" I'm not a risk taker " : Risk Perceptions of Nursing Home Residents With Dementia.

BACKGROUND: Persons living with Alzheimer disease and related dementia (ADRD) in nursing homes (NH) are often excluded from conversations about their health/safety. These omissions impinge on personhood and the rights to have care preferences heard and honored. While persons with ADRD maintain the ability to communicate their preferences long after their decision-making abilities are affected, little is known about how persons with ADRD understand the risks associated with their preferences. METHODS: As part of a larger focused ethnography, in-depth interviews and an adapted risk propensity questionnaire explored the risk perceptions of NH residents with ADRD (N=7) associated with their preferences for care and activities of daily living. RESULTS: Residents generally self-identified as risk avoiders ( M =3.2±1.84) on the risk propensity scale and were able to rate risk associated with preferences described within 5 thematic categories: 1) participation in decision-making, 2) risk awareness, 3) paying attention to safety, 4) reliance on nursing home staff and family, and 5) impacts on quality of life and quality of care. DISCUSSION: Results suggest NH residents with ADRD can express risk surrounding their preferences and should be encouraged to participate in discussions about their health and safety.

A Qualitative Study of Resident Advocacy Work.

BACKGROUND: Advocacy is a critical component of pediatric training and practice. Pediatric resident advocacy experiences include skill development and real-world projects, but little is known about how pediatric residents participate in advocacy. Without this knowledge, educators run the risk of underpreparing residents for the full scope of advocacy work. This study sought to investigate how residents participate in advocacy by characterizing their projects using an evidence-informed conceptual framework and describing the unique lessons were learned by the residents. METHODS: The authors used principles of thematic analysis to interrogate existing documents derived from pediatric residents from 2013 to 2021 at 1 institution. They purposefully sampled and deidentified project proposals and written reflections. Using a constant comparative method, they created codes. Codes, connections between codes, and findings were refined by discussion. RESULTS: Residents demonstrated 4 different types of advocacy: some residents participated in directed agency or activism and others focused on shared agency or activism. Residents reflected on different learning experiences; residents who participated in shared forms of advocacy learned skills such as "Partnering," "Evaluating," and "Planning." Residents who were involved in directed forms of advocacy shared lessons on "Leading," "Presenting," and "Intervening." Advocacy work also changed over time: in later projects (2016-2021) residents took ownership of the role of "advocate"; social and political climate was salient in reflections. CONCLUSIONS: Pediatric residents advocate through shared activism and agency and directed activism and agency. Educators should recognize, support, and supplement the experiences of residents as they participate in different types of advocacy.

Why Competency Frameworks Are Insufficiently Nuanced for Health Equity Teaching and Assessment.

This article suggests how competency-based medical education should robustly integrate health equity by focusing on physicians' responsibilities to (1) know why and how underlying structural mechanisms contribute to health equity and then (2) take action to achieve health equity in their practice. This article first canvasses currently available frameworks for helping trainees cultivate these 2 specific skills of discernment and action. This article then offers strategies for teaching and assessing these skills in specific learning activities.

Inequity is woven into the fabric: a discourse analysis of assessment in pediatric residency training.

Intrinsic inequity in assessment refers to sources of harmful discrimination inherent in the design of assessment tools and systems. This study seeks to understand intrinsic inequity in assessment systems by studying assessment policies and associated procedures in residency training, using general pediatrics as a discourse case study. Foucauldian discourse analysis (FDA) was conducted on assessment policy and procedure documents. Two authors independently prepared structured analytic notes using guiding questions. Documents and respective analytic notes were subsequently reviewed independently by all authors. Each author prepared further unstructured analytic notes on the documents' discourse. The authors then compared notes and constructed truth statements (i.e., interpretations of what the discourse establishes as true about the construct under study) and sub-strands (i.e., themes) that were repeated and legitimized across the documents via iterative discussion. Based on analysis, the authors constructed two truth statements. These truth statements, "good assessment is equitable assessment," and "everyone is responsible for inequity," conceptualized inequity in assessment as an isolated or individual-level aberration in an otherwise effective or neutral system. Closer examination of the truth statements and sub-strands in the discourse presented an alternative view, suggesting that inequity may in fact not be an aberration but rather an inherent feature of assessment systems.

Reconstructing Neurath's Ship: A Case Study in Reevaluating Equity in a Program of Assessment.

Inequity in assessment has been described as a "wicked problem"-an issue with complex roots, inherent tensions, and unclear solutions. To address inequity, health professions educators must critically examine their implicit understandings of truth and knowledge (i.e., their epistemologies) with regard to educational assessment before jumping to solutions. The authors use the analogy of a ship (program of assessment) sailing on different seas (epistemologies) to describe their journey in seeking to improve equity in assessment. Should the education community repair the ship of assessment while sailing or should the ship be scrapped and built anew? The authors share a case study of a well-developed internal medicine residency program of assessment and describe efforts to evaluate and enable equity using various epistemological lenses. They first used a postpositivist lens to evaluate if the systems and strategies aligned with best practices, but found they did not capture important nuances of what equitable assessment entails. Next, they used a constructivist approach to improve stakeholder engagement, but found they still failed to question the inequitable assumptions inherent to their systems and strategies. Finally, they describe a shift to critical epistemologies, seeking to understand who experiences inequity and harm to dismantle inequitable systems and create better ones. The authors describe how each unique sea promoted different adaptations to their ship, and challenge programs to sail through new epistemological waters as a starting point for making their own ships more equitable.

What is the Perceived Role of the Dietitian Amongst People with Cystic Fibrosis? Results of an International survey.

Cystic fibrosis (CF) is a chronic condition requiring continued input from the CF dietitian as an integral part of the CF multidisciplinary team. In recent years, the longer life expectancy experienced by people with CF (PwCF) means that nutrition advice and therapy are evolving from a focus on nutrition support to prevention and management of comorbidities. Little has been reported regarding the perceived role of the CF dietitian amongst PwCF. We report the responses to 11 questions that were part of a larger international survey distributed to members of national CF charities in 2018-2019. These questions evaluated PwCFs' perspectives on (i) the importance of the CF diet, (ii) how often PwCF obtain dietary/nutritional advice from their dietitian, (iii) the perceived reliability of information given by the dietitian, (iv) other sources of CF information and their perceived reliability, and (v) how CF nutrition/diet, as well as CF-related diabetes, ranked as research priorities. There were 295 respondents from 13 countries. Almost half of the respondents (46.8%) contacted their CF dietitian on a frequent/more regular basis, compared to medical/scientific journals/medical/scientific search engines. The CF dietitian was considered a reliable source of information, as 84% of the respondents indicated that the information provided was very/generally reliable. At a time when CF care and expectations are changing rapidly, PwCF are in need of trusted and reliable information to make positive changes in lifestyle and habits. Dietitians working with PwCF should appreciate the pivotal and valued role they perform as purveyors of robust evidence-based information to this chronic disease population.

Comparison of innovative communication approaches in nutrition to promote and improve health literacy.

The translation of scientific evidence into guidelines and advice is a fundamental aspect of scientific communication within nutrition and dietetics. For communication to be effective for all patients, health literacy (HL) must be considered, i.e. an individual's capacity to obtain, comprehend and utilise information to empower decision-making and promote their own health. HL levels are varied and difficult to judge on an individual basis and have not been quantified, thus not giving a population mean HL competency indication. It has been evidenced that most of the working age population in England cannot comprehend healthcare materials due to complexity, thereby promoting a need for agreed readability thresholds for written healthcare information. A wide range of modalities within dietetics are used to communicate to a varied audience with the primary form written, e.g. journal articles, plain language summaries and leaflets. Audio/visual and digital communications are increasing in dietetic care and welcomed by patients; however, the effectiveness of such approaches has not been studied thoroughly and digital exclusion remains a concern. Communication considering a patient's HL level leads to empowerment which is key to effective management of chronic diseases with a high treatment burden. Therefore; this review will focus on the importance of modalities used to communicate science in nutrition to ensure they are appropriate in relation to Health Literacy.

Replace, amplify, transform: a qualitative study of how postgraduate trainees and supervisors experience and use telehealth for instruction in ambulatory patient care.

BACKGROUND: Little is known about using telehealth patient visits as an educational mode. Therefore, rapid implementation of telehealth during the COVID-19 pandemic had to be done without understanding how to optimize telehealth for education. With the likely sustained/post-pandemic use of telehealth in ambulatory patient care, filling gaps in our understanding of how telehealth can be used for instruction in this context is critical. This study sought to understand perceptions of pediatric postgraduate trainees and supervisors on the use of telehealth for instruction in ambulatory settings with the goal of identifying effective ways to enhance learning during telehealth visits. METHODS: In May-June of 2020, the authors purposefully sampled first- and third-year postgraduate trainees and supervising attendings from pediatric fellowship programs at one institution that implemented telehealth for instructional activities. They conducted semi-structured interviews; interviews lasted a median of 51 min (trainees) and 41 min (supervisors). They conducted interviews and data analysis iteratively until reaching saturation. Using thematic analysis, they created codes and constructed themes from coded data. They organized themes using the Replace-Amplify-Transform (RAT) model, which proposes that technology can replace in-person learning and/or amplify and transform learning. RESULTS: First-year trainees (n = 6), third-year trainees (n = 5) and supervisors (n = 6) initially used telehealth to replace in-person learning. However, skills that could be practiced in telehealth visits differed from in-person visits and instructional activities felt rushed or awkward. Trainees and supervisors adapted and used telehealth to amplify learning by enhancing observation and autonomy. They also transformed learning, using telehealth to develop novel skills. CONCLUSIONS: To harness telehealth for instructional activities, our findings indicated that trainees and supervisors should shift from using it as a direct replacement for in-person education to taking advantage of novel opportunities to amplify and transform education in PGME. The authors provide data-driven recommendations to help PGME trainees, supervisors and educators capitalize on the educational advantages of telehealth.

Implementation and Use of Workplace-Based Assessment in Clinical Learning Environments: A Scoping Review.

PURPOSE: Workplace-based assessment (WBA) serves a critical role in supporting competency-based medical education (CBME) by providing assessment data to inform competency decisions and support learning. Many WBA systems have been developed, but little is known about how to effectively implement WBA. Filling this gap is important for creating suitable and beneficial assessment processes that support large-scale use of CBME. As a step toward filling this gap, the authors describe what is known about WBA implementation and use to identify knowledge gaps and future directions. METHOD: The authors used Arksey and O'Malley's 6-stage scoping review framework to conduct the review, including: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; (5) collating, summarizing, and reporting the results; and (6) consulting with relevant stakeholders. RESULTS: In 2019-2020, the authors searched and screened 726 papers for eligibility using defined inclusion and exclusion criteria. One hundred sixty-three met inclusion criteria. The authors identified 5 themes in their analysis: (1) Many WBA tools and programs have been implemented, and barriers are common across fields and specialties; (2) Theoretical perspectives emphasize the need for data-driven implementation strategies; (3) User perceptions of WBA vary and are often dependent on implementation factors; (4) Technology solutions could provide useful tools to support WBA; and (5) Many areas of future research and innovation remain. CONCLUSIONS: Knowledge of WBA as an implemented practice to support CBME remains constrained. To remove these constraints, future research should aim to generate generalizable knowledge on WBA implementation and use, address implementation factors, and investigate remaining knowledge gaps.