Implementation and utilisation of Australian critical care practice standards: What do we know?

BACKGROUND: The Australian College of Critical Care Nurses published the third edition of practice standards (PSs) for specialist critical care nurses in 2015. Higher-education providers currently use these standards to inform critical care curricula; however, how critical care nurses perceive and use PSs in clinical practice is unknown. OBJECTIVES: The objective of this study was to explore critical care nurses' perceptions about the Australian College of Critical Care Nurses PS for specialty critical care nursing, to understand how the PSs are used in clinical practice, and what opportunities exist to support their implementation. METHODS: An exploratory qualitative descriptive design was used. A purposive sampling strategy was used, with 12 critical care specialist nurses consenting to participate in semistructured interviews. The interviews were recorded and transcribed verbatim. Transcripts were analysed thematically using an inductive coding approach. FINDINGS: Three main themes were identified: (i) lack of awareness of the PS; (ii) minimal to no utilisation of the PS in clinical practice and the challenges contributing to this; and (iii) improving the implementation and utilisation of the PS in clinical practice. CONCLUSIONS: There is a significant lack of awareness and utilisation of the PS in clinical practice. To overcome this, increasing recognition, endorsement, and valuation of the PSs to stakeholders at an individual, health service, and legislative level are suggested. Further research is required to establish relevance of the PS in clinical practice and understand how clinicians use the PS to promote and develop critical care nursing.

Novel COVID-19 vaccine hesitancy and acceptance, and associated factors, amongst medical students: a scoping review.

Medical students are likely to be exposed to COVID-19 patients so achieving high vaccination coverage rates for this group of healthcare workers is important, as is their potential as vaccination role models. The aim of this scoping review was to evaluate the current literature to determine the rates of COVID-19 vaccine hesitancy and acceptance, and associated factors, amongst medical students. Systematic searches of the Medline Ovid, Embase, PubMed, and Education Resources Information Centre (ERIC) online databases was conducted for relevant articles with keywords: 'COVID-19', 'vaccine hesitancy & acceptance' and 'medical students'. Articles were included for review if they reported the rates of vaccine hesitancy and acceptance, and associated factors, amongst medical students. Of the 258 articles identified, 52 met the inclusion criteria and underwent full-text review. Rates of vaccine hesitancy ranged from 5.4-86.7%, with generally positive attitudes towards COVID-19 vaccination. The main factors associated with vaccine hesitancy were concerns about the safety and efficacy of vaccines due to their accelerated development, being a pre-clinical medical student, and low perceived personal risk of COVID-19 infection. Inconsistencies were found for the influence of gender on attitudes towards vaccinations. Previous vaccination behaviours were predictive of willingness to receive the COVID-19 vaccine. Knowledge about COVID-19 vaccinations and their importance was found to be deficient amongst vaccine hesitant medical students. Generally, medical students express low levels of vaccine hesitancy. However, due to the variability in the factors associated with vaccine hesitancy across different populations and the dynamic and contextual nature of hesitancy, it is recommended that vaccination intent and associated attitudes are monitored on a longitudinal basis. It is important to map vaccine hesitancy at a local level to allow medical schools to develop strategies to encourage vaccination specific to their school's needs.

Pregnancy and parental leave policies at Australian and New Zealand medical schools.

BACKGROUND: Research into how medical schools support students who are pregnant or with current parental responsibilities has been mostly limited to the US context. OBJECTIVES: To review pregnancy and parental leave policies for students at Australian/New Zealand medical schools. DESIGN: A cross-sectional survey. METHODS: Data were collected between June and September 2021. Websites of Australian/New Zealand medical schools (n = 23) were searched for freely available information on pregnancy and parental leave policies. Each school was contacted to provide supplementary information on the processes to support students who apply for pregnancy and/or parental leave. Outcome harvesting techniques were used to analyse the key attributes and processes used by medical schools. RESULTS: None of the 23 accredited Australian/New Zealand medical schools had specific pregnancy and/or parental leave policies. Fourteen of the 23 Australian/New Zealand medical schools responded to the request for more information. All confirmed, beyond their University's general student leave policies, they had no additional pregnancy and parental leave policy. Analysis of each school's processes identified the following themes: lack of school specific pregnancy and/or parental leave policies; lack of public statements of support for medical students who are pregnant and/or with current parental responsibilities; and lack of attention to the specific needs of medical students who are pregnant and/or with current parental responsibilities, including those with pregnant partners or are a birth support person. CONCLUSION: There was a lack of documentation and formalized processes related to the support of this group of students. By creating easily accessible information on pregnancy and parental leave which is nuanced to the challenges of medical school and clinical placements, medical schools and medical education accreditation bodies in Australia/New Zealand can address the needs of medical students who are pregnant and/or with current parental responsibilities and normalize pregnancy and parental status within entry-to-practice medical courses.

Teaching medical students how to interact with the pharmaceutical industry: A scoping review.

Objectives: The influence of the pharmaceutical industry is of significant concern in physician prescribing decisions; medical students may not be fully equipped with the knowledge or skills to manage interactions with industry prior to graduation. The aim of this study was to evaluate the characteristics of educational interventions undertaken to improve students' knowledge, attitudes, and skills in managing interactions with the pharmaceutical industry. Methods: A systematic search of Ovid Medline, EMBASE, CINAHL and ERIC databases identified 3210 primary studies with keywords related to "pharmaceutical industry" and "undergraduate medical education". Eleven articles were included for review. Results: Disparate methods of teaching medical students how to interact with the pharmaceutical industry were identified, making it difficult to compare the effectiveness of different educational interventions. All the included studies achieved the aims of the described intervention, at least in the short term, suggesting perhaps any education related to interactions with the pharmaceutical industry can aid students in managing these situations. Conclusions: The lack of an evidence-base means more research into the identification of educational interventions which engender durable changes in students' knowledge, attitudes, and skills to manage interactions with the pharmaceutical industry are required. Any intervention will likely be context-dependent, as a universal approach is hindered by the fact different countries have different laws governing pharmaceutical industry-physician interaction.

Burnout in rehabilitation medicine trainees: a call for more research.

Burnout is recognised as a significant occupational hazard for medical professionals. For graduate trainees, across various medical specialties, there is growing evidence burnout results in personal harm and reduces the quality of patient care. Rehabilitation medicine, with its challenge of emotional exhaustion bought about by greater involvement in patient psychosocial well-being over a prolonged period, is significantly under-represented in research into burnout prevalence, impact and prevention strategies. We argue the lack of any evidence base in the Australian healthcare context negatively impacts the ability of training organisations to appropriately support trainees experiencing burnout.

Assessing a Capstone Research Project in Medical Training: Examiner Consistency Using Generic Versus Domain-Specific Rubrics.

Rubrics are utilized extensively in tertiary contexts to assess student performance on written tasks; however, their use for assessment of research projects has received little attention. In particular, there is little evidence on the reliability of examiner judgements according to rubric type (general or specific) in a research context. This research examines the concordance between pairs of examiners assessing a medical student research project during a two-year period employing a generic rubric followed by a subsequent two-year implementation of task-specific rubrics. Following examiner feedback, and with consideration to the available literature, we expected the task-specific rubrics would increase the consistency of examiner judgements and reduce the need for arbitration due to discrepant marks. However, in contrast, results showed that generic rubrics provided greater consistency of examiner judgements and fewer arbitrations compared with the task-specific rubrics. These findings have practical implications for educational practise in the assessment of research projects and contribute valuable empirical evidence to inform the development and use of rubrics in medical education.

Teaching complementary and alternative medicine in undergraduate medical education: a scoping review.

OBJECTIVES: This scoping review explores the extent to which undergraduate medical education have incorporated complementary and alternative medicine in their curricula and evaluates the teaching, delivery and assessment approaches used. METHODS: ERIC, Ovid Medline and Pubmed databases were searched with keywords related to "complementary and alternative medicine" and "undergraduate medical education" for relevant articles published until August 2020. Data extraction included the presence/absence of complementary and alternative medicine integration, program duration, instructor background, and assessment methods. RESULTS: Of 1146 citations, 26 met the inclusion criteria. Complementary and alternative medicine teaching in undergraduate medical education was widely inconsistent and not well aligned with clearly identified aims and objectives. Various complementary and alternative medicine disciplines were taught, demonstrated or observed, and several programs included teaching on evidence-based medicine. Educational outcomes mainly assessed student satisfaction and learning through self-evaluation and rarely assessed for effectiveness with regards to changing clinical practice or impacts on patient outcomes. CONCLUSIONS: Inconsistencies in complementary and alternative medicine teaching and assessment in undergraduate medical education reflect the lack of defined graduate competencies. An evidence-based medicine component of an educational program is a potential solution to overcoming breadth and content challenges. Curriculum developers would be better guided with research that determines if complementary and alternative medicine program design, content and assessment influence clinical practice and/or patient outcomes.

Defining competency for Royal Australian and New Zealand College of Obstetricians and Gynaecologists training: An exploratory study of Victorian Integrated Training Program coordinators' understanding of competency.

BACKGROUND: Competency-based medical education (CBME) is increasingly employed by postgraduate training programs worldwide, including obstetrics and gynaecology. Focusing on assessment of outcomes rather than time-in-training, and utilising a well-defined curricular framework, CBME aims to train doctors capable of meeting the needs of modern society. When this study was undertaken, in 2019, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) had a time-based curriculum and was due to undergo a curriculum review starting in 2020. AIMS: To explore Victorian RANZCOG Integrated Training Program (ITP) coordinators' understanding of the concept of competency and how it is taught and assessed within RANZCOG training. MATERIALS AND METHODS: A qualitative, grounded theory design using semi-structured interviews was employed. Victorian RANZCOG ITP coordinators from inner and outer metropolitan, and regional sites, were approached to participate. Transcripts were coded and analysed using thematic analysis. RESULTS: Themes identified were: Competence, Vision and Innovation, Structures, ITP Coordinator Role and Teaching and Learning. Competence was defined as a combination of independent practice and understanding of ones' own limits, in addition to required clinical skills and knowledge. Enablers and barriers to achieving competency were identified and associated with structures, human and logistical factors. Victorian ITP coordinators believed the current training program has positive elements but could be further improved. CONCLUSIONS: Several areas for future research were identified regarding understanding of competency, relevant if RANZCOG is to introduce a CBME framework. Replicating this research across all RANZCOG jurisdictions in Australia and New Zealand would be prudent to determine if the themes are universal.

Determining Expected Research Skills of Medical Students on Graduation: a Systematic Review.

BACKGROUND: Global interest in research skills in undergraduate medical education is growing. There is no consensus regarding expected research skills of medical students on graduation. We conducted a systematic review to determine the aims and intended learning outcomes (ILOs) of mandatory research components of undergraduate medical curricula incorporating the teaching, assessment, and evaluation methods of these programs. METHODS: Using the PRISMA protocol, MEDLINE and ERIC databases were searched with keywords related to "medical student research programs" for relevant articles published up until February 2020. Thematic analysis was conducted according to student experience/reactions, mentoring/career development, and knowledge/skill development. RESULTS: Of 4880 citations, 41 studies from 30 institutions met the inclusion criteria. Programs were project-based in 24 (80%) and coursework only-based in 6 (20%). Program aims/ILOs were stated in 24 programs (80%). Twenty-seven different aims/ILOs were identified: 19 focused on knowledge/skill development, 4 on experience/reactions, and 4 on mentoring/career development. Project-based programs aimed to provide an in-depth research experience, foster/increase research skills, and critically appraise scientific literature. Coursework-based programs aimed to foster/apply analytical skills for decision-making in healthcare and critically appraise scientific literature. Reporting of interventions was often incomplete, short term, and single institution. There was poor alignment between aims, teaching, assessment, and evaluation methods in most. CONCLUSIONS: The diversity of teaching programs highlights challenges in defining core competencies in research skills for medical graduates. Incomplete reporting limits the evidence for effective research skills education; we recommend those designing and reporting educational interventions adopt recognized educational reporting criteria when describing their findings. Whether students learn by "doing", "proposing to do", or "critiquing", good curriculum design requires constructive alignment between teaching, assessment, and evaluation methods, aims, and outcomes. Peer-reviewed publications and presentations only evaluate one aspect of the student research experience.

Motivations & Experiences of Postgraduate Anatomy Training.

This article was migrated. The article was marked as recommended. Background: Anatomy teaching at medical schools has undergone significant changes in philosophy, and reduction in content, in recent years. Senior clinicians and speciality training Colleges have raised concerns regarding these changes and questioned their impact on 'anatomical competence' and adequacy of training for safe clinical practice. The literature on the perceptions of medical school anatomy teaching among those preparing to enter post-graduate training (i.e. towards a specialist qualification) is sparse. Aim: To assess the motivations for study, and experiences of training, in junior doctors undertaking an intensive post-graduate anatomy training program. Methods: A sample of candidates (13/119, 10%) undertaking the University of Melbourne Graduate Diploma in Surgical Anatomy were recruited for interview. These interviews were recorded, transcribed and then analysed using a combination of thematic and contextual approaches. Key themes were identified and explored. Results: Participant responses fell into two broad categories - motivations for enrolling into the course and their actual experiences of the course. The primary motivation for enrolling into the course was the perceived career requirement to do so, with participants asserting that attending such courses was perceived as mandatory for success in specialty training. Once enrolled, participants valued the teaching and learning and enjoyed the academic pursuit of high-level anatomy study. These benefits, however, were offset by a range of undesirable outcomes associated with undertaking the course. Participants identified the financial cost of the course, the unwillingness of employers to provide rostered study leave and the negative impact on work-life balance as the most significant challenges. Conclusions: Understanding the concerns and expectations of junior doctors preparing for a speciality training program by increasing their anatomy knowledge has implications for both Colleges and medical educators. The participants in this study recognised the limitations in their anatomy knowledge and actively sought additional training at significant financial and personal cost to themselves. This was counterbalanced by the perceived benefits to their career, and an opportunity to enter a specialist training program, by completing additional study.

Clinical phenotypes of perinatal depression and time of symptom onset: analysis of data from an international consortium.

BACKGROUND: The perinatal period is a time of high risk for onset of depressive disorders and is associated with substantial morbidity and mortality, including maternal suicide. Perinatal depression comprises a heterogeneous group of clinical subtypes, and further refinement is needed to improve treatment outcomes. We sought to empirically identify and describe clinically relevant phenotypic subtypes of perinatal depression, and further characterise subtypes by time of symptom onset within pregnancy and three post-partum periods. METHODS: Data were assembled from a subset of seven of 19 international sites in the Postpartum Depression: Action Towards Causes and Treatment (PACT) Consortium. In this analysis, the cohort was restricted to women aged 19-40 years with information about onset of depressive symptoms in the perinatal period and complete prospective data for the ten-item Edinburgh postnatal depression scale (EPDS). Principal components and common factor analysis were used to identify symptom dimensions in the EPDS. The National Institute of Mental Health research domain criteria functional constructs of negative valence and arousal were applied to the EPDS dimensions that reflect states of depressed mood, anhedonia, and anxiety. We used k-means clustering to identify subtypes of women sharing symptom patterns. Univariate and bivariate statistics were used to describe the subtypes. FINDINGS: Data for 663 women were included in these analyses. We found evidence for three underlying dimensions measured by the EPDS: depressed mood, anxiety, and anhedonia. On the basis of these dimensions, we identified five distinct subtypes of perinatal depression: severe anxious depression, moderate anxious depression, anxious anhedonia, pure anhedonia, and resolved depression. These subtypes have clear differences in symptom quality and time of onset. Anxiety and anhedonia emerged as prominent symptom dimensions with post-partum onset and were notably severe. INTERPRETATION: Our findings show that there might be different types and severity of perinatal depression with varying time of onset throughout pregnancy and post partum. These findings support the need for tailored treatments that improve outcomes for women with perinatal depression. FUNDING: Janssen Research & Development.

Analysing clinical reasoning characteristics using a combined methods approach.

BACKGROUND: Despite a major research focus on clinical reasoning over the last several decades, a method of evaluating the clinical reasoning process that is both objective and comprehensive is yet to be developed.The aim of this study was to test whether a dual approach, using two measures of clinical reasoning, the Clinical Reasoning Problem (CRP) and the Script Concordance Test (SCT), provides a valid, reliable and targeted analysis of clinical reasoning characteristics to facilitate the development of diagnostic thinking in medical students. METHODS: Three groups of participants, general practitioners, and third and fourth (final) year medical students completed 20 on-line clinical scenarios -10 in CRP and 10 in SCT format. Scores for each format were analysed for reliability, correlation between the two formats and differences between subject-groups. RESULTS: Cronbach's alpha coefficient ranged from 0.36 for SCT 1 to 0.61 for CRP 2, Statistically significant correlations were found between the mean f-score of the CRP 2 and total SCT 2 score (0.69); and between the mean f-score for all CRPs and all mean SCT scores (0.57 and 0.47 respectively). The pass/fail rates of the SCT and CRP f-score are in keeping with the findings from the correlation analysis (i.e. 31% of students (11/35) passed both, 26% failed both, and 43% (15/35) of students passed one but not the other test), and suggest that the two formats measure overlapping but not identical characteristics. One-way ANOVA showed consistent differences in scores between levels of expertise with these differences being significant or approaching significance for the CRPs. CONCLUSION: SCTs and CRPs are overlapping and complementary measures of clinical reasoning. Whilst SCTs are more efficient to administer, the use of both measures provides a more comprehensive appraisal of clinical skills than either single measure alone, and as such could potentially facilitate the customised teaching of clinical reasoning for individuals. The modest reliability of SCTs and CRPs in this study suggests the need for an increased number of items for testing. Further work is needed to determine the suitability of a combined approach for assessment purposes.

Early identification of autism: a comparison of the Checklist for Autism in Toddlers and the Modified Checklist for Autism in Toddlers.

There is still debate as to what is the most effective strategy for identifying the early signs of autism in very young children. Two levels of screening having been advocated: broad-based developmental surveillance and targeted screening. Two popular tools for use in developmental surveillance are the Checklist for Autism in Toddlers (CHAT) and the Modified Checklist for Autism in Toddlers (M-CHAT). The purpose of this article is to summarise the current evidence for screening for autistic symptoms in very young children using CHAT and M-CHAT. A systematic search was carried out of electronic database and other sources for original studies which evaluated the use of CHAT and M-CHAT in screening for autism in children younger than 5 years of age. Studies were included for review if they evaluated the sensitivity and/or specificity of CHAT or M-CHAT, or described the best age to administer these instruments. The available evidence suggests that characteristic behaviours in autism should be evident in simple forms before the age of 18 months, while screening at 24 months should be conducted to identify those who regress. Administering a screening tool during 18- to 24-month well-child visits improves early identification of autism, while the stability of diagnosis at the ages of 18 months and 24 months is confirmed. M-CHAT has slightly better sensitivity and specificity compared to CHAT, and is preferable to use as a developmental surveillance screening instrument.

Use of video feedback intervention in an inpatient perinatal psychiatric setting to improve maternal parenting.

This study utilizes video feedback to improve maternal parenting behavior in clinically depressed mothers admitted to a perinatal inpatient psychiatric unit. Depressed mothers (n = 74) were randomized to "video" (n = 25), "verbal" (n = 26), or "standard care" (n = 23). "Video" mothers were taped playing with their infant; interaction was reviewed with a mental health specialist. "Verbal" mothers only discussed interaction with their infant. "Standard care" mothers received only routine inpatient care. Mothers were assessed for mental health status, perceptions of baby behavior, and parenting competence. There was significant improvement in mental health status of all participants, regardless of intervention. Neither intervention had an advantage, compared to standard care, in improving parenting confidence or perceptions of infant behavior. Video mothers were more likely to report no change in their parenting confidence the more feedback sessions completed. The number of intervention sessions for each participant was limited by the duration of their inpatient admission. Most participants were on simultaneous pharmacotherapy and psychotherapy, as well as receiving intensive mothercraft assistance; this may have influenced intervention effectiveness. Results suggest that this type of intervention may be beneficial, but in the current format does not add sufficiently to standard care to be detected by the measures used.

Clinical teaching and learning: from theory and research to application.

Learning in the clinical setting is the cornerstone of medical school education, but there are strong imperatives to optimise the ways in which students acquire clinical expertise. Deliberate practice is characterised by attention, concentration, effort and repetition of skills; it is an important tool for developing and maintaining professional expertise. Research has led to a greater understanding of how medical students develop core clinical skills, especially in the areas of diagnostic reasoning, communication and physical examination. Advances in information technology and instructional design are helping to strengthen the links between formal educational activities and opportunistic learning in the clinical setting.

The requirement for bioscience knowledge in medical education.

The recent 100-year anniversary of the Flexner review and the release of the Australian Medical Education Study have stimulated vigorous debate about the role of bioscience knowledge in medical education. Two critical questions define debate in this area: does bioscience learning assist in educating medical students to become competent doctors, and, if so, what are the most effective teaching and learning methods to facilitate this outcome? There is tacit acceptance that specific bioscience knowledge is critical for the development of clinical expertise; however, there are few empirical data to support this notion. Two differing theories have been proposed to describe the role of bioscience learning in the development of clinical reasoning skills - the "two-worlds" model and the "encapsulation" model. A series of studies provides support for the encapsulation model. Some medical programs are now integrating bioscience teaching into the clinical years of the course. Evidence of the effectiveness of this on outcomes, such as improved clinical reasoning, is inconclusive.

Primary care physician's attitudes and practices regarding antidepressant use during pregnancy: a survey of two countries.

Little is known about the practices of primary care physicians regarding the prescribing of antidepressants during pregnancy. An anonymous survey was administered to a group of nonrandomly selected Australian general practitioners (n = 61 out of 77) and randomly selected Canadian family physicians (n = 35 out of 111). Responses to a hypothetical scenario and questions regarding beliefs about the use of antidepressant medication during pregnancy were collected. Physicians from both countries feel strongly that antidepressant use during pregnancy is a decision complicated by conflicting reports of safety and risk.

Review of patients admitted to a specialist inpatient parent-infant psychiatric service.

OBJECTIVE: The aim of this paper is to review the clinical, demographic and psychosocial characteristics of consecutive admissions to a specialist inpatient parent-infant psychiatric service during a 2-year period. METHODS: Data from consecutive admissions between January 2006 and December 2007 were evaluated in terms of primary and secondary diagnosis, demographics and psychosocial risk, psychiatric history, referral source, inpatient care and child protection involvement. RESULTS: The majority of admissions (n = 149) recorded during the audit period were for a major depressive disorder (n = 69; 46%), schizophrenia (n = 29; 19%) or postnatal psychosis (n = 19; 13%); the most common comorbidities were a physical health problem (35%), substance abuse (24%) or borderline personality disorder (15%). The average length-of-stay was 23.8 ± 15.5 days; the average baby's age at admission was 15.1 ± 11.6 weeks. There were no statistically significant differences between women with a history of a mood disorder and those with no such history, in any of the demographic or psychosocial variables evaluated. CONCLUSION: This paper provides a unique appraisal of those individuals actively seeking psychiatric assessment and treatment through a specialist perinatal psychiatric service. Such information is useful in promoting better understanding of this population and the complex treatment and management needs of this patient group.