The lived experience of Competence by Design: Canadian resident physicians' perspectives.

PURPOSE: Canadian specialist residency programs are in the process of transitioning to a hybrid time and competence model, Competence by Design (CBD), developed by the Royal College of Physicians and Surgeons Canada. Although there is extensive literature around competency-based medical education (CBME), few studies have evaluated the experience of residents after CBME implementation. The purpose of this study was to obtain a rich perspective on the lived experience of residents. METHODS: We designed a qualitative study with inductive thematic analysis of semistructured interview data. The study population was residents in CBD postgraduate training programs in anesthesiology, internal medicine, or surgery (including all surgical subspecialties) at Dalhousie University (Halifax, NS, Canada). RESULTS: Residents identified the following benefits of their programs and CBD: supportive peers and clinical supervisors, a roadmap for residency, formalized feedback opportunities, and program evolution. Resident-identified drawbacks of CBD included: a lack of transparency around CBD, CBD not as advertised, a lack of buy-in, increased administrative burden, difficulties obtaining evidence for entrustable professional activities (EPAs); the onus for CBD on residents, inconsistent feedback, cumbersome technology, and significant psychological burden. Resident-suggested improvements were reducing the number of EPAs, streamlining EPA requirements, increasing transparency and communication with competence committees, providing incentives and continuous education for clinical supervisors, improving on existing electronic interfaces, and developing technology better suited to the needs of CBD. CONCLUSION: This study highlights that the significant administrative and psychological burden of CBD detracts from clinical learning and enthusiasm for residency. Future research could explore whether overcoming the identified challenges will improve residents' experiences.

RéSUMé: OBJECTIF: Les programmes canadiens de résidence spécialisée sont en train de passer à un modèle hybride de temps et de compétence, soit la compétence par conception (CPC); ce modèle a été élaboré par le Collège royal des médecins et chirurgiens du Canada. Bien qu'il existe une abondante documentation sur la formation médicale fondée sur les compétences (FMFC), peu d'études ont évalué l'expérience des résidentes et résidents après la mise en œuvre de la FMFC. Le but de cette étude était d'obtenir une perspective enrichie quant à l'expérience vécue par les résidents et résidentes. MéTHODE: Nous avons conçu une étude qualitative avec une analyse thématique inductive des données d'entretiens semi-structurés. La population étudiée était composée de résident·es des programmes de formation postdoctorale en anesthésiologie, en médecine interne ou en chirurgie (y compris toutes les surspécialités chirurgicales) à l'Université Dalhousie (Halifax, N.-É., Canada). RéSULTATS: Les personnes interrogées ont identifié les avantages suivants de leurs programmes et de la CPC : le soutien des pairs et des superviseur·es cliniques, une feuille de route pour la résidence, des possibilités de rétroaction officielles et l'évolution du programme. Parmi les inconvénients de la CPC identifiés par les résident·es, mentionnons : un manque de transparence autour de la CPC, une CPC ne correspondant pas à ce qui avait été annoncé, un manque d'adhésion, un fardeau administratif accru, des difficultés à obtenir des preuves de participation à des actes professionnels non supervisés (APNS); le fardeau de la CPC incombant aux résident·es, une rétroaction incohérente, une technologie lourde et un fardeau psychologique important. Les améliorations suggérées par les résident·es comprenaient la réduction du nombre d'APNS, la rationalisation des exigences des APNS, l'augmentation de la transparence et de la communication avec les comités de compétence, l'offre d'incitations et de formation continue aux superviseur·es cliniques, l'amélioration des interfaces électroniques existantes et le développement d'une technologie mieux adaptée aux besoins de la CPC. CONCLUSION: Cette étude souligne que le fardeau administratif et psychologique important de la CPC nuit à l'apprentissage clinique et à l'enthousiasme pour la résidence. Les recherches futures pourraient déterminer si le fait de surmonter les défis identifiés améliorerait l'expérience des résidentes et résidents.

Colorful Luminescent Magnetic Supraparticles: Expanding the Applicability, Information Capacity, and Security of Micrometer-Scaled Identification Taggants by Dual-Spectral Encoding.

(Sub)micrometer-scaled identification (ID) taggants enable direct identification of arbitrary goods, thereby opening up application fields based on the possibility of tracking, tracing, and anti-counterfeiting. Due to their small dimensions, these taggants can equip in principle even the smallest subcomponents or raw materials with information. To achieve the demanded applicability, the mostly used optically encoded ID taggants must be further improved. Here, micrometer-scaled supraparticles with spectrally encoded luminescent and magnetically encoded signal characteristics are reported. They are produced in a readily customizable bottom-up fabrication procedure that enables precise adjustment of luminescent and magnetic properties on multiple hierarchy levels. The incorporation of commonly used magnetic nanoparticles and fluorescent dyes, respectively, into polymer nanocomposite particles, establishes a convenient toolbox of magnetic and luminescent building blocks. The subsequent assembly of selected building blocks in the desired ratios into supraparticles grants for all the flexibility to freely adjust both signal characteristics. The obtained spectrally resolved visible luminescent and invisible magnetic ID signatures are complementary in nature, thus expanding applicability and information security compared to recently reported optical- or magnetic-encoded taggants. Additionally, the introduced ID taggant supraparticles can significantly enhance the coding capacity. Therefore, the introduced supraparticles are considered as next-generation ID taggants.

Impact of a nurse engagement intervention on pain, agitation and delirium assessment in a community intensive care unit.

BACKGROUND: In 2013, the Society of Critical Care Medicine published a revised version of the ICU Pain, Agitation, and Delirium (PAD) guidelines. Immobility and sleep were subsequently added in 2018. Despite the well-established advantages of implementing these guidelines, adoption and adherence remain suboptimal. This is especially true in community settings, where PAD assessment is performed less often, and the implementation of PAD guidelines has not yet been studied. The purpose of this prospective interventional study is to evaluate the effect of a multifaceted nurse engagement intervention on PAD assessment in a community intensive care unit (ICU). METHODS: All patients admitted to our community ICU for over 24 hours were included. A 20-week baseline audit was performed, followed by the intervention, and a 20-week postintervention audit. The intervention consisted of a survey, focus groups and education sessions. Primary outcomes included rates of daily PAD assessment using validated tools. RESULTS: There were improvements in the number of patients with at least one assessment per day of pain (67.5% vs 59.3%, p=0.04), agitation (93.1% vs 78.7%, p<0.001) and delirium (54.2% vs 39.4%, p<0.001), and the number of patients with target Richmond Agitation-Sedation Scale ordered (63.1% vs 46.8%, p=0.002). There was a decrease in the rate of physical restraint use (10.0% vs 30.9%, p<0.001) and no change in self-extubation rate (0.9% vs 2.5%, p=0.2). CONCLUSION: The implementation of a multifaceted nurse engagement intervention has the potential to improve rates of PAD assessment in community ICUs. Screening rates in our ICU remain suboptimal despite these improvements. We plan to implement multidisciplinary interventions targeting physicians, nurses and families to close the observed care gap.

Qualitative descriptive study to explore nurses' perceptions and experience on pain, agitation and delirium management in a community intensive care unit.

OBJECTIVES: The purpose of this study was to explore the experiences, beliefs and perceptions of intensive care unit (ICU) nurses on the management of pain, agitation and delirium (PAD) in critically ill patients. DESIGN: A qualitative descriptive study. SETTING: This study took place in a community hospital ICU located in a medium size Canadian city. PARTICIPANTS: Purposeful sampling was conducted. Participants included full-time nurses working in the ICU. Forty-six ICU nurses participated. METHODS: A total of five focus group sessions were held to collect data. There were one to three separate groups in each focus group session, with no more than seven participants in each group. There were 10 separate groups in total. A semistructured question guide was used. Thematic analysis method was adopted to analyse the data, and to search for emergent themes and patterns. RESULTS: Three main themes emerged: (1) the professional perspectives on patient wakefulness state, (2) the professional perspectives on PAD management of critically ill patients and (3) the factors impacting PAD management. Nurses have different opinions on the optimal level of patient sedation and felt that many factors, including environmental, healthcare teams, patients and family members, can influence PAD management. This potentially leads to inconsistent PAD management in critically ill patients. The nurses also believed that PAD management requires a multidisciplinary approach including healthcare teams and patients' families. CONCLUSIONS: Many external and internal factors contribute to the complexity of PAD management including the attitudes of nursing staff towards PAD. The themes emerged from this study suggested the need of a multifaceted and multidisciplinary quality improvement programme to optimise the management of PAD in the ICU.

Supraparticles with silica protection for redispersible, calcined nanoparticles.

Calcination of nanoparticles is always accompanied by undesired sintering. A calcination route preventing hard-agglomeration to bulk lumps, which is transferable to almost any kind of metal oxide nanoparticle, is developed by surrounding targeted nanoparticles by silica nanoparticles within a nanostructured microparticle. After calcination, the desired nanoparticles are regained as a monodisperse sol via silica dissolution.

Pain, agitation and delirium assessment and management in a community medical-surgical ICU: results from a prospective observational study and nurse survey.

BACKGROUND: Delirium is a common manifestation in the intensive care unit (ICU) that is associated with increased mortality and morbidity. Guidelines suggested appropriate management of pain, agitation and delirium (PAD) is crucial in improving patient outcomes. However, the practice of PAD assessment and management in community hospitals is unclear and the mechanisms contributing to the potential care gap are unknown. OBJECTIVES: This quality improvement initiative aimed to review the practice of PAD assessment and management in a community medical-surgical ICU (MSICU) and to explore the community MSICU nurses' perceived comfort and satisfaction with PAD management in order to understand the mechanisms of the observed care gap and to inform subsequent quality improvement interventions. METHODS: We prospectively collected basic demographic data, clinical information and daily data on PAD process measures including PAD assessment and target Richmond Agitation-Sedation Scale (RASS) score ordered by intensivists on all patients admitted to a community MSICU for >24 hours over a 20-week period. All ICU nurses in the same community MSICU were invited to participate in an anonymous survey. RESULTS: We collected data on a total of 1101 patient-days (PD). 653 PD (59%), 861 PD (78%) and 439 PD (39%) had PAD assessment performed, respectively. Target RASS was ordered by the intensivists on 515 PD (47%). Our nurse survey revealed that 88%, 85% and 41% of nurses were comfortable with PAD assessment, respectively. CONCLUSIONS: Delirium assessment was not routinely performed. This is partly explained by the discomfort nurses felt towards conducting delirium assessment. Our results suggested that improvement in nurse comfort with delirium assessment and management is needed in the community MSICU setting.

Core-Satellite Supraparticles To Ballistically Stamp Nanostructures on Surfaces.

Nanostructured surfaces are of great importance in a very wide range of fields. They can be obtained by imprint or deposition techniques. However, these are usually sophisticated to perform. Generally, it is not easy to equip an object/product with a nanostructure after manufacturing. Yet, it would be very beneficial to achieve a modification of an arbitrary surface with a nanostructure of choice at a later stage by an approach that is simple to perform without the need of sophisticated equipment or excessive treatment by physicochemical methods. Herein, such a process is reported, which combines two "old-fashioned" techniques, namely, sandblasting and rubber-stamping, and translates them to the "nanoworld". By creating core-satellite supraparticles via spray-drying, a ballistic core-satellite stamp particle system is obtained, which can be used to easily transfer a wide range of nanoparticles to a great variety of surfaces to equip these with a nanostructure and subsequently advanced properties. These include water-repellant, antifouling, or antidust surfaces. Moreover, it is also demonstrated that the approach can be used to manufacture well-defined nanoimprinted surfaces. Such surfaces showed an improved spreading behavior for aliphatic alcohols, thus making such surfaces, for instance, very susceptible for disinfectants. All in all, the simple technique described herein has a great potential for creating nanostructured surfaces on nearly any surface.