Care complexity, perceptions of complexity and preferences for interprofessional collaboration: an analysis of relationships and social networks in paediatrics.

BACKGROUND: In the context of increasingly intricate healthcare systems, professionals are compelled to collaborate within dynamically changing interprofessional teams. Moreover, they must adapt these collaborative processes to effectively and efficiently manage the evolving complexity of care needs. It remains unclear how professionals determine care complexity and relate this complexity to their preferences for interprofessional collaboration (IPC). This study investigated the relationships between care complexity, professionals' perceived complexity and IPC preferences, and examined the variation in individual and team characteristics of IPC-practices across different levels of complexity in paediatric care. METHODS: In an online questionnaire, 123 healthcare professionals working at an academic tertiary children's hospital scored their perceptions of complexity and preferences for IPC. They also selected family and various professions as members of the interprofessional (IP-) team based on thirteen patient cases. We employed conjoint analysis to systematically model the complexity of case descriptions across the five domains of the International Classification of Functioning, Disability and Health (ICF). Additionally, we applied social network analysis to identify important professions, crucial connectors and influential professions in the IP-team, and to describe the cohesiveness of IP-teams. RESULTS: Modelled case complexity, professionals' perceived complexity and IPC preferences were positively associated. We found large inter-individual variations in the degree of these associations. Social network analysis revealed that the importance and influence of professions was more equally distributed when case complexity increased. Depending on the context and complexity of the case, different professions (e.g. medical doctors, social professionals, extramural professionals) were considered to be more crucial connectors within the IP-team. Furthermore, team cohesion was positively associated with modelled and perceived care complexity. CONCLUSIONS: In conclusion, our study contributes to the existing knowledge by integrating task-specific insights and broadening the use of conjoint and social network analysis in the context of IPC. The findings substantiate the contingency theory that relates characteristics of IPC to care complexity, offering quantified insights into how IP-teams adapt to situational needs. This understanding of relationships and variations within IPC holds crucial implications for designing targeted interventions in both clinical and health profession education contexts. Consequently, it contributes to advancements in healthcare systems.

Opening the black box of team-based learning (TBL): A study of verbal interactions in online application sessions.

CONTEXT: In team-based learning (TBL), an instructional strategy that encourages in-depth team discussion and deep learning, interactions in terms of sharing, co-construction, constructive conflict and procedural interactions are important. Since TBL has also been applied online in recent years, the question is whether these interactions are sufficiently present in an online setting. AIM: Gain insight into the nature and extent of these types of interactions in online TBL application sessions and to what extent these vary between teams and sessions. METHODS: We made audiovisual recordings of 12 TBL teams in two online application sessions during assignments. Transcripts were coded and analyzed using a framework derived. RESULTS: Teams spent more than 85% of their time on all four types of interactions in both sessions. The largest proportion of time was spent on sharing and co-construction. Constructive conflict occurred to a limited extent. We observed variation in proportion of time spent on and the distribution of the four types of interactions between teams and sessions. DISCUSSION: All interactions important for achieving deep learning occurred in online TBL application sessions. However, the effective use of these types of interaction should not be left to chance.

Team-based learning (TBL): Each phase matters! An empirical study to explore the importance of each phase of TBL.

CONTEXT: In Team Based Learning (TBL), it is, based on theory, assumed that knowledge development in each phase contributes to the subsequent phase and to learning performance. However, there is no empirical evidence for this assumption. AIM: In order to find support for the relation between TBL and the underlying theory, we determined to what extent each phase of TBL is associated with the knowledge development in the next phase and with the total learning performance. METHODS: We measured the scientific concepts recalled by 56 second-year undergraduate medical students before TBL, after each of the three phases and after TBL. We used multivariate regression analysis to determine the statistical association between the phases as well as the total learning performance. RESULTS: Results showed that in each phase, students produced new concepts in addition to those previously recalled. Regression models showed statistically significant explained variance ranging from 0.19 to 0.26, between the three phases and the total learning performance. DISCUSSION: Each phase of the TBL is significantly associated with knowledge development in the subsequent phase and with the total learning performance, and therefore matters. This study contributes to the scientific underpinning of TBL and offers leads to more elaborate research and interventions to improve TBL.

How nursing students' placement preferences and perceptions of community care develop in a more 'community-oriented' curriculum: a longitudinal cohort study.

BACKGROUND: Extramuralisation in healthcare has influenced medical and nursing curricula internationally with the incorporation of themes related to primary/ community care. Despite this, students do not easily change their career preferences. The hospital is still favourite, leading to labour market shortages in extramural care. This study investigates how baccalaureate nursing students' perceptions of community care and placement preferences develop over time in a more 'community-care-oriented' curriculum, to gain insights on which curriculum elements potentially influence career choices. METHODS: A nursing student cohort of a University of Applied Sciences in the Netherlands (n = 273) underwent a new four-year curriculum containing extended elements of community care. The primary outcome was assessed with the Scale on Community Care Perceptions (SCOPE). Data were collected each year of study. Descriptive statistics were used to investigate students' placement preferences and perceptions, and linear mixed model techniques (LMMs) for measuring how students' perceptions develop over time. Patterns of placement preferences at individual level were visualised. RESULTS: Students' perceptions of community care, as measured with SCOPE, show a slight decrease between year 1 and 4, while items mutually differ substantially. In contrast, the preference of community care for a placement increases from 2.6% in year 1 tot 8.2% in year 4. The hospital is favourite in year 1 (79.8%), and remains most popular. At individual level, students often change placement preferences, although a preference for the hospital is more consistent. The LMMs indicates that, at the four time-points, the estimated marginal means of students' perceptions fluctuate between 6 and 7 (range 1-10). A placement in community care did not positively influence students' perceptions, and an intensive 1 week theoretical programme was only temporarily influential. CONCLUSIONS: Although interest for placement in community care increased substantially, it was not clear which curriculum elements stimulated this, nor did the curriculum positively influence students' perceptions. As most students do not look forward to the high responsibility of the field, other curricula with educational tracks for more mature students/ nurses with a vocational training may be an alternative contribution to solving the labour market problems in community care.

Influencing nursing students' perceptions of community care with curriculum-redesign; a quasi-experimental cohort study.

BACKGROUND: The shift in healthcare to extramural leads to more patients with complex health problems receiving nursing care at home. However, the interest of baccalaureate nursing students for community nursing is moderate, which contributes to widespread labour-market shortages. This study investigates the effect of a more 'community-care-oriented' curriculum on nursing students' perceptions of community care. METHODS: A quasi-experimental quantitative survey study with a historic control group (n = 477; study cohorts graduating in 2015, 2016, and 2017; response rate 90%) and an intervention group (n = 170; graduating in 2018; response rate 93%) was performed in nursing students of a University of Applied Sciences in a large city in the Netherlands. The intervention group underwent a new curriculum containing extended elements of community care. The primary outcome was assessed with the Scale on Community Care Perceptions (SCOPE). The control and intervention group were compared on demographics, placement preferences and perceptions with a chi-square or T-test. Multiple regression was used to investigate the effect of the curriculum-redesign on nursing students' perceptions of community care. RESULTS: The comparison between the control and intervention group on students' perceptions of community care shows no significant differences (mean 6.18 vs 6.21 [range 1-10], respectively), nor does the curriculum-redesign have a positive effect on students' perceptions F (1,635) = .021, p = .884, R2 = < .001. The comparison on placement preferences also shows no significant differences and confirms the hospital's popularity (72.7% vs 76.5%, respectively) while community care is less often preferred (9.2% vs 8.2%, respectively). The demographics 'working in community care' and 'belonging to a church/religious group' appear to be significant predictors of more positive perceptions of community care. CONCLUSIONS: Graduating students who experienced a more 'community-care-oriented' curriculum did not more often prefer community care placement, nor did their perceptions of community care change. Apparently, four years of education and placement experiences have only little impact and students' perceptions are relatively static. It would be worth a try to conduct a large-scale approach in combination with a carefully thought out strategy, based on and tying in with the language and culture of younger people.

Thiamine Levels During Intensive Insulin Therapy in Critically Ill Patients.

INTRODUCTION: Thiamine is an essential cofactor in carbohydrate metabolism, and deficiency can therefore cause various organ dysfunctions. Little is known about the prevalence and possible worsening of thiamine deficiency in critically ill patients. In this study, we investigated the prevalence of thiamine deficiency at admission to the intensive care unit (ICU) and hypothesized that intensive insulin therapy, aimed at regulating glucose levels, increases thiamine utilization and therefore might cause or worsen deficiency in patients with limited thiamine stores. MATERIALS AND METHODS: An observational prospective cohort study was carried out in a medical-surgical ICU in a general teaching hospital in Apeldoorn, the Netherlands. All adults who were treated during that time with intensive insulin therapy were included. Deficiency was defined as a thiamine level <100 nmol/L. No thiamine supplementation was administered except for normal amounts present in standard enteral feeding. RESULTS: A total of 58 patients were available for analysis. Median thiamine level at admission was 111 nmol/L. Deficiency was present in 39.7% of patients and was significantly associated with the presence of gastrointestinal pathology and with recent surgery. Thiamine levels increased a median of 14 nmol/L in 48 hours. Only 3.4% of patients showed a predefined relevant decline in thiamine levels. CONCLUSION: Intensive insulin therapy does not appear to cause or worsen thiamine deficiency. However, based on the high prevalence of deficiency at admission, it might be warranted to supplement thiamine in all patients admitted to the ICU, especially when there is an underlying gastrointestinal disease or recent surgery.

Incident and error reporting systems in intensive care: a systematic review of the literature.

PURPOSE: We performed a systematic review to assess (i) to what extent incident reporting systems (IRSs) on the adult intensive care unit (ICU) meet the criteria of the WHO Draft Guidelines for Adverse Event Reporting and Learning Systems, (ii) to what extent the IRSs comply with the four aspects of the iterative quality loop and (iii) whether IRSs have led to improvement measures in clinical practice. DATA SOURCES: The authors searched multiple electronic databases from 1966 until 26 June 2014. STUDY SELECTION: Studies were included if they reported incident reporting systems on the adult ICU. DATA EXTRACTION: Data on study design, characteristics of the incident reporting system, implementation, feedback and improvement measures were collected using structured data extraction forms. RESULTS OF DATA SYNTHESIS: A total of 2098 studies were identified and 36 studies reported IRSs on the adult ICU. Studies were divided into: ICU-specific IRSs and general IRSs. Items of the WHO checklist were assessed and categorized into the four phases of the iterative quality loop. CONCLUSION: None of the IRSs completely fulfilled the WHO checklist criteria. With respect to the iterative loop, data input and data collection are well established but not much attention was given to analyzing incidents and to give feedback. This resulted in an administrative report system, rather than the much desired instrument for change of practice and increase of quality as an IRS can only effectively contribute to improve patient safety and quality of care if more attention is given to analyzing incidents and feedback.

Ambulance Transfer in Case of Postpartum Hemorrhage after Birth in Primary Midwifery Care in The Netherlands: A Prospective Cohort Study.

BACKGROUND: The objective of this prospective cohort study was to assess whether the 45-minute prehospital limit for ambulance transfer is met in case of postpartum hemorrhage (PPH) after midwifery-supervised home birth in The Netherlands and evaluate the process of ambulance transfer, maternal condition during transfer, and outcomes in relation to whether this limit was met. METHODS: Using ambulance report forms and medical charts, ambulance intervals, urgency coding, clinical condition (using the lowest Revised Trauma Score, [RTS]), and maternal outcomes were collected. From April 2008 to April 2010, midwives reported 72 cases of PPH. Associations between duration of the ambulance transfer, maternal condition during ambulance transfer and outcomes were analyzed. The main outcome measures were duration of ambulance transfer, RTS, blood loss, surgical procedures, and blood transfusions. RESULTS: Seventy-two cases were reported, 18 (25%) were excluded: 54 cases were analyzed. In 63 percent, the 45-minute prehospital limit was met, 75.9 percent received a RTS of 12, indicating optimal Glasgow Coma Scale, systolic blood pressure, and respiratory frequency. In 24.1 percent a decrease in systolic blood pressure was found (RTS 10 or 11). We found no difference in outcomes between women with different RTS or in whom the 45-minute prehospital limit was or was not met. CONCLUSIONS: We found no relation between the duration of ambulance transfer and maternal condition or outcomes. All women fully recovered. The low-risk profile of women in primary care, well-organized midwifery, and ambulance care in The Netherlands are likely to contribute to these findings.

Generalized joint hypermobility in professional dancers: a sign of talent or vulnerability?

OBJECTIVE: To study the impact of generalized joint hypermobility (GJH) in professional dancers on physical fitness, musculoskeletal complaints and psychological distress. METHODS: Thirty-six professional dancers were recruited and compared with control subjects (mean age 20.1, range 17-27). Height, weight, Beighton score, physical fitness (walking distance, muscle strength, estimated VO2max), musculoskeletal complaints (pain, fatigue) and psychological distress (anxiety, depression) were measured. RESULTS: Univariate analysis revealed, in between-group analysis, that dancers (with and without GJH) had higher physical fitness [the six-minute walk test (6MWT): ΔD = +8.4%, P = 0.001; VO2max: ΔD = +12.8%, P = 0.01], fatigue (checklist individual strength: ΔD = +80.3%, P < 0.0001) and greater psychological distress (Hospital Anxiety and Depression Scale: ΔD = +115.0%, P < 0.0001). When comparing dancers and control subjects with GJH to those without GJH, lower levels of physical fitness (muscle strength: ΔD = -11.3%, P < 0.0001; 6MWT: ΔD = -9.9%, P < 0.0001), more fatigue (checklist individual strength: ΔD = +84.4%, P < 0.0001) and greater psychological distress (Hospital Anxiety and Depression Scale: ΔD = +79.6%, P < 0.0001) were observed in subjects with GJH. Multivariate analysis showed that dancers have higher levels of physical fitness (6MWT, P = 0.001; VO2max, P = 0.020); however, when taking GJH into account, this advantage disappeared, indicating lower levels of physical fitness in comparison with control subjects (6MWT, P = 0.001; muscle strength, P < 0.0001; VO2max, P = 0.040). Dancers experienced more fatigue (P = 0.001) and psychological distress (P < 0.0001). This was associated with even more fatigue (P = 0.010) and psychological distress (P = 0.040) when GJH was present. CONCLUSION: Dancers with GJH seem more vulnerable to musculoskeletal and psychological complaints. In addition, GJH was also associated with lower physical fitness, despite training. Caregivers for professional dancers should monitor closely the physical capabilities and the amount of psychological strain.

Perception of oral health related quality of life and orofacial aesthetics following restorative treatment of tooth wear: A five-year follow-up.

OBJECTIVES: Non-carious tooth wear often has a multifactorial etiology and may lead to functional or aesthetically related problems. The most common complaints associated with tooth wear are dissatisfaction with dental appearance and a negative impact on the experienced Oral Health Related Quality of Life (OHRQoL). The aim of this study was to investigate the change in OHRQoL and the perception of aesthetics, following restorative treatment of moderate to severe tooth wear patients, with a five-year follow-up. METHODS: An explorative study, based on prospective data, was performed. OHRQoL and the perception of aesthetics were measured with the OHIP-NL and OES-NL. These questionnaires were completed before treatment, one month after treatment, and at 1-, 3- and 5-years post-treatment. Treatment involved full mouth reconstruction with composite resin restorations. The data was analysed as repeated measures by using a linear mixed-effects model. RESULTS: One hundred and twenty-three tooth wear patients that received restorative rehabilitation were included (97 males, 26 females, 37.5 ± 8.8 years-old). Data showed a statistically significant increase in both experienced OHRQoL and orofacial appearance after restorative treatment. The OHIP-scores remained stable over time, while the OES-scores slightly decreased during the years after treatment. Regarding the seven domains of the OHIP, the largest difference in OHIP-score was found in the domain of 'Psychological Discomfort'. The mean overall OHIP-score was 1.8 at baseline and 1.3 at the 5-years recall. The mean OES score increased from 41.8 at baseline to 66.1 at the 5-years follow-up. CONCLUSIONS: Tooth wear patients reported significant improvements in their OHRQoL and their perception of orofacial aesthetics after restorative treatment. This increase remained at least five years post-treatment. CLINICAL SIGNIFICANCE: The clinical impact of restorative treatment for tooth wear patients is considerable. This paper emphasizes the need to include a discussion of the patient related outcome measures when planning care.

The effect of a more community-oriented curriculum on nursing students' intervention choice in community care: A quasi-experimental cohort study.

AIM: The aim of this study is to investigate the effect of a more 'community-oriented' baccalaureate nursing curriculum on students' intervention choice in community care. BACKGROUND: Following a healthcare shift with increased chronic diseases in an ageing patient population receiving care at home, nursing education is revising its curricula with new themes (e.g., self-management) on community care. Although it seems obvious that students incorporate these themes in their nursing care interventions, this is unclear. This study investigates the effect of a redesigned curriculum on students' care intervention choice in community nursing. DESIGN: A quasi-experimental quantitative study. METHODS: This study with an historic control group (n = 328; study cohorts graduating in 2016 and 2017; response rate 83 %) and an intervention group n = 152; graduating in 2018; response rate 80 %) was performed at a University of Applied Sciences in the Netherlands. The intervention group experienced a curriculum-redesign containing five new themes related to community care (e.g., enhancing self-management, collaboration with the patients' social network, shared decision making, using health technology and care allocation). The primary outcome 'intervention choice in community nursing' was assessed with a specially developed vignette instrument 'Assessment of Intervention choice in Community Nursing' (AICN). Through multiple regression analyses we investigated the effect of the curriculum-redesign on students' intervention choice (more 'traditional' interventions versus interventions related to the five new themes). The control and intervention groups were compared on the number of interventions per theme and on the number of students choosing a theme, with a chi-square or T-test. RESULTS: Students who studied under the more community-oriented curriculum chose interventions related to the new themes significantly more often, F(1461) = 14.827, p = <0.001, R2 = .031. However, more traditional interventions are still favourite (although less in the intervention group): 74.5 % of the chosen interventions in the historic control group had no relation with the new curriculum-themes, vs. 71.3 % in the intervention group; p = .055). CONCLUSIONS: Students who experienced a more 'community-oriented' curriculum were more likely, albeit to a limited extent, to choose the new community care themes in their caregiving. Seeing this shift in choices as a step in the right direction, it can be expected that the community care field in the longer term will benefit from these better skilled graduates.

Additional preconditioning program for bariatric surgery: Any benefits? A large cohort study.

Postbariatric outcomes may improve by providing an additional preconditioning program (APP) in targeted patients. However, APPs are a demand for health resources while only little and inconsistent evidence consists to support their effectiveness. This cohort study aims to evaluate the effectiveness of APP, by comparing outcomes of patients with and without such APP. We carried out a retrospective single-centre cohort study in a before-after design. Patients signing up for primary gastric bypass or sleeve gastrectomy and eligible for surgery were included if screened as vulnerable patients. Vulnerable patients screened between September 2017 and March 2018 followed an APP and formed the APP-group. Due to a policy change, APPs were no longer performed since September 2018. Vulnerable patients screened between September 2018 and March 2019 thus did not receive an APP (comparator-group). Multidisciplinary follow-up remained unchanged. Endpoints included percentage total weight loss (%TWL), bodyweight, evolution of comorbidities, protein intake, and number of no-shows. The APP-group comprised 231 patients and the comparator-group 153. %TWL differed statistically significantly at 7 (Δ1.5%, p = .01) and 12 months postoperative (Δ2.8%, p < .01) in favour of the comparator-group, as did bodyweight 12 months postoperative (Δ1.8 kg, p < .01). Statistically significant differences were also found in the evolution of comorbidities, protein intake, and the number of no-shows, most in favour for the comparator-group. APP proofed not to be superior to Non-App. It is debatable whether statically significant differences are clinically relevant given their small magnitude. A care pathway without an APP seems at least as effective as a care pathway without.

Safe early discharge for patients undergoing high dose chemotherapy with or without stem cell transplantation: a prospective analysis of clinical variables predictive for complications after treatment.

AIM: To identify which patient groups can be safely discharged early after high dose chemotherapy. BACKGROUND: Until recently, the standard of care for patients with haematological malignancies who have been treated with high dose chemotherapy has been to hospitalise them until neutrophil recovery and clinical improvement. Over the past years, a more liberal approach has resulted in a tendency to discharge patients earlier. However, currently it is unclear which clinical variables are important and which patient groups are most suitable to be discharged early. DESIGN: Prospective cohort study. METHODS: The study group of 55 patients underwent 82 admission periods for a total of 2269 patient days, which could be classified into four categories: induction treatment, consolidation treatment and autologous or allogeneic stem cell transplantation. Different clinical variables potentially interfering with early discharge were subsequently analysed for their association with each treatment group. RESULTS: The median duration of admission was 27 days. The incidence of fever (82.9%) and use of intravenous antibiotics (79.3%) was high in all treatment groups. The only statistically significant differences between groups were found for performance status and mucositis. In the patient group undergoing consolidation chemotherapy for acute myeloid leukaemia, the performance status was better and mucositis was less severe. The decline in performance status and the severity of mucositis were as expected most obvious 10-14 days after the start of chemotherapy. CONCLUSION: Patients undergoing consolidation chemotherapy appear to be the most suitable candidates for early discharge, especially in the first-week postchemotherapy treatment. Early discharge can also be considered in patients with a good performance status in the autologous stem cell transplantation group, directly after transplantation. RELEVANCE TO CLINICAL PRACTICE: An important factor in developing an early discharge programme is a good infrastructure, both at home and in the hospital.

Kashin Beck Disease: more than just osteoarthrosis: a cross-sectional study regarding the influence of body function-structures and activities on level of participation.

The purpose of this study was to investigate the influence of body function, activities and pain on the level of activity in adults with Kashin Beck Disease (KBD). Seventy-five KBD patients with a mean age of 54.8 years (SD 11.3) participated. Anthropometrics, range of joint motion (ROM) and muscle strength were measured as well as the time-up-and-go test and functional tests for the lower and upper extremities. Activity was assessed with the participation scale and the WHO DAS II. In the shoulder, elbow, hip and knee joints, a severe decrease in ROM and bilateral pain was noted. A decrease in muscle strength was observed in almost all muscles. The timed-up-and-go test scores decreased. No or mild restriction in activity was found in 35%, and 33% experienced a moderate restriction whereas 32% had severe to extreme restriction. Activities in the lower extremities were mildly to moderately correlated to ROM and muscle strength, whereas in the upper extremities activities were correlated to range of joint motion. Activity was significantly associated with ROM after correction for muscle strength, gender and age. Participation was borderline significantly associated with ROM after correction for muscle strength, gender, age and the activity time-up-and-go. In KBD adults, a severe decrease in activity is primarily caused by decrease in ROM. These findings have strong influence on rehabilitation and surgical intervention.

Diagnostic accuracy of emergency nurse practitioners versus physicians related to minor illnesses and injuries.

INTRODUCTION: Our objectives were to determine the incidence of missed injuries and inappropriately managed cases in patients with minor injuries and illnesses and to evaluate diagnostic accuracy of the emergency nurse practitioners (ENPs) compared with junior doctors/senior house officers (SHOs). METHODS: In a descriptive cohort study, 741 patients treated by ENPs were compared with a random sample of 741 patients treated by junior doctors/SHOs. Groups were compared regarding incidence and severity of missed injuries and inappropriately managed cases, waiting times, and length of stay. RESULTS: Within the total group, 29 of the 1,482 patients (1.9%) had a missed injury or were inappropriately managed. No statistically significant difference was found between the ENP and physician groups in terms of missed injuries or inappropriate management, with 9 errors (1.2%) by junior doctors/SHOs and 20 errors (2.7%) by ENPs. The most common reason for missed injuries was misinterpretation of radiographs (13 of 17 missed injuries). There was no significant difference in waiting time for treatment by junior doctors/SHOs versus ENPs (20 minutes vs 19 minutes). The mean length of stay was significantly longer for junior doctors/SHOs (65 minutes for ENPs and 85 minutes for junior doctors/SHOs; P < .001; 95% confidence interval, 72.32-77.41). DISCUSSION: ENPs showed high diagnostic accuracy, with 97.3% of the patients being correctly diagnosed and managed. No significant differences between nurse practitioners and physicians related to missed injuries and inappropriate management were detected.

The number of smokers needed to screen and treat in a smoking cessation programme.

OBJECTIVE: Smoking cessation is an important factor in reducing cardiovascular mortality, but considerable effort is needed to successfully persuade patients to quit smoking. We studied the efficiency of the Minimal Intervention Strategy (C-MIS) in addition to nicotine replacement therapy (NRT) for smoking cessation in cardiovascular outpatients in relation to the outcome of mortality. DESIGN: Prospective cohort data studying the C-MIS in three outpatient clinics: cardiology, vascular surgery and vascular medicine. METHODS: Two thousand, two hundred and seventy-five consecutive patients attending the clinics for first or routine follow-up visits were screened for atherosclerosis and smoking. The efficiency of the C-MIS was expressed as the number of smokers needed to screen and needed to treat in relation to the number of deaths prevented over a 5-year period. Mortality estimates were derived from the literature. RESULTS: One thousand, four hundred and thirty-one patients were screened at first-time follow-up visits and 1294 at routine follow-up visits. With a rate of effectiveness of 4.3% for the C-MIS, the number needed to treat was 240 (min-max: 64-infinity) to prevent one death. The corresponding number needed to screen was 687 (min-max: 141-infinity) in the cardiology clinic, 574 (min-max: 134-infinity) in the vascular surgery clinic and 444 (min-max: 90-infinity) in the vascular medicine clinic. Within 5 years, 10 (min-max: 0-58) deaths could be prevented in all three clinics together. With the effectiveness of the C-MIS for first-time and routine follow-up attendees, only six (min-max: 0-36) and zero (min-max: 0-25) deaths could be prevented, respectively. CONCLUSION: In terms of the efficiency of the C-MIS in addition to nicotine replacement therapy, there is some benefit for first-time attendees and no benefit for routine follow-up attendees in preventing death.

Nurses' critical event risk assessments: a judgement analysis.

AIMS: To explore and explain nurses' use of readily available clinical information when deciding whether a patient is at risk of a critical event. BACKGROUND: Half of inpatients who suffer a cardiac arrest have documented but unacted upon clinical signs of deterioration in the 24 hours prior to the event. Nurses appear to be both misinterpreting and mismanaging the nursing-knowledge 'basics' such as heart rate, respiratory rate and oxygenation. Whilst many medical interventions originate from nurses, up to 26% of nurses' responses to abnormal signs result in delays of between one and three hours. METHODS: A double system judgement analysis using Brunswik's lens model of cognition was undertaken with 245 Dutch, UK, Canadian and Australian acute care nurses. Nurses were asked to judge the likelihood of a critical event, 'at-risk' status, and whether they would intervene in response to 50 computer-presented clinical scenarios in which data on heart rate, systolic blood pressure, urine output, oxygen saturation, conscious level and oxygenation support were varied. Nurses were also presented with a protocol recommendation and also placed under time pressure for some of the scenarios. The ecological criterion was the predicted level of risk from the Modified Early Warning Score assessments of 232 UK acute care inpatients. RESULTS: Despite receiving identical information, nurses varied considerably in their risk assessments. The differences can be partly explained by variability in weightings given to information. Time and protocol recommendations were given more weighting than clinical information for key dichotomous choices such as classifying a patient as 'at risk' and deciding to intervene. Nurses' weighting of cues did not mirror the same information's contribution to risk in real patients. Nurses synthesized information in non-linear ways that contributed little to decisional accuracy. The low-moderate achievement (R(a)) statistics suggests that nurses' assessments of risk were largely inaccurate; these assessments were applied consistently among 'patients' (scenarios). Critical care experience was statistically associated with estimates of risk, but not with the decision to intervene. CONCLUSION: Nurses overestimated the risk and the need to intervene in simulated paper patients at risk of a critical event. This average response masked considerable variation in risk predictions, the need for action and the weighting afforded to the information they had available to them. Nurses did not make use of the linear reasoning required for accurate risk predictions in this task. They also failed to employ any unique knowledge that could be shown to make them more accurate. The influence of time pressure and protocol recommendations depended on the kind of judgement faced suggesting then that knowing more about the types of decisions nurses face may influence information use. RELEVANCE TO CLINICAL PRACTICE: Practice developers and educators need to pay attention to the quality of nurses' clinical experience as well as the quantity when developing judgement expertise in nurses. Intuitive unaided decision making in the assessment of risk may not be as accurate as supported decision making. Practice developers and educators should consider teaching nurses normative rules for revising probabilities (even subjective ones) such as Bayes' rule for diagnostic or assessment judgements and also that linear ways of thinking, in which decision support may help, may be useful for many choices that nurses face. Nursing needs to separate the rhetoric of 'holism' and 'expertise' from the science of predictive validity, accuracy and competence in judgement and decision making.

Decision making in interhospital transport of critically ill patients: national questionnaire survey among critical care physicians.

OBJECTIVE: This study assessed the relative importance of clinical and transport-related factors in physicians' decision-making regarding the interhospital transport of critically ill patients. METHODS: The medical heads of all 95 ICUs in The Netherlands were surveyed with a questionnaire using 16 case vignettes to evaluate preferences for transportability; 78 physicians (82%) participated. The vignettes varied in eight factors with regard to severity of illness and transport conditions. Their relative weights were calculated for each level of the factors by conjoint analysis and expressed in beta. The reference value (beta = 0) was defined as the optimal conditions for critical care transport; a negative beta indicated preference against transportability. RESULTS: The type of escorting personnel (paramedic only: beta = -3.1) and transport facilities (standard ambulance beta = -1.21) had the greatest negative effect on preference for transportability. Determinants reflecting severity of illness were of relative minor importance (dose of noradrenaline beta = -0.6, arterial oxygenation beta = -0.8, level of peep beta = -0.6). Age, cardiac arrhythmia, and the indication for transport had no significant effect. CONCLUSIONS: Escorting personnel and transport facilities in interhospital transport were considered as most important by intensive care physicians in determining transportability. When these factors are optimal, even severely critically ill patients are considered able to undergo transport. Further clinical research should tailor transport conditions to optimize the use of expensive resources in those inevitable road trips.

The effects of time pressure and experience on nurses' risk assessment decisions: a signal detection analysis.

BACKGROUND: Time pressure and, occasionally, suboptimal assessment decisions are features of nursing in acute care. OBJECTIVES: To explore the effect of generic and specialist clinical experience on the ability to detect the need to take action in acute care and the impact of time pressure on nurses' decision-making performance. METHODS: Experienced acute care registered nurses (n = 241) were presented with 50 vignettes of real clinical risk assessments. Each vignette contained seven information cues. In response to these vignettes, nurses had to decide whether to intervene or not. The 26 vignettes were time limited and mixed randomly into the 50 cases. Signal detection analysis was used to establish nurses' performance, personal decision thresholds ([beta]), and their abilities (d') to distinguish a signal of clinical risk from the clinical noise of noncontributory information. RESULTS: Nurses had significantly lower d' and were significantly less likely to indicate intervening under time pressure. For ability-but not threshold-there was a significant interaction of time pressure and years of experience in acute care. With no time pressure, d' increased in line with years of experience. Under time pressure, there was no effect. DISCUSSION: Time pressure reduced nurses' ability to detect the need and the tendency to report intervening. Thus, there were more failures to report appropriate intervention under time pressure, and the positive effects of clinical experience were negated under time pressure. More and larger scale research on the effect on clinical outcomes of time pressured nursing choices is required.

The Scale on COmmunity care PErceptions (SCOPE) for nursing students: A development and psychometric validation study.

The aim of this study was to develop a valid instrument to measure student nurses' perceptions of community care (SCOPE). DeVellis' staged model for instrument development and validation was used. Scale construction of SCOPE was based on existing literature. Evaluation of its psychometric properties included exploratory factor analysis and reliability analysis. After pilot-testing, 1062 bachelor nursing students from six institutions in the Netherlands (response rate 81%) took part in the study. SCOPE is a 35-item scale containing: background variables, 11 measuring the affective component, 5 measuring community care perception as a placement, 17 as a future profession, and 2 on the reasons underlying student preference. Principal axis factoring yielded two factors in the affective component scale reflecting 'enjoyment' and 'utility', two in the placement scale reflecting 'learning possibilities' and 'personal satisfaction', and four in the profession scale: 'professional development', 'collaboration', 'caregiving', and 'complexity and workload'. Cronbach's α of the complete scale was 0.892 and of the subscales 0.862, 0.696, and 0.810 respectively. SCOPE is a psychometrically sound instrument for measuring students' perceptions of community care. By determining these perceptions, it becomes possible to positively influence them with targeted curriculum redesign, eventually contributing to decreasing the workforce shortage in community nursing.