A systematic review of effective quality feedback measurement tools used in clinical skills assessment.

BACKGROUND: Objective Structured Clinical Examination (OSCE) is a valid tool to assess the clinical skills of medical students. Feedback after OSCE is essential for student improvement and safe clinical practice. Many examiners do not provide helpful or insightful feedback in the text space provided after OSCE stations, which may adversely affect learning outcomes. The aim of this systematic review was to identify the best determinants for quality written feedback in the field of medicine.   Methods: PubMed, Medline, Embase, CINHAL, Scopus, and Web of Science were searched for relevant literature up to February 2021. We included studies that described the quality of good/effective feedback in clinical skills assessment in the field of medicine. Four independent reviewers extracted determinants used to assess the quality of written feedback. The percentage agreement and kappa coefficients were calculated for each determinant. The ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) tool was used to assess the risk of bias. RESULTS: 14 studies were included in this systematic review. 10 determinants were identified for assessing feedback. The determinants with the highest agreement among reviewers were specific, described gap, balanced, constructive and behavioural; with kappa values of 0.79, 0.45, 0.33, 0.33 and 0.26 respectively. All other determinants had low agreement (kappa values below 0.22) indicating that even though they have been used in the literature, they might not be applicable for good quality feedback. The risk of bias was low or moderate overall. CONCLUSIONS: This work suggests that good quality written feedback should be specific, balanced, and constructive in nature, and should describe the gap in student learning as well as observed behavioural actions in the exams.  Integrating these determinants in OSCE assessment will help guide and support educators for providing effective feedback for the learner.

Evaluation of Consecutive Guided Training to Improve Interrater Agreement in Identifying Elements of Situation Awareness in Objective Structured Clinical Examination Assessments.

This article was migrated. The article was marked as recommended. Introduction: Little is known about the medical student's cognitive ability in diagnostic and therapeutic accuracy. Literature does not suggest a methodology to quantify students' cognitive processing. Situation Awareness (SA) is described as having the proficiency to obtain awareness of the surrounding and to integrate this consciousness into the situational context and potential forthcoming development. OSCEs might be a suitable instrument to evaluate students' awareness of the situation. Methods: Consecutive guided training was provided to obtain a consistent comprehension of the model of SA. 4 independent researchers consecutively examined 6 randomised OSCE forms in a qualitative and quantitative method. Final interrater agreement was expressed as Cohens kappa. Generalisability theory determined the impact of the main facets on the variation in disagreement. Results: Evaluation of identifying and categorising elements of SA within OSCE forms demonstrated a moderate to very good interrater agreement. The G-Theory revealed key facets for variance: OSCE forms, Levels of SA, Items embedded in the Levels, Interaction between Forms and Levels and Forms and Items embedded within Levels. Conclusion: Consecutive guided training improved the identification of elements of SA within OSCE assessments. Further research is necessary to improve the assessment of SA in undergraduate medical curricula.

Inter-rater reliability in clinical assessments: do examiner pairings influence candidate ratings?

BACKGROUND: The reliability of clinical assessments is known to vary considerably with inter-rater reliability a key contributor. Many of the mechanisms that contribute to inter-rater reliability however remain largely unexplained and unclear. While research in other fields suggests personality of raters can impact ratings, studies looking at personality factors in clinical assessments are few. Many schools use the approach of pairing examiners in clinical assessments and asking them to come to an agreed score. Little is known however, about what occurs when these paired examiners interact to generate a score. Could personality factors have an impact? METHODS: A fully-crossed design was employed with each participant examiner observing and scoring. A quasi-experimental research design used candidate's observed scores in a mock clinical assessment as the dependent variable. The independent variables were examiner numbers, demographics and personality with data collected by questionnaire. A purposeful sample of doctors who examine in the Final Medical examination at our institution was recruited. RESULTS: Variability between scores given by examiner pairs (N = 6) was less than the variability with individual examiners (N = 12). 75% of examiners (N = 9) scored below average for neuroticism and 75% also scored high or very high for extroversion. Two-thirds scored high or very high for conscientiousness. The higher an examiner's personality score for extroversion, the lower the amount of change in his/her score when paired up with a co-examiner; reflecting possibly a more dominant role in the process of reaching a consensus score. CONCLUSIONS: The reliability of clinical assessments using paired examiners is comparable to assessments with single examiners. Personality factors, such as extroversion, may influence the magnitude of change in score an individual examiner agrees to when paired up with another examiner. Further studies on personality factors and examiner behaviour are needed to test associations and determine if personality testing has a role in reducing examiner variability.

Effects of Biopsychosocial Education on the Clinical Judgments of Medical Students and GP Trainees Regarding Future Risk of Disability in Chronic Lower Back Pain: A Randomized Control Trial.

BACKGROUND: Chronic lower back pain (CLBP) is a major health care burden and often results in workplace absenteeism. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions informed by the flags approach, which integrates cognitive and behavioral approaches via identification of biopsychosocial barriers to recovery, have resulted in reduced pain-related work absences and increased return to work for individuals with CLBP. However, research indicates that physicians' adherence to biopsychosocial guidelines is low. OBJECTIVE: The current study examined the effects of a flags approach-based educational intervention on clinical judgments of medical students and general practitioner (GP) trainees regarding the risk of future disability of CLBP patients. DESIGN: Randomized controlled trial (trial registration number: ISRCTN53670726). SETTING: University classroom. SUBJECTS: Medical students and GP trainees. METHODS: Using 40 fictional CLBP cases, differences in clinical judgment accuracy, weighting, and speed (experimental N = 32) were examined pre- and postintervention, as were flags approach knowledge, pain attitudes and beliefs, and empathy, in comparison with a no-intervention control group (control N = 31). RESULTS: Results revealed positive effects of the educational intervention on flags approach knowledge, pain-related attitudes and beliefs, and judgment weighting of psychologically based cues; results are discussed in light of existing theory and research. CONCLUSIONS: Short flags approach-based educational video interventions on clinical judgment-making regarding the risk of future disability of CLBP patients may provide opportunities to gain biopsychosocial knowledge, overcome associated attitude barriers, and facilitate development of clinical judgment-making more aligned with psychological cues.

True communication skills assessment in interdepartmental OSCE stations: Standard setting using the MAAS-Global and EduG.

BACKGROUND: Comparing outcome of clinical skills assessment is challenging. This study proposes reliable and valid comparison of communication skills (1) assessment as practiced in Objective Structured Clinical Examinations (2). The aim of the present study is to compare CS assessment, as standardized according to the MAAS Global, between stations in a single undergraduate medical year. METHODS: An OSCE delivered in an Irish undergraduate curriculum was studied. We chose the MAAS-Global as an internationally recognized and validated instrument to calibrate the OSCE station items. The MAAS-Global proportion is the percentage of station checklist items that can be considered as 'true' CS. The reliability of the OSCE was calculated with G-Theory analysis and nested ANOVA was used to compare mean scores of all years. RESULTS: MAAS-Global scores in psychiatry stations were significantly higher than those in other disciplines (p<0.03) and above the initial pass mark of 50%. The higher students' scores in psychiatry stations were related to higher MAAS-Global proportions when compared to the general practice stations. CONCLUSION: Comparison of outcome measurements, using the MAAS Global as a standardization instrument, between interdisciplinary station checklists was valid and reliable. PRACTICE IMPLICATIONS: The MAAS-Global was used as a single validated instrument and is suggested as gold standard.

Situational awareness within objective structured clinical examination stations in undergraduate medical training - a literature search.

BACKGROUND: Medical students may not be able to identify the essential elements of situational awareness (SA) necessary for clinical reasoning. Recent studies suggest that students have little insight into cognitive processing and SA in clinical scenarios. Objective Structured Clinical Examinations (OSCEs) could be used to assess certain elements of situational awareness. The purpose of this paper is to review the literature with a view to identifying whether levels of SA based on Endsley's model can be assessed utilising OSCEs during undergraduate medical training. METHODS: A systematic search was performed pertaining to SA and OSCEs, to identify studies published between January 1975 (first paper describing an OSCE) and February 2017, in peer reviewed international journals published in English. PUBMED, EMBASE, PsycINFO Ovid and SCOPUS were searched for papers that described the assessment of SA using OSCEs among undergraduate medical students. Key search terms included "objective structured clinical examination", "objective structured clinical assessment" or "OSCE" and "non-technical skills", "sense-making", "clinical reasoning", "perception", "comprehension", "projection", "situation awareness", "situational awareness" and "situation assessment". Boolean operators (AND, OR) were used as conjunctions to narrow the search strategy, resulting in the limitation of papers relevant to the research interest. Areas of interest were elements of SA that can be assessed by these examinations. RESULTS: The initial search of the literature retrieved 1127 publications. Upon removal of duplicates and papers relating to nursing, paramedical disciplines, pharmacy and veterinary education by title, abstract or full text, 11 articles were eligible for inclusion as related to the assessment of elements of SA in undergraduate medical students. DISCUSSION: Review of the literature suggests that whole-task OSCEs enable the evaluation of SA associated with clinical reasoning skills. If they address the levels of SA, these OSCEs can provide supportive feedback and strengthen educational measures associated with higher diagnostic accuracy and reasoning abilities. CONCLUSION: Based on the findings, the early exposure of medical students to SA is recommended, utilising OSCEs to evaluate and facilitate SA in dynamic environments.

Measuring situation awareness in medical education objective structured clinical examination guides.

Background: Medical errors are among the most prevalent and serious adverse events in health care. Lack of situation awareness (SA) is an important factor leading to such errors. SA can be understood using Endsley's three-tier model: level 1 is perception, level 2 is comprehension, and level 3 is projection. While there is extensive literature on the theory of SA, it is difficult to measure and quantify. The purpose of this pilot study was to measure, identify, and characterize SA in some medical objective structured clinical examination (OSCE) guides, including a 1st year National University of Ireland, Galway (NUIG) OSCE. Methods: Two independent observers analyzed two online OSCE guides and a 1st year OSCE examination using a self-developed tool. This tool was an inferential measure of SA. The guides were first qualitatively analyzed using NVivo and then quantitatively analyzed using Excel. Results: The results indicated strong internal validity and moderate inter-rater reliability. There was limited statistically significant variance between the observers. The NUIG OSCE had relatively the fewest relative observations of SA and the Geeky Medics OSCE Guide had relatively the most observations of SA. In all guides, Level 1 SA was observed more frequently than Level 2 or 3 SA. Discussion: SA is an important factor in clinical decision-making and patient safety. The challenging aspect is how to best teach and assess SA in medical education. Simulations, such as informative and/or summative OSCEs, are considered a valuable and safe way to do so. Inter-rater reliability can be improved using tool training sessions.

Effectiveness of a biopsychosocial e-learning intervention on the clinical judgements of medical students and GP trainees regarding future risk of disability in patients with chronic lower back pain: study protocol for a randomised controlled trial.

INTRODUCTION: Chronic lower back pain (CLBP) is a major healthcare problem with wide ranging effects. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions that identify biopsychosocial barriers to recovery have been observed to lead to successfully reduced pain-related work absences and increased return to work for individuals with CLBP. Modern conceptualisations of pain adopt a biopsychosocial approach, such as the flags approach. Biopsychosocial perspectives have been applied to judgements about future adjustment, recovery from pain and risk of long-term disability; and provide a helpful model for understanding the importance of contextual interactions between psychosocial and biological variables in the experience of pain. Medical students and general practitioner (GP) trainees are important groups to target with education about biopsychosocial conceptualisations of pain and related clinical implications. AIM: The current study will compare the effects of an e-learning intervention that focuses on a biopsychosocial model of pain, on the clinical judgements of medical students and trainees. METHODS AND ANALYSIS: Medical student and GP trainee participants will be randomised to 1 of 2 study conditions: (1) a 20 min e-learning intervention focused on the fundamentals of the flags approach to clinical judgement-making regarding risk of future pain-related disability; compared with a (2) wait-list control group on judgement accuracy and weighting (ie, primary outcomes); flags approach knowledge, attitudes and beliefs towards pain, judgement speed and empathy (ie, secondary outcomes). Participants will be assessed at preintervention and postintervention. ETHICS AND DISSEMINATION: The study will be performed in agreement with the Declaration of Helsinki and is approved by the National University of Ireland Galway Research Ethics Committee. The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN53670726; Pre-results.

Calibration of communication skills items in OSCE checklists according to the MAAS-Global.

BACKGROUND: Communication skills (CS) are commonly assessed using 'communication items' in Objective Structured Clinical Examination (OSCE) station checklists. Our aim is to calibrate the communication component of OSCE station checklists according to the MAAS-Global which is a valid and reliable standard to assess CS in undergraduate medical education. METHOD: Three raters independently compared 280 checklists from 4 disciplines contributing to the undergraduate year 4 OSCE against the 17 items of the MAAS-Global standard. G-theory was used to analyze the reliability of this calibration procedure. RESULTS: G-Kappa was 0.8. For two raters G-Kappa is 0.72 and it fell to 0.57 for one rater. 46% of the checklist items corresponded to section three of the MAAS-Global (i.e. medical content of the consultation), whilst 12% corresponded to section two (i.e. general CS), and 8.2% to section one (i.e. CS for each separate phase of the consultation). 34% of the items were not considered to be CS. CONCLUSION: A G-Kappa of 0.8 confirms a reliable and valid procedure for calibrating OSCE CS checklist items using the MAAS-Global. We strongly suggest that such a procedure is more widely employed to arrive at a stable (valid and reliable) judgment of the communication component in existing checklists for medical students' communication behaviours. PRACTICE IMPLICATIONS: It is possible to measure the 'true' caliber of CS in OSCE stations. Students' results are thereby comparable between and across stations, students and institutions. A reliable calibration procedure requires only two raters.

Back to the future: An online OSCE Management Information System for nursing OSCEs.

BACKGROUND: The Objective Structured Clinical Examination (OSCE) is an established tool in the repertoire of clinical assessment methods in nurse education. The use of OSCEs facilitates the assessment of psychomotor skills as well as knowledge and attitudes. Identified benefits of OSCE assessment include development of students' confidence in their clinical skills and preparation for clinical practice. However, a number of challenges exist with the traditional paper methodology, including documentation errors and inadequate student feedback. OBJECTIVES: To explore electronic OSCE delivery and evaluate the benefits of using an electronic OSCE management system. To explore assessors' perceptions of and attitudes to the computer based package. DESIGN: This study was conducted using electronic software in the management of a four station OSCE assessment with a cohort of first year undergraduate nursing students delivered over two consecutive years (n=203) in one higher education institution in Ireland. A quantitative descriptive survey methodology was used to obtain the views of the assessors on the process and outcome of using the software. METHODS: OSCE documentation was converted to electronic format. Assessors were trained in the use of the OSCE management software package and laptops were procured to facilitate electronic management of the OSCE assessment. Following the OSCE assessment, assessors were invited to evaluate the experience. RESULTS: Electronic software facilitated the storage and analysis of overall group and individual results thereby offering considerable time savings. Submission of electronic forms was allowed only when fully completed thus removing the potential for missing data. The feedback facility allowed the student to receive timely evaluation on their performance and to benchmark their performance against the class. CONCLUSIONS: Assessors' satisfaction with the software was high. Analysis of assessment results can highlight issues around internal consistency being moderate and examiners variability. Regression analysis increases fairness of result calculations.

Reliability and validity of OSCE checklists used to assess the communication skills of undergraduate medical students: A systematic review.

OBJECTIVES: To explore inter-rater agreement between reviewers comparing reliability and validity of checklist forms that claim to assess the communication skills of undergraduate medical students in Objective Structured Clinical Examinations (OSCEs). METHODS: Papers explaining rubrics of OSCE checklist forms were identified from Pubmed, Embase, PsycINFO, and the ProQuest Education Databases up to 2013. Included were those studies that report empirical validity or reliability values for the communication skills assessment checklists used. Excluded were those papers that did not report reliability or validity. RESULTS: Papers focusing on generic communication skills, history taking, physician-patient communication, interviewing, negotiating treatment, information giving, empathy and 18 other domains (ICC -0.12-1) were identified. Regarding the validity and reliability of the communication skills checklists, agreement between reviewers was 0.45. CONCLUSIONS: Heterogeneity in the rubrics used in the assessment of communication skills and a lack of agreement between reviewers makes comparison of student competences within and across institutions difficult. PRACTICE IMPLICATIONS: Consideration should be afforded to the adoption of a standardized measurement instrument to assess communication skills in undergraduate medical education. Future research will focus upon evaluating the potential impact of adoption of a standardized measurement instrument.

The fairness, predictive validity and acceptability of multiple mini interview in an internationally diverse student population--a mixed methods study.

BACKGROUND: International medical students, those attending medical school outside of their country of citizenship, account for a growing proportion of medical undergraduates worldwide. This study aimed to establish the fairness, predictive validity and acceptability of Multiple Mini Interview (MMI) in an internationally diverse student population. METHODS: This was an explanatory sequential, mixed methods study. All students in First Year Medicine, National University of Ireland Galway 2012 were eligible to sit a previously validated 10 station MMI. Quantitative data comprised: demographics, selection tool scores and First Year Assessment scores. Qualitative data comprised separate focus groups with MMI Assessors, EU and Non-EU students. RESULTS: 109 students participated (45% of class). Of this 41.3% (n = 45) were Non-EU and 35.8% (n = 39) did not have English as first language. Age, gender and socioeconomic class did not impact on MMI scores. Non-EU students and those for whom English was not a first language achieved significantly lower scores on MMI than their EU and English speaking counterparts (difference in mean 11.9% and 12.2% respectively, P<0.001). MMI score was associated with English language proficiency (IELTS) (r = 0.5, P<0.01). Correlations emerged between First Year results and IELTS (r = 0.44; p = 0.006; n = 38) and EU school exit exam (r = 0.52; p<0.001; n = 56). MMI predicted EU student OSCE performance (r = 0.27; p = 0.03; n = 64). In the analysis of focus group data two overarching themes emerged: Authenticity and Cultural Awareness. MMI was considered a highly authentic assessment that offered a deeper understanding of the applicant than traditional tools, with an immediate relevance to clinical practice. Cultural specificity of some stations and English language proficiency were seen to disadvantage international students. Recommendations included cultural awareness training for MMI assessors, designing and piloting culturally neutral stations, lengthening station duration and providing high quality advance information to candidates. CONCLUSION: MMI is a welcome addition to assessment armamentarium for selection, particularly with regard to stakeholder acceptability. Understanding the mediating and moderating influences for differences in performance of international candidates is essential to ensure that MMI complies with the metrics of good assessment practice and principles of both distributive and procedural justice for all applicants, irrespective of nationality and cultural background.

Comparing the clinical-effectiveness and cost-effectiveness of an internet-delivered Acceptance and Commitment Therapy (ACT) intervention with a waiting list control among adults with chronic pain: study protocol for a randomised controlled trial.

INTRODUCTION: Internet-delivered psychological interventions among people with chronic pain have the potential to overcome environmental and economic barriers to the provision of evidence-based psychological treatment in the Irish health service context. While the use of internet-delivered cognitive-behavioural therapy programmes has been consistently shown to have small-to-moderate effects in the management of chronic pain, there is a paucity in the research regarding the effectiveness of an internet-delivered Acceptance and Commitment Therapy (ACT) programme among people with chronic pain. The current study will compare the clinical-effectiveness and cost-effectiveness of an online ACT intervention with a waitlist control condition in terms of the management of pain-related functional interference among people with chronic pain. METHODS AND ANALYSIS: Participants with non-malignant pain that persists for at least 3 months will be randomised to one of two study conditions. The experimental group will undergo an eight-session internet-delivered ACT programme over an 8-week period. The control group will be a waiting list group and will be offered the ACT intervention after the 3-month follow-up period. Participants will be assessed preintervention, postintervention and at a 3-month follow-up. The primary outcome will be pain-related functional interference. Secondary outcomes will include: pain intensity, depression, global impression of change, acceptance of chronic pain and quality of life. A qualitative evaluation of the perspectives of the participants regarding the ACT intervention will be completed after the trial. ETHICS AND DISSEMINATION: The study will be performed in agreement with the Declaration of Helsinki and is approved by the National University of Ireland Galway Research Ethics Committee (12/05/05). The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN18166896.

Magnetic resonance myocardial perfusion imaging in the diagnosis of functionally significant obstructive coronary artery disease: a systematic review protocol.

BACKGROUND: Cardiac magnetic resonance (CMR) myocardial perfusion imaging has been suggested as a non-invasive alternative to pressure wire guided fractional flow reserve (FFR) in detecting haemodynamically significant obstructive coronary artery disease (CAD). The objective of this systematic review is to determine the diagnostic accuracy of CMR and to compare it to FFR. METHODS/DESIGN: A systematic review of diagnostic test accuracy of CMR and FFR will be conducted. Relevant English-language articles published before November 2013 in Medline, PubMed, EMBASE, Google scholar, Scopus and Cochrane databases will be identified. Relevant referenced articles from those selected will also be analysed. Articles describing diagnostic studies that compared CMR to FFR in patients with known or suspected coronary artery disease will be included. Two investigators will independently screen, assess quality and extract data from the selected articles. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool will be used to assess methodological quality. STATA 13 (the xtmelogit command) software will be used to calculate bivariate random effects models and estimate pooled sensitivity and specificity with 95% confidence intervals. Forests plots and summary receiver operating characteristics curves will also be generated. Sub-group pooled analyses using image quality of CMR (in terms of magnetic flux density - Tesla) and basis of analyses (coronary arterial territory vs. patients basis) at different FFR cutoffs (≤0.75 and ≤0.8) will also be performed. DISCUSSION: This systematic review will help to determine if CMR is an adequate alternative to FFR in the diagnosis of significant and obstructive CAD. We will also be able to assess diagnostic accuracy of specific types of CMR scan at different FFR cutoffs. SYSTEMATIC REVIEW REGISTRATION: This systematic review had been registered at PROSPERO and the registration number is CRD42013006180.

Interns' attitudes to IV cannulation: a KAP study.

UNLABELLED: One of the most common procedures for junior medical doctors is peripheral intravenous cannulation (PIVC). Considering this, an understanding of the peripheral intravenous cannulation procedure is paramount. AIM: The objective of this study was to identify the level of understanding of interns regarding intravenous cannulation. METHOD: An anonymized structured questionnaire using a knowledge attitude and practices (KAP) format was distributed to 60 interns affiliated to a university college hospital in Ireland. FINDINGS: This study suggests that interns are poorly prepared for one of the most common clinical skills they will perform. They showed poor understanding of whether peripheral cannulation is a clean or aseptic technique, and lacked knowledge of the potential side effects of peripheral cannulation and IV therapy. RECOMMENDATIONS: A structured learning module on peripheral intravenous cannulation is required. A rigid, evidence-based, Objective Structured Clinical Examination (OSCE) on peripheral cannulation is recommended. The reduction of junior doctors' weekly working hours to 48 under the European Working Time Directive offers the potential for nurses to take ownership of IV cannulation. This will allow junior doctors to focus on other clinical skills and assessments, which can only be to the advantage of the patient.

How we implemented an integrated professionalism curriculum to 2nd year medical students at the National University of Ireland Galway Medical School, with examples from students' final output.

Since the introduction of professionalism in medical curricula worldwide, little evidence has been published to exemplify good educational practice. The Medical school at the National University of Ireland Galway teaches professionalism in an interdisciplinary manner, integrating the learning objectives of health informatics, understanding health & illness in society, medical law and ethics. Students work in small groups on clinical cases. Enquiry-based learning is used as the teaching method following a few introductory lectures on specific objectives. Students present their work in the format of a scientific essay. The latter is assessed by a board of reviewers. The purpose of this article is to demonstrate evidence of excellent professional output and illustrate the benefits to a fully integrated professionalism curriculum.

A pilot intravenous cannulation team: an Irish perspective.

Peripheral intravenous cannulation (PIVC) is a potentially painful and distressing procedure for patients, and is traditionally carried out by medical personnel. A university hospital in Ireland was chosen to initiate a pilot intravenous (IV) cannulation team, to ascertain whether this procedure could be performed effectively by a team of nurses. The team was introduced to support the implementation of the European working time directive (EWTD). A team of four registered general nurses, led by a senior phlebotomist, provided PIVC. Request books were placed on each ward and data was recorded before and after each insertion. A constantly increasing percentage of first-time cannulation success is displayed from the first five months of the study. In-depth analysis on an orthopaedic ward reveal a preference for distal site insertion and routine change at 72 hours. IV teams performing IV cannulation can effectively reduce insertion rate attempts, and potentially offer a solution to the manpower issues arising as a result of implementation of the EWTD.

General practitioners' attitudes and preparedness towards Clinical Decision Support in e-Prescribing (CDS-eP) adoption in the West of Ireland: a cross sectional study.

BACKGROUND: Electronic clinical decision support (CDS) is increasingly establishing its role in evidence-based clinical practice. Considerable evidence supports its enhancement of efficiency in e-Prescribing, but some controversy remains. This study evaluated the practicality and identified the perceived benefits of, and barriers to, its future adoption in the West of Ireland. METHODS: This cross sectional study was carried out by means of a 27-part questionnaire sent to 262 registered general practitioners in Counties Galway, Mayo and Roscommon. The survey domains encompassed general information of individual's practice, current use of CDS and the practitioner's attitudes towards adoption of CDS-eP. Descriptive and inferential analyses were performed to analyse the data collected. RESULTS: The overall response rate was 37%. Nearly 92% of respondents employed electronic medical records in their practice. The majority acknowledged the value of electronic CDS in improving prescribing quality (71%) and reducing prescribing errors (84%). Despite a high degree of unfamiliarity (73%), the practitioners were open to the use of CDS-eP (94%) and willing to invest greater resources for its implementation (62%). Lack of a strategic implementation plan (78%) is the main perceived barrier to the incorporation of CDS-eP into clinical practice, followed by i) lack of financial incentives (70%), ii) lack of standardized product software (61%), iii) high sensitivity of drug-drug interaction or medication allergy markers (46%), iv) concern about overriding physicians' prescribing decisions(44%) and v) lack of convincing evidence on the systems' effectiveness (22%). CONCLUSIONS: Despite favourable attitudes towards the adoption of CDS-eP, multiple perceived barriers impede its incorporation into clinical practice. These merit further exploration, taking into consideration the structure of the Irish primary health care system, before CDS-eP can be recommended for routine clinical use in the West of Ireland.

Interobserver reliability of physical examination of shoulder girdle.

The object of this study was to assess interobserver reliability in 23 tests concerning physical examination of the shoulder girdle. A physical therapist and a physical therapist/manual therapist independently performed a physical examination of the shoulder girdle in 91 patients with shoulder complaints of varying severity and duration. The observers assessed 23 items in total: active and passive abductions, passive external rotation, hand in neck (HIN) test, hand in back (HIB) test, impingement test according to Neer, springing test of the first rib and joint play test of the acromioclavicular joint. The interobserver reliability was evaluated by means of a Cohen's Kappa, the weighted Kappa and the intraclass correlation (ICC). Criteria for acceptable reliability were: Kappa value>or=0.60, ICC>or=0.75 or an absolute agreement>or=80%. The results showed that Kappa values varied from 0.09 (springing test first rib, stiffness) to 0.66 (springing test first rib, pain), weighted Kappa varied from 0.35 (pain during HIB) to 0.73 (range of motion HIB) and ICC varied from 0.54 (abduction passive starting point painful arc) to 0.96 (active and passive ranges of motion in abduction). In total 11 (48%) items fulfilled the criteria of acceptable reliability. In conclusion, there appears to be a great deal of variation in the reliability of the tests used in the physical examination of the shoulder girdle. Over 50% of the tests did not meet the statistical criteria for acceptable reliability.