breaks between study or practice sessions with priority information. METHOD: Reviewing literature published over 20 years at every level of nursing education, the authors conducted a scoping review to determine the extent to which research of nursing education includes attention to distributed practice. RESULTS: In the 13 articles meeting criteria, distributed practice was most common in continuing professional development, with an emphasis in learning psychomotor skills. Study authors used a variety of terms and descriptions in referring to the strategy. CONCLUSION: By way of research, distributed practice appears underutilized in nursing education, especially at prelicensure and graduate levels, and could benefit from clear and consistent use of terminology.

Science of Learning Strategy Series: Article 2, Retrieval Practice.

ABSTRACT: Retrieval practice is an evidence-based, science of learning strategy that is relevant to the planning and implementation of continuing professional development (CPD). Retrieval practice requires one to examine long-term memory to work with priority information again in working memory. Retrieval practice improves learning in two ways. It improves memory for the information itself (direct benefit), and retrieval practice provides feedback about what needs additional effort (indirect). Both benefits contribute significantly to durable learning. Research from cognitive psychology and neuroscience provides the rationale for retrieval practice, and examples of its implementation in health professions education are increasingly available in the literature. Through appropriate utilization, CPD participants can benefit from retrieval practice by making more-informed educational choices, and CPD planners can benefit in efforts to improve educational activities.

Science of Learning Strategy Series: Article 1, Distributed Practice.

ABSTRACT: Distributed practice is an evidence-based, learning-science strategy that is relevant to the planning and implementation of continuing professional development (CPD). Spacing-out study or practice over time allows the brain multiple opportunities to process new and complex information in an efficient way, thus increasing the likelihood of mastery and memory. Research from cognitive psychology and neuroscience provide the rationale for distributed practice, and examples of its implementation in health professions education have begun to appear in the literature. If used appropriately or extended creatively, some common CPD interventions can fully leverage distributed practice. Through increased understanding, CPD planners can benefit from distributed practice in efforts to improve educational activities, and CPD participants can benefit by making more informed educational choices.

Definitions of Physician Certification Used in the North American Literature: A Scoping Review.

INTRODUCTION: The authors sought to identify how physician specialty certification is defined in the North American literature. METHODS: A rigorous, established six-stage scoping review framework was used to identify the North American certification literature published between January 2006 and May 2016 relating to physician specialty certification. Data were abstracted using a charting form developed by the study team. Quantitative summary data and qualitative thematic analysis of the purpose of certification were derived from the extracted data. RESULTS: A two stage screening process identified 88 articles that met predefined criteria. Only 14 of the 88 articles (16%) contained a referenced purpose of certification. Eighteen definitions were identified from these articles. Definitional concepts included lifelong learning and continuous professional development, assessment of competence and performance, performance improvement, public accountability, and professional standing. DISCUSSION: Most articles identified in this scoping review did not define certification or describe its purpose or intent. Future studies should provide a definition of certification to further scholarly examination of its intent and effects and inform its further evolution.

Constructing a Sensitizing Definition of Certification in Nursing for Research Purposes: A Hybrid Methodology Using Consensus-Building Approach.

OBJECTIVE: The aim of this study was to construct a sensitizing definition of certification in nursing for research purposes that can provide a foundation from which to further develop a coherent research program building evidence about the impact of certification on healthcare outcomes. BACKGROUND: The lack of a single definition of certification in nursing makes it difficult to draw conclusions about the relationship between specialty certification and patient outcomes. METHODS: This study was guided by the Delphi-Chaffee hybrid methodology proposed by Grant et al. DISCUSSION: Constructing a single, sensitizing definition of certification: 1) provides coherency for direction of certification research; 2) serves as a guide for researchers; and 3) facilitates multimethodological approaches to exploring the relationship among the different components of the definition of certification. CONCLUSION: A sensitizing definition of certification provides an opportunity for researchers to study the relationship between nursing certification and patient outcomes.

Recent climate warming drives ecological change in a remote high-Arctic lake.

The high Arctic is the fastest warming region on Earth, evidenced by extreme near-surface temperature increase in non-summer seasons, recent rapid sea ice decline and permafrost melting since the early 1990's. Understanding the impact of climate change on the sensitive Arctic ecosystem to climate change has so far been hampered by the lack of time-constrained, high-resolution records and by implicit climate data analyses. Here, we show evidence of sharp growth in freshwater green algae as well as distinct diatom assemblage changes since ~1995, retrieved from a high-Arctic (80 °N) lake sediment record on Barentsøya (Svalbard). The proxy record approaches an annual to biennial resolution. Combining remote sensing and in-situ climate data, we show that this ecological change is concurrent with, and is likely driven by, the atmospheric warming and a sharp decrease in the length of the sea ice covered period in the region, and throughout the Arctic. Moreover, this research demonstrates the value of palaeoclimate records in pristine environments for supporting and extending instrumental records. Our results reinforce and extend observations from other sites that the high Arctic has already undergone rapid ecological changes in response to on-going climate change, and will continue to do so in the future.

Conceptualization and Operationalization of Certification in the US and Canadian Nursing Literature.

OBJECTIVE: To identify how certification is defined, conceptualized, and discussed in the nursing literature. BACKGROUND: Although it is hypothesized that credentialing is associated with better patient outcomes, the evidence is relatively limited. Some authors have suggested that the lack of consistency used to define certification in nursing literature may be one of the dominant obstacles in credentialing research. METHODS: This scoping review was guided by Arksey and O'Malley's framework, and quantitative and qualitative analyses were conducted. RESULTS: The final data set contained a total of 36 articles, of which 14 articles provided a referenced definition of certification. Thematic analysis of the definitions yielded 8 dominant themes. CONCLUSION: The lack of a common definition of certification in nursing must be addressed to advance research into the relationship between certification processes in nursing and healthcare outcomes.

Learning science as a potential new source of understanding and improvement for continuing education and continuing professional development.

Learning science is an emerging interdisciplinary field that offers educators key insights about what happens in the brain when learning occurs. In addition to explanations about the learning process, which includes memory and involves different parts of the brain, learning science offers effective strategies to inform the planning and implementation of activities and programs in continuing education and continuing professional development. This article provides a brief description of learning, including the three key steps of encoding, consolidation and retrieval. The article also introduces four major learning-science strategies, known as distributed learning, retrieval practice, interleaving, and elaboration, which share the importance of considerable practice. Finally, the article describes how learning science aligns with the general findings from the most recent synthesis of systematic reviews about the effectiveness of continuing medical education.

Integrating Essential Components of Quality Improvement into a New Paradigm for Continuing Education.

Continuing education (CE) that strives to improve patient care in a complex health care system requires a different paradigm than CE that seeks to improve clinician knowledge and competence in an educational setting. A new paradigm for CE is necessary in order to change clinician behavior and to improve patient outcomes in an increasingly patient-centered, quality-oriented care context. The authors assert that a new paradigm should focus attention on an expanded and prioritized list of educational outcomes, starting with those that directly affect patients. Other important components of the paradigm should provide educational leaders with guidance about what interventions work, reasons why interventions work, and what contextual factors may influence the impact of interventions. Once fully developed, a new paradigm will be helpful to educators in designing and implementing more effective CE, an essential component of quality improvement efforts, and in supporting policy trends and in promoting CE scholarship. The purpose of this article is to rekindle interest in CE theory and to suggest key components of a new paradigm.

What Is Implementation Science and What Forces Are Driving a Change in Medical Education?

Evidence-based interventions to improve health care and medical education face multiple complex barriers to adoption and success. Implementation science focuses on the period following research dissemination, which is necessary but insufficient to address important gaps in clinician performance and patient outcomes. This article describes the forces on health care institutions, medical schools, physician clinicians, and trainees that have created the imperative to design educational interventions to address the gap between evidence and practice. These forces include accreditation, certification, licensure, and regulatory and research funding initiatives focused on improving the quality of health professions education and clinical practice. Medical educators must expand their focus on "what to change" to include "how to change" in order to prepare health care professionals and institutions to effectively adopt new evidence-based practices to improve patient, and ultimately population, outcomes.

Description and Impact Evaluation of a Statewide Collaboration to Reduce Preventable Hospital Readmissions.

This article describes how a Medicare-funded Quality Improvement Organization collaborated with a hospital association and multiple cross-continuum partners on a statewide effort to reduce hospital readmissions. Interventions included statewide education on quality improvement strategies and community-specific technical assistance on collaboration approaches, data collection and analysis, and selection and implementation of interventions. Fifteen communities, comprising 16 acute care hospitals, 119 nursing homes, 70 home health agencies, and 32 other health care or social service providers, actively participated over a 4.5-year period. Challenges included problems with end-of-life discussions (80.0%), physician engagement (70.0%), staffing (70.0%), and communication between settings (60.0%). Thirty-day all-cause readmission rates in fee-for-service Medicare patients decreased in most hospital service areas across the state (22/24), and the aggregate statewide readmission rate dropped from 15.2/1000 to 12.1/1000, a relative decrease of 20.3% ( P < .001). Despite these positive findings, the specific impact of this collaboration could not be determined because of multiple confounding interventions.

Key Features of Academic Detailing: Development of an Expert Consensus Using the Delphi Method.

BACKGROUND: Academic detailing is an outreach education technique that combines the direct social marketing traditionally used by pharmaceutical representatives with unbiased content summarizing the best evidence for a given clinical issue. Academic detailing is conducted with clinicians to encourage evidence-based practice in order to improve the quality of care and patient outcomes. The adoption of academic detailing has increased substantially since the original studies in the 1980s. However, the lack of standard agreement on its implementation makes the evaluation of academic detailing outcomes challenging. OBJECTIVE: To identify consensus on the key elements of academic detailing among a group of experts with varying experiences in academic detailing. METHODS: This study is based on an online survey of 20 experts with experience in academic detailing. We used the Delphi process, an iterative and systematic method of developing consensus within a group. We conducted 3 rounds of online surveys, which addressed 72 individual items derived from a previous literature review of 5 features of academic detailing, including (1) content, (2) communication process, (3) clinicians targeted, (4) change agents delivering intervention, and (5) context for intervention. Nonrespondents were removed from later rounds of the surveys. For most questions, a 4-point ordinal scale was used for responses. We defined consensus agreement as 70% of respondents for a single rating category or 80% for dichotomized ratings. RESULTS: The overall survey response rate was 95% (54 of 57 surveys) and nearly 92% consensus agreement on the survey items (66 of 72 items) by the end of the Delphi exercise. The experts' responses suggested that (1) focused clinician education offering support for clinical decision-making is a key component of academic detailing, (2) detailing messages need to be tailored and provide feasible strategies and solutions to challenging cases, and (3) academic detailers need to develop specific skill sets required to overcome barriers to changing clinician behavior. CONCLUSION: Consensus derived from this Delphi exercise can serve as a useful template of general principles in academic detailing initiatives and evaluation. The study findings are limited by the lack of standard definitions of certain terms used in the Delphi process.

Characteristics of Academic Detailing: Results of a Literature Review.

BACKGROUND: Academic detailing is an evidence-based strategy to improve patient care. Efforts to understand the intervention and to use it strategically require an understanding of its important characteristics. A recent systematic review and a subsequent reporting framework call for more accurate and complete reporting of continuing medical education interventions. OBJECTIVES: Building on a previously published systematic review of 69 studies, we sought to determine how an expanded set of 106 academic detailing studies, including many recently published articles, fared with respect to reporting of important data about this intervention. METHODS: We conducted a search of MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (clinical) database, and Scopus, from which we identified 38 additional randomized controlled trials published from August 2007 through March 2013. Including the original 69 studies, we abstracted 106 available English-language studies and quantitatively analyzed information about 4 important characteristics of academic detailing: content of visits, clinicians being visited, communication process underlying visits, and outreach workers making visits. RESULTS: We found considerable variation (36.5%-100%) in the extent of reporting intervention characteristics, especially about the communication process underlying visits and the outreach workers making visits. The best overall documentation of intervention characteristics of any single study was 68%. Results also demonstrate wide variation in the approach to academic detailing. CONCLUSIONS: This study demonstrates the need for a standardized approach to collecting and reporting data about academic detailing interventions. Our findings also highlight opportunities for using academic detailing more effectively in research and quality-improvement efforts.