An Interactive Online Interprofessional Opioid Education Training Using Standardized Patients.

Introduction: Opioid pain management is complex and requires a collaborative approach. To prepare health professions students to care for patients who have chronic pain, we developed an interprofessional education (IPE) session for delivery using a virtual platform that featured a standardized patient (SP) interaction. Methods: The SP case highlighted a patient on opioids for chronic low back pain resulting from a car accident. Despite no improvement in pain or function, the patient continued taking opioids and developed behaviors that could represent opioid misuse. During the synchronous, online session, interprofessional teams of students interviewed an SP and collaborated to develop a holistic care plan to address the patient's pain and potential opioid misuse. The session evaluation included pre- and postsession surveys. Results: Over 750 students from medicine, pharmacy, nursing, and social work programs participated in the virtual IPE sessions during a single year. Students rated the session positively. Matched survey responses suggested improved confidence in knowledge and skills, and learning through Zoom was rated favorably. Discussion: We successfully implemented a synchronous online IPE session involving SP interactions that allowed students to practice team-based care of a patient with chronic pain who was taking opioids. Based on the success of this IPE session, including the success of the online delivery model, future IPE sessions will continue virtually.

Brief Report: Performance of Tuberculosis Symptom Screening Among Hospitalized ART-Naive Children With HIV in Kenya.

BACKGROUND: The World Health Organization (WHO) recommends tuberculosis (TB) diagnostic evaluation for children with HIV (CHIV) who have history of TB contact, poor weight gain, cough, or fever. These screening criteria were developed based on studies of symptomatic CHIV with incomplete microbiologic confirmation. We performed routine TB microbiologic evaluation of hospitalized CHIV with and without symptoms to develop a data-driven TB symptom screen. METHODS: Among hospitalized antiretroviral therapy-naive Kenyan CHIV enrolled in the Pediatric Urgent Start of Highly Active Antiretroviral Therapy (PUSH) trial, we performed Xpert MTB/RIF and mycobacterial culture of respiratory and stool specimens independent of TB symptoms. We evaluated performance of WHO and other published pediatric TB screening criteria and derived optimized criteria using a combination of symptoms. RESULTS: Of 168 CHIV who underwent TB microbiologic evaluation, 13 (8%) had confirmed TB. WHO TB symptom screening had 100% sensitivity and 4% specificity to detect confirmed TB. Published TB screening criteria that relied on prolonged symptoms missed cases of confirmed TB (sensitivity 85%-92%). An optimized symptom screen including weight loss, cough, anorexia, or TB contact had 100% sensitivity and improved specificity (31%) compared with the WHO pediatric TB symptom screen. CONCLUSIONS: The WHO TB symptom screen was highly sensitive but resulted in a high proportion of hospitalized CHIV who would require TB diagnostic evaluation. Other published TB screening criteria missed CHIV with confirmed TB. Our optimized screening tool increased specificity while preserving sensitivity. Future multicenter studies are needed to improve TB screening tools for CHIV in both inpatient and outpatient settings.

Interprofessional education on opioid use and pain identifies team-based learning needs.

BACKGROUND: An interprofessional education (IPE) activity was designed for health professional students in pharmacy, medicine, nursing, social work, and addiction studies. The goals were to practice team-based collaboration for patients who are prescribed opioids for chronic pain and to evaluate student responses to the activity. INTERPROFESSIONAL EDUCATION ACTIVITY: Student teams were guided through an unfolding patient case that included evaluating the patient's history, screening tool results, morphine equivalent dose, prescription monitoring program report, and videos of a patient-provider interaction. The two-hour, in-person IPE activity culminated in creation of a patient-centered treatment plan. Surveys were administered to compare pre- and post-course opioid knowledge and post-course IPE attitudes among the healthcare professions. DISCUSSION: Pharmacy students' baseline opioid knowledge scores were similar to nursing students, significantly lower than medical students, and significantly higher than social work students. Pharmacy students reported significantly higher gains in opioid knowledge than medical students. Nursing and social work students showed significantly higher levels of agreement that the course enhanced attitudes toward interprofessional collaboration compared to medicine and pharmacy students. Students most frequently noted working with other professions as the most valuable aspect of the IPE activity. IMPLICATIONS: Training gaps can be met using novel IPE activities specific to chronic pain and opioid use. Depending on profession, students demonstrated varied baseline knowledge regarding opioid use for chronic pain. Comparing knowledge gains and attitudes on IPE collaboration among professions can detect areas for program refinement to address each professions' unique needs.

Prevalence and Incidence of Sexually Transmitted Infection in Injectable Progestin Contraception Users in South Africa.

Introduction: Whether intramuscular depot medroxyprogesterone acetate (DMPA-IM) and norethisterone enanthate (NET-EN) have a differential impact on the incidence of sexually transmitted infection (STI) remains unclear. In the Vaginal and Oral Interventions to Control the Epidemic (VOICE) trial, HIV-1 acquisition was higher for DMPA-IM users vs. NET-EN users. We compared DMPA-IM and NET-EN users with regard to chlamydia, gonorrhea, trichomoniasis, syphilis, and herpes simplex virus type 2 (HSV-2) infection. Materials and Methods: Prospective data were analyzed from VOICE, a randomized trial of HIV-1 chemoprophylaxis. Participants were evaluated annually and as indicated for chlamydia, gonorrhea, trichomoniasis, and syphilis. Stored specimens were tested for HSV-2. Proportional hazards models compared the risk of STI between DMPA-IM and NET-EN users. Results: Among 2,911 injectable contraception users in South Africa, 1,800 (61.8%) used DMPA-IM and 1,111 used NET-EN (38.2%). DMPA-IM and NET-EN users did not differ in baseline chlamydia: 15.1 vs. 14.3%, p= 0.54; gonorrhea: 3.4 vs. 3.7%, p= 0.70; trichomoniasis: 5.7 vs.5.0%, p= 0.40; or syphilis: 1.5 vs. 0.7%, p= 0.08; but differed for baseline HSV-2: (51.3 vs. 38.6%, p < 0.001). Four hundred forty-eight incident chlamydia, 103 gonorrhea, 150 trichomonas, 17 syphilis, and 48 HSV-2 infections were detected over 2,742, 2,742, 2,783, 2,945, and 756 person-years (py), respectively (chlamydia 16.3/100 py; gonorrhea 3.8/100 py; trichomoniasis 5.4/100 py; syphilis 0.6/100 py; HSV-2 6.4/100 py). Comparing DMPA-IM with NET-EN users, no difference was noted in the incidence of chlamydia, gonorrhea, trichomoniasis, syphilis, or HSV2 infections, including when adjusted for confounders [chlamydia (aHR 1.03, 95% CI 0.85-1.25), gonorrhea (aHR 0.88, 95% CI 0.60-1.31), trichomoniasis (aHR 1.07, 95% CI 0.74-1.54), syphilis (aHR 0.41, 95% CI 0.15-1.10), and HSV-2 (aHR 0.83, 95% CI 0.45-1.54, p= 0.56)]. Discussion: Among South African participants enrolled in VOICE, DMPA-IM and NETEN users differed in prevalence of HSV-2 at baseline but did not differ in the incidence of chlamydia, gonorrhea, trichomoniasis, syphilis, or HSV-2 infection. Differential HIV-1 acquisition, previously demonstrated in this cohort, does not appear to be explained by differential STI acquisition. However, the high incidence of multiple STIs reinforces the need to accelerate access to comprehensive sexual and reproductive health services.

Standardized Patient Simulation Using SBIRT (Screening, Brief Intervention, and Referral for Treatment) as a Tool for Interprofessional Learning.

Introduction: Substance misuse is a critical social and health care issue, and learning how to effectively screen for misuse and perform a brief intervention is useful for all health care professions. As an intercollegiate, interprofessional group, we developed a mechanism for delivering interprofessional education (IPE) using SBIRT (screening, brief intervention, and referral for treatment) as a tool to identify potential substance misuse. Methods: A total of 1,255 students from nursing, pharmacy, medicine, physician assistant, social work, dietetics, and occupational therapy programs participated in the training and evaluation of this IPE experience over 2 academic years. The training incorporated asynchronous SBIRT training, in-person student role-plays, and a standardized patient (SP) interaction. Results: A significant majority of participants indicated that this IPE experience enhanced their interprofessional skills (91%), was useful for interprofessional development (79%), was relevant to their career (92%), and would benefit their clients (93%). Faculty debrief sessions supported the efficacy of SBIRT as a platform for IPE. Discussion: Students believed that utilizing SBIRT as an interprofessional learning experience enhanced their overall educational experience and assisted with developing interprofessional relationships and that team-based care would lead to improved patient outcomes. Faculty found this learning activity to be effective in developing student insight regarding future professional peers and patient interview skill development through role-plays with peers and SPs.

An Innovative Transitional Care Program Improves Community Health.

In this month's Magnet® Perspectives column, Barbara Richardson, MSN, RN-BC, CCRN, clinical nurse specialist at the Southwestern Vermont Medical Center, examines the ways in which a robust transitional care program improves community health, reduces readmissions and emergency department visits, and provides valuable social support for even the most complex patients. Richardson shares critical factors that impacted the program's success, including a Magnet® environment of innovation, a visionary hospital leadership team, strong community alliances, and collaborative solutions to previously intractable problems. Her efforts to build and implement a successful transitional care program earned Richardson the 2016 National Magnet® Nurse of the Year Award for Structural Empowerment.

Terrestrial support of aquatic food webs depends on light inputs: a geographically-replicated test using tank bromeliads.

Food webs of freshwater ecosystems can be subsidized by allochthonous resources. However, it is still unknown which environmental factors regulate the relative consumption of allochthonous resources in relation to autochthonous resources. Here, we evaluated the importance of allochthonous resources (litterfall) for the aquatic food webs in Neotropical tank bromeliads, a naturally replicated aquatic microcosm. Aquatic invertebrates were sampled in more than 100 bromeliads within either open or shaded habitats and within five geographically distinct sites located in four different countries. Using stable isotope analyses, we determined that allochthonous sources comprised 74% (±17%) of the food resources of aquatic invertebrates. However, the allochthonous contribution to aquatic invertebrates strongly decreased from shaded to open habitats, as light incidence increased in the tanks. The density of detritus in the tanks had no impact on the importance of allochthonous sources to aquatic invertebrates. This overall pattern held for all invertebrates, irrespective of the taxonomic or functional group to which they belonged. We concluded that, over a broad geographic range, aquatic food webs of tank bromeliads are mostly allochthonous-based, but the relative importance of allochthonous subsidies decreases when light incidence favors autochthonous primary production. These results suggest that, for other freshwater systems, some of the between-study variation in the importance of allochthonous subsidies may similarly be driven by the relative availability of autochthonous resources.

Dominant predators mediate the impact of habitat size on trophic structure in bromeliad invertebrate communities.

Local habitat size has been shown to influence colonization and extinction processes of species in patchy environments. However, species differ in body size, mobility, and trophic level, and may not respond in the same way to habitat size. Thus far, we have a limited understanding of how habitat size influences the structure of multitrophic communities and to what extent the effects may be generalizable over a broad geographic range. Here, we used water-filled bromeliads of different sizes as a natural model system to examine the effects of habitat size on the trophic structure of their inhabiting invertebrate communities. We collected composition and biomass data from 651 bromeliad communities from eight sites across Central and South America differing in environmental conditions, species pools, and the presence of large-bodied odonate predators. We found that trophic structure in the communities changed dramatically with changes in habitat (bromeliad) size. Detritivore : resource ratios showed a consistent negative relationship with habitat size across sites. In contrast, changes in predator: detritivore (prey) ratios depended on the presence of odonates as dominant predators in the regional pool. At sites without odonates, predator: detritivore biomass ratios decreased with increasing habitat size. At sites with odonates, we found odonates to be more frequently present in large than in small bromeliads, and predator: detritivore biomass ratios increased with increasing habitat size to the point where some trophic pyramids became inverted. Our results show that the distribution of biomass amongst food-web levels depends strongly on habitat size, largely irrespective of geographic differences in environmental conditions or detritivore species compositions. However, the presence of large-bodied predators in the regional species pool may fundamentally alter this relationship between habitat size and trophic structure. We conclude that taking into account the response and multitrophic effects of dominant, mobile species may be critical when predicting changes in community structure along a habitat-size gradient.

Evolving role of the transitional care nurse in a small rural community.

The shift in focus from individual episodes of illness to a focus on health and wellness, and population health, has created a need for care coordination to address the complex needs of high-risk patients as they transition through the healthcare continuum. A Vermont medical center identified the Clinical Nurse Specialist as having the requisite skills to fill the role of care coordinator. This article describes the development of the Transitional Care Nurse (TCN) program and includes case studies that exemplify how the TCN can intervene to improve care coordination.

Living with hepatitis C: a phenomenological study.

AIMS AND OBJECTIVES: To explore the experience of adults living with hepatitis C over time. BACKGROUND: Hepatitis C virus is a growing problem affecting thousands of people worldwide. The majority of individuals infected develop chronic liver disease, but treatment is not always successful, leaving many to live with the virus indefinitely. Experiences of living with hepatitis C are poorly understood yet essential to meet the needs of an increasing number of affected people. DESIGN: A qualitative study using a descriptive phenomenological methodology. METHODS: Unstructured interviews were conducted with 23 hepatitis C-positive individuals in the East of England; participants were interviewed twice within a year. RESULTS: Data analysis revealed six themes of the experience of living with hepatitis C: hepatitis C and self; hepatitis C, self and others; self and handling hepatitis C; self and handling hepatitis C treatment issues; living with the consequences of hepatitis C; self, hepatitis C and thoughts of the future. CONCLUSIONS: Diagnosis of hepatitis C can disrupt people's sense of identity and trigger a life transition. A complex range of factors create uncertainty for people living with hepatitis C. Many struggle to make a healthy transition to life with the condition, instead living in a state of sustained uncertainty. RELEVANCE TO CLINICAL PRACTICE: Nurses working within a chronic care framework of ongoing advice and support can improve experiences for those living with hepatitis C. Practice aimed at reducing both the disruptive effect of the diagnosis and the uncertainties it creates can help facilitate a transition to life with the disease.

Healthcare experiences of patients following faecal output stoma-forming surgery: a qualitative exploration.

BACKGROUND: Approximately 102,000 individuals live with an excretory stoma in the UK. Existing research shows huge variation in how individuals experience living with a new stoma but little is known of the individual experience of contemporary health care from the patient perspective. OBJECTIVE: To explore the individual experience of living with a new stoma and interactions with healthcare over time with the purpose of informing health care services. DESIGN: An existential phenomenological methodology underpinned interviews with twelve people with a new stoma at three, nine and fifteen months post-surgery. Ten healthcare professionals were interviewed on one occasion to provide adjunct data. METHODS: Open one-to one exploratory interviews lasting 35-90 min were conducted by one researcher using topic guides. A five-staged analytical framework facilitated iterative scrutiny of data to give a universal understanding of the experience. RESULTS: Three themes of healthcare experiences of people following stoma-forming surgery were identified: Relationships with health care professionals; being prepared; and regaining autonomy. They revealed how building a new sense of embodied self and increasing social confidence was facilitated by regaining physical capacity, mastering stoma function, purposeful care, and acceptance and support of others. Some conflict between the role of specialist and ward-based nurses is highlighted. Provision of responsive healthcare from all disciplines helped to establish patient self-determination in adaptation to and acceptance of self-with-a-stoma. CONCLUSIONS: The study contributes to defining a plan of care that assists individuals with a new stoma to adapt to and accept a changed sense of embodied self. It highlights the powerful influence of health care professionals in facilitating this process through their knowledge, experience and individual approaches to care. There is an identified need for on-going review of the work of nurses and others providing care for patients following stoma-forming surgery. The findings of this UK study can have resonance with patient healthcare experiences in other countries, if, despite cultural differences in delegation of professional duties and responsibilities, the global aim is to facilitate meeting individual patient needs.

Implementing a safe and reliable process for medication administration.

PURPOSE/OBJECTIVES: The goal of this article was to outline a process change in medication administration using technology and led by clinical nurse specialists (CNSs) that has been successful and sustainable over time. BACKGROUND/RATIONALE: The Institute of Medicine published a landmark report in September 1999 estimating that between 44 000 and 98 000 patients die each year because of medical errors. Errors are rarely the result of incompetent individuals using intentionally unsafe practices. Instead, errors usually result from poorly designed systems that do not prevent errors from occurring. Medication administration is an example of a multistep system that, because of its complexity, can be a challenge to accomplish safely and without error. It is estimated that errors from medication administration have led to 7000 deaths per year. DESCRIPTION OF THE PROJECT/INNOVATION: Using an electronic medication administration record with bar-code scanning for both patient and medication verification at the bedside is a technological methodology known to enhance medication administration safety. Many organizations have adopted these technologies, but not all have shown exceptional and sustained successes leading to a safer hospital experience for their patients. This article outlines the key steps that guided the CNSs from a small Magnet-designated New England hospital to improve medication administration safety. The project improvements were framed in the methods of reliability science. OUTCOME: The article describes a practice change for nurses and pharmacists that resulted in sustained bedside medication scan rates of greater than 97% and medication error reduction from 2.89 errors per 10 000 doses before implementation of electronic medication administration record to a current rate of 1.48 errors per 10 000 doses. INTERPRETATION/CONCLUSION: This improvement project demonstrates that CNSs can play a vital role in bringing electronic medication administration to the hospital environment. The CNS leaders established a network of relationships with experts in pharmacy, information technology, and patient safety to address the varied stakeholder interests.

Interdisciplinary health science research collaboration: strengths, challenges, and case example.

The mandate for interdisciplinary health research is clear, but barriers persist and researchers are unprepared for collaborative roles. This article explores strengths/challenges/facilitative approaches for interdisciplinary research. Teen Eating and Activity Mentoring in Schools, an example of interdisciplinary research, uses comprehensive communication and information management to enhance interdisciplinary research.

Evidence-based practice day: an innovative educational opportunity.

To maximize patient outcomes, the latest research and practice updates must be disseminated across the patient care continuum to include all members of the nursing team. The Clinical Research Council (CRC) recognized the need to bridge the gap between nursing research and practice, using evidence to decrease variation in practice. To meet this challenge, a Magnet-designated, rural community hospital developed an innovative educational program. This article describes Evidence-Based Practice (EBP) day, an interactive learning environment that engages nursing staff and strengthens their understanding of the science that guides practice. Topics for inclusion were selected based on staff requests, current research, quality improvement data, and institutional priorities. Evidence was provided in a format that supported rapid implementation into practice. Key components of the program included a clinical scenario, internal and external data, nursing interventions, patient outcomes (nursing-sensitive and organizational), and regulatory requirement updates.

Metasynthesis of qualitative inquiry research studies in physiotherapy.

BACKGROUND: The current emphasis on evidence based physiotherapy focuses on building knowledge through systematic review of quantitative inquiry studies. Knowledge that provides a framework for practice can help practitioners to decide when and how to use this evidence in their practice contexts. PURPOSE: This paper argues for increased attention to metasynthesis of qualitative inquiry research studies to help identify an underpinning professional knowledge base of physiotherapy that is relevant to day to day practice and education, and to emphasize an epistemological dimension of physiotherapy practice as a socially embedded professional activity. METHODS: An outline of knowledge development in physiotherapy is followed by an explanation and description of the process of metasynthesis and an evaluation of the value of metasynthesis to physiotherapy practice and education. ARGUMENT: Integration of substantive knowledge from metasynthesis of individual qualitative inquiry studies, can generate middle range theory to give a degree of abstraction which can provoke broader questions and insights to re-conceptualize issues of practice. CONCLUSIONS: The methodological approach of metasynthesis can lead to broader and deeper conceptualization of the quality of professional activities which are fundamental to integrating research evidence in successful physiotherapy service delivery.

Learning to be a physiotherapist: a metasynthesis of qualitative studies.

BACKGROUND AND PURPOSE: The health system is increasingly engaging in a wider concept of health which includes lifestyle conditions and well being as well as disease. This challenges physiotherapy educators to take an active role in preparing students for modern health care. Few studies have explored the experience of learning to be a physiotherapist from the student perspective to help illuminate the learning process. The aim of this study was to gain a higher level of theoretical understanding of the longitudinal process of students' learning to be a physiotherapist across the curriculum. METHODS: A metasynthesis design was used to analyse the findings of four individual research studies, based on interviews with a cohort of 18 physiotherapy students. A qualitative phenomenographic approach to analysis was adopted within the metasynthesis. RESULTS: Three patterns of learning, described as 'Learning to cure body structure', 'Learning to educate about movement problems' and 'Learning to manage peoples' health' indicate differences in the focus of learning, the ways in which learning occurs, the learning partners and the context of learning. CONCLUSION: A variation in patterns of learning identified in students' experience of learning to be a physiotherapist reflects different views of knowledge and learning throughout the education programme which progresses the theoretical base on which models of education can be developed.

Effects of dynamic elastomeric fabric orthoses on children with cerebral palsy.

This phase 1 exploratory study aimed to establish proof of concept of the effects of dynamic elastomeric fabric orthoses (DEFOs) on the gait of children with spastic diplegic cerebral palsy. Replicated single case experiments employing an ABA methodology were carried out on eight subjects (median age 5.5 years, range 3-13 years; 4 girls/boys) utilizing quantitative/qualitative data collection. Outcome measures were: Ten metre walking test (10MWT); physiological cost index (PCI); visual analogue scale (VAS) scoring of perceived gait changes; functional mobility changes using Patient Specific Functional Scale (PSFS); subject/carer perceptions recorded in daily diaries. Results identified following analysis of quantitative data indicated a treatment effect from the orthoses which could be corroborated by participant subjective impressions and comments. Statistically significant (p < 0.05) intervention-related improvements in gait velocity and gait consistency were identified respectively in 5/8 and 4/8 subjects. Power calculations support the feasibility of a larger controlled study to further investigate this orthotic intervention. This study indicates that DEFO leggings can confer beneficial effects on the gait of some children with spastic diplegia resulting from CP. These findings have implications for orthotic intervention with this subject group.

Bodily change following faecal stoma formation: qualitative interpretive synthesis.

AIM: This paper is a report of a literature review conducted to answer the question 'How has the experience of bodily change following stoma formation been explored and interpreted through existing qualitative research?'. BACKGROUND: A faecal stoma alters the function, appearance and sensation of the body. Quantitative research highlights the importance of bodily change following stoma formation but is limited in being able to explore what this experience means to ostomists. Qualitative research can identify ways in which ostomists experience their changed body but a conceptual framework of their experience drawn from qualitative findings which can inform patient-centred care has not yet been identified. METHOD: The Amed, ASSIA, CINAHL, Embase, Medline and Psycinfo databases were searched from inception to April 2009 using predefined inclusion criteria. Of 144 papers identified, 11 were selected for review. An interpretive review methodology for qualitative research synthesis was employed. FINDINGS: Three broad themes of bodily experience following stoma formation were identified: loss of embodied wholeness, awareness of a disrupted lived body and disrupted bodily confidence. These highlight the impact of the experience of living with a stoma on the embodied self and the ostomist's embodiment within their lifeworld. CONCLUSION: A loss of embodied wholeness which underpins the experience of stoma formation can be represented through awareness of the disrupted lived body and impact on the lifeworld. Findings suggest the need for further research to identify a comprehensive conceptualization of bodily change, which can more closely match healthcare service to individual patient need.

Pediatric HIV-1 in Kenya: pattern and correlates of viral load and association with mortality.

BACKGROUND: There is limited information regarding the pattern and correlates of viral replication in vertically HIV-1-infected children and its role on their outcomes in resource-limited settings. METHODS: HIV-1-infected infants were followed from birth to 24 months. Serial HIV-1 RNA levels were compared in infants infected in utero (<48 hours), peripartum (48 hours-1 month), and late postnatal (after 1 month). Cofactors for viral peak [highest viral load (VL) within 6 months of infection] and set point and mortality were determined. RESULTS: Among 85 HIV-1-infected infants, 24 were infected in utero, 41 peripartum, 13 late postnatal; 7 had no 48-hour assay. HIV-1 VL set point was significantly lower in infants infected >1 month vs. < or = 1 month (5.59 vs. 6.24 log10 copies per milliliter, P = 0.01). Maternal VL correlated with peak infant VL (P < 0.001). Univariately, infant peak and set point VL and 6-month CD4% <15% predicted mortality; and 6-month CD4% <15% remained independently predictive in multivariate analyses (hazard ratio = 4.85, 95% confidence interval: 1.90 to 12.36). CONCLUSIONS: Infants infected after the age of 1 month contained virus better than infants infected before 1 month of age. Maternal VL predicted infant VL, which, in turn was associated with early mortality.