Clinical Reasoning Curricula in Health Professions Education: A Scoping Review.

OBJECTIVES: This scoping review aimed to explore and synthesize current literature to advance the understanding of how to design clinical reasoning (CR) curricula for students in health professions education. METHODS: Arksey and O'Malley's 6-stage framework was applied. Peer-reviewed articles were searched in PubMed, Web of Science, CINAHL, and manual searches, resulting in the identification of 2932 studies. RESULTS: Twenty-six articles were included on CR in medical, nursing, physical therapy, occupational therapy, midwifery, dentistry, and speech language therapy education. The results describe: features of CR curriculum design; CR theories, models, and frameworks that inform curricula; and teaching content, methods, and assessments that inform CR curricula. CONCLUSIONS: Several CR theories, teaching, and assessment methods are integrated into CR curricula, reflecting the multidimensionality of CR among professions. Specific CR elements are addressed in several curricula; however, no all-encompassing CR curriculum design has been identified. These findings offer useful insights for educators into how CR can be taught and assessed, but they also suggest the need for further guidance on educational strategies and assessments while learners progress through an educational program.

Developing a European longitudinal and interprofessional curriculum for clinical reasoning.

Clinical reasoning is a complex and crucial ability health professions students need to acquire during their education. Despite its importance, explicit clinical reasoning teaching is not yet implemented in most health professions educational programs. Therefore, we carried out an international and interprofessional project to plan and develop a clinical reasoning curriculum with a train-the-trainer course to support educators in teaching this curriculum to students. We developed a framework and curricular blueprint. Then we created 25 student and 7 train-the-trainer learning units and we piloted 11 of these learning units at our institutions. Learners and faculty reported high satisfaction and they also provided helpful suggestions for improvements. One of the main challenges we faced was the heterogeneous understanding of clinical reasoning within and across professions. However, we learned from each other while discussing these different views and perspectives on clinical reasoning and were able to come to a shared understanding as the basis for developing the curriculum. Our curriculum fills an important gap in the availability of explicit clinical reasoning educational materials both for students and faculty and is unique with having specialists from different countries, schools, and professions. Faculty time and time for teaching clinical reasoning in existing curricula remain important barriers for implementation of clinical reasoning teaching.

Flexible interprofessional student encounters based on virtual patients: a contribution to an interprofessional strategy.

It is challenging to organize interprofessional activities in terms of coordinating students' various schedules. These challenges can be overcome by providing flexible online opportunities based on virtual patients (VPs). This study set out to study feasibility of using a blended approach based on virtual patients and a flexible interprofessional student encounter. The encounter was arranged in pairs or triads between nursing and medical students from two separate courses. Data were gathered through a questionnaire and followed up with group interviews. Reflective texts from the interprofessional encounters were analyzed in relation to descriptions of interprofessional competence. The great majority (86%) chose to meet online due to its flexibility. The participants gained an understanding of the other profession's roles and competences and a holistic patient awareness. Given its flexible and scalable opportunities, the blended online virtual patient approach provides a valuable contribution to an interprofessional programme.

Using interviews and observations in clinical practice to enhance authenticity in virtual patients for interprofessional education.

BACKGROUND: Interprofessional collaboration is increasingly important in healthcare, but interprofessional education (IPE) faces challenges, such as different study programmes with varied schedules and campuses. These challenges can be met, in part, by using web-based virtual patients (VPs) as a tool in IPE. However, demands for relevant patient presentations and clinical practice increase when VPs are used by students from different programmes. The aim of this study was to improve the presentation of professional perspectives regarding nurses and physicians and their collaboration in order to increase the clinical authenticity of existing VPs. METHODS: Clinical observations were conducted to gain familiarity with the context. Semi-structured interviews were performed with individual nurses and physicians with experience of patients with leg ulcers. The interviews were recorded, transcribed and analysed using thematic analysis. RESULTS: The clinical observations exposed a lack of interprofessional collaboration in practice with regard to patients with leg ulcers. The interview analysis resulted in two themes: Clinical care and Organizational structure. The theme Clinical care included nursing with a holistic approach to the patient and awareness of the patient's well-being, including nutrition and home situation. The theme Organizational structure revealed a lack of teamwork in primary care. The interviewees stressed learning together and sharing responsibility, and they emphasised the importance of implementing interprofessional learning in the education of nurses and physicians in order to stimulate future teamwork. The VP should offer a broad medical history so that healthcare students are made aware of how a disease can affect the patient's social situation, and thereby illustrate the importance of interprofessional collaboration. The information should also be comprehensive and clear, leading to a diagnosis, so the student can gain clinical knowledge and build a foundation for discussion of treatment. CONCLUSIONS: Interviews and observations in clinical practice can be used to enhance authenticity in VPs for interprofessional learning. A thorough look at authentic clinical environments can enrich and improve educational settings using VPs, and it can highlight the challenges students can encounter in clinical care of the patient and in an organisation with regard to interprofessional collaboration.

General practitioners' knowledge of leg ulcer treatment in primary healthcare: an interview study.

AIM: To describe general practitioners' (GPs') knowledge and the development of their knowledge regarding leg ulcer treatment when treating patients with leg ulceration at primary healthcare centers. BACKGROUND: Earlier research regarding GPs' knowledge of leg ulcer treatment in a primary healthcare context has focused primarily on the assessment of wounds and knowledge of wound care products. Less is known about GPs' understandings of their own knowledge and knowledge development regarding leg ulceration in the everyday clinical context. This study, therefore, sets out to highlight these aspects from the GPs' perspective. METHODS: Semi-structured interviews were conducted with 16 individual GPs working at both private and county council run healthcare centers. The data were analyzed inductively using a thematic analysis. RESULTS: Four themes were identified. 'Education and training' describe the GPs' views regarding their knowledge and knowledge development in relation to leg ulcer treatment. 'Experience' refers to GPs' thoughts about the importance of clinical experience when treating leg ulcers. 'Prioritization' describes the issues GPs raised around managing the different knowledge areas in their clinical work. 'Time constraints' explore the relationship between GPs' sense of time pressure and their opportunities to participate in professional development courses. CONCLUSIONS: The study shows that the GPs working in primary healthcare are aware of the need for ongoing competence development concerning leg ulceration. They describe their current knowledge of leg ulcer treatment as insufficient and point to the lack of relevant courses that are adapted for their level of knowledge and the limited opportunities for clinical training.

Characteristics of two questionnaires used to assess interprofessional learning: psychometrics and expert panel evaluations.

BACKGROUND: Interprofessional learning activities are included in many curricula but are difficult to assess. For languages that are not widely spoken such as Swedish, few validated questionnaires exist that relate to interprofessional outcomes. Therefore, the aim was to examine two such questionnaires in relation to interprofessional competence domains. METHODS: Psychometric characteristics, such as homogeneity of items and internal consistency, were assessed for the Swedish versions of the Jefferson Scale of Attitudes Towards Physician-Nurse Collaboration (JSAPNC) and the Readiness for Interprofessional Learning Scale (RIPLS). The questionnaires were distributed directly following IPL activities. Mokken scale analysis based on Loevinger's coefficient for homogeneity and Cronbach's alpha were used to evaluate the scales. Two expert panels performed a qualitative analysis of items in relation to four internationally defined interprofessional competences. RESULTS: In total, 88 and 84 responded to the JSAPNC and RIPLS questionnaires, respectively. Estimates of homogeneity were low for both the JSAPNC (H = 0.16) and the RIPLS (H = 0.21). Reliabilities were weak (0.62 and 0.66, respectively) for the total scales. The expert panels categorised 68% of items into similar competence domains. However, their discussion revealed ambiguous wordings and imbalances in the two questionnaires in relation to domains. CONCLUSION: Interprofessional competence domains are defined but few validated tools exist to assess them. Examined tools relating to interprofessional learning in Swedish do not qualify for assessing overarching IPL outcomes, and summed scores from these tools should be used with caution.

Attitudes and perceptions from nursing and medical students towards the other profession in relation to wound care.

Lack of nurse‒physician collaboration in wound care may result in prolonged healing times for patients. In order to facilitate future professional collaboration, undergraduate learning activities in interprofessional education (IPE) have been proposed. The aim of this study was to investigate nursing and medical students' attitudes and perceptions towards each other's future professions and interprofessional collaboration in wound care. Nursing and medical students took part in an interprofessional learning activity about wound care. Data were collected using the Jefferson Scale of Attitudes towards Physician‒Nurse Collaboration questionnaire to student groups before and after an IPE activity (pooled n = 221). Focus groups were conducted to deepen the knowledge about students' attitudes and perceptions. The results showed high scores on the attitude scale (mean 53.2, possible maximum = 60) both before and after IPE, indicating positive attitudes towards nurse‒physician collaboration. Nursing students scored higher than medical students both pre-IPE (p < 0.001) and post-IPE (p = 0.006). However, no difference on scale scores could be identified between pre- and post-IPE. The following themes emerged in the analysis of focus group discussions: "Approaching patient care from different perspectives," "Need for collaboration and clear professional roles in practice," "Structures hindering future collaboration," and "IPE as a tool for professional practice and roles." The shared learning activity provided insights into the other profession's competence. This kind of learning activity may increase future interprofessional collaboration, and thus, improve wound care.

Vitamin D levels after UVB radiation: effects by UVA additions in a randomized controlled trial.

BACKGROUND: Ultraviolet B (UVB) radiation increases the serum level of 25-hydroxyvitamin D [25(OH)D]. However, the impact of UVA on vitamin D synthesis by UVB is poorly understood clinically. OBJECTIVE: To examine how different combinations of UVA and UVB radiation affect S-25(OH)D for the same vitamin D-weighted exposure. MATERIALS AND METHODS: Healthy participants were recruited and subsequently divided into four comparable groups regarding initial 25(OH)D value. The different radiations given were whole-body UVB (n = 23), UVAB (n = 23) and UVA (n = 10). The controls (n = 19) had no intervention. The exposure times were chosen to give the same calculated vitamin D effective dose (suberythemal exposures ≤1 standard erythema dose). Blood samples were collected before the first irradiation (t0), immediately after the last (fifth) irradiation (t1) and then after another 2 days after the last (fifth) irradiation (t2). RESULTS: UVB and UVAB radiation significantly increased 25(OH)D levels. In the UVA group the increase was less with the same vitamin D-weighted radiation dose. CONCLUSIONS: Short sessions of UVB or UVAB radiation with the same vitamin D-weighted exposure increased 25(OH)D levels. The UVA dose does not influence 25(OH)D levels under short exposure times. However, there was a significantly lower increase of 25(OH)D levels during longer UVA irradiation (≥9 min).

Previous extensive sun exposure and subsequent vitamin D production in patients with basal cell carcinoma of the skin, has no protective effect on internal cancers.

BACKGROUND: It has been suggested that sunlight through production of vitamin D might have a protective effect on a number of internal cancers. Consequently, in spite of the well known skin cancer risks, some researchers advocate more exposure to ultraviolet radiation, supported by the solarium industry. We estimated the risk of internal cancer before the patient contracted a basal cell carcinoma (BCC) of the skin, the most common cancer in white populations and strongly associated with extensive sun exposure. METHODS: A nested case control study was undertaken in the whole Swedish population. 115,016 patients with BCC and 987,893 controls were linked to population based registers. FINDINGS: The cases had an increased risk of getting another form of cancer before the BCC diagnosis: odds ratio (OR)=1.84; 95% confidence interval (CI) 1.81-1.86. This risk was mainly due to skin cancer: OR=4.95; 95% CI 4.81-5.09 but also non-skin cancer risk was elevated: OR=1.37; 95% CI 1.35-1.39. We adjusted the estimates for age, level of income, occupational status in national censuses, place of living and sex, where appropriate. Of the cancers specifically suggested to be related to vitamin D status: colon, prostate, breast, and ovary cancer, all had slightly increased ORs whilst for pancreatic and gastric cancer no increased OR was found. INTERPRETATION: Patients with BCC, a proxy for extensive sun exposure, run an increased risk of other forms of cancer prior to the diagnosis of BCC. The findings in this study contradict that vitamin D production through extensive sun exposure has any protective effect on internal cancer but emphasise the increased risk for skin cancer.

Antiviral therapy in children with hydroa vacciniforme.

Hydroa vacciniforme is a rare, usually quite severe, photo-dermatosis. Association with Epstein-Barr virus infection and a possibly increased risk of lymphoproliferative malignancy have been demonstrated. We describe here four patients with Epstein-Barr virus-associated hydroa vacciniforme treated with acyclovir/valacyclovir therapy with a good clinical response. The children were reported to have less fatigue, fewer eruptions, less scarring, and increased ability to spend time outdoors without provoking new eruptions. This was also in agreement with clinical observations. However, one patient progressed into an anaplastic lymphoma kinase-1-negative anaplastic large-cell lymphoma in the upper jaw. This was preceded by an increase in EBV viral load. Acyclovir/valacyclovir therapy is a safe treatment. Further studies are required to confirm these results.