Development and initial validation of a Swedish inventory to screen for symptoms of deficient perineum in women after vaginal childbirth: 'Karolinska Symptoms After Perineal Tear Inventory'.

BACKGROUND: Perineal tears are common after vaginal birth and may result in pelvic floor symptoms. However, there is no validated questionnaire that addresses long-term symptoms in women with a deficient perineum after vaginal birth. Thus, the objective of this study was to develop and psychometrically evaluate a clinical screening inventory that estimates subjective symptoms in women with a deficient perineum more than one year after vaginal delivery. MATERIAL AND METHODS: The development and psychometric evaluation employed both qualitative and quantitative methods. Qualitative strategies involved content validity and Think Aloud protocol for generation of items. The psychometric evaluation employed principal component analysis to reduce the number of items. The inventory was completed by women with persistent symptoms after perineal tears (N = 170). Results were compared to those of primiparous women giving birth by caesarean section (N = 54) and nulliparous women (N = 338). RESULTS: A preliminary 41-item inventory was developed, and the psychometric evaluation resulted in a final 11-item inventory. Women with confirmed deficient perineum after perineal trauma scored significantly higher on the symptoms inventory than women in control groups. A cut-off value of ≥ 8 could distinguish patients from controls with high sensitivity (100%) and specificity (87-91%). CONCLUSIONS: The Karolinska Symptoms After Perineal Tear Inventory, is a psychometrically valid 11-item patient-reported outcome measure for symptoms of deficient perineum more than one year after vaginal birth. More research is needed to validate the inventory in various patient populations as well as its use in pelvic floor interventions. The inventory has the potential to improve patient counseling and care in the future.

Threshold concepts in health professions education research: a scoping review.

Threshold concepts (TCs) are increasingly used in health professions education (HPE) research. TCs are claimed to be conceptual gateways which are often traversed with substantial difficulty. In this paper, we report on a scoping review investigating the following research question: What is the scope and nature of the currently available research on threshold concepts in health professions education literature? We employed Arksey and O'Malley's model for scoping reviews. A search for literature on TCs in HPE research between 2003 and 2020 yielded 999 records of which 59 were included in the review. The data set was subject to quantitative descriptive analysis of article characteristics as well as qualitative thematic analysis of the scope of research on TCs. Among the 59 articles selected for review, there were 30 empirical, 26 conceptual and three reviews. A majority were published in 2015 or later. Almost half of the included articles attempted to identify possible TCs within HPE. Others investigated how TCs can be traversed or suggested how TCs could influence curriculum design. Some critically appraised the framework of TC. Although TCs are increasingly utilised in HPE, the present review identified how researchers came across methodological challenges related to identifying possible TCs and definitional challenges around identifying the essential characteristics of TCs. Before embracing TCs as the next go-to theory for learning in HPE, we acknowledge the need for methodological stringeny and rigour as well as more data to support TCs. Until then, any implementation of TCs in HPE curricula should be done cautiously.

Balancing acting and adapting: a qualitative study of medical students' experiences of early clinical placement.

BACKGROUND: Clinical learning experience is an important part of medical education. In the clinical learning environment, students are exposed to various aspects of medical care and may train their skills under supervision. Supervision, in which students' learning needs and the outcomes of placements are met, is essential. The aim of this study was to explore medical students' experiences of the early stages of clinical training. METHODS: In 2021, 18 individual semi-structured interviews were conducted with medical students after their first clinical placements in semester 5. The interviews were transcribed verbatim and analyzed using qualitative content analysis according to Graneim and Lundman. RESULTS: The findings resulted in an overall theme: balancing acting and adapting. Three categories described that the clinical learning environment was a big leap from campus, that personal relationships influenced learning, and that the organization of clinical placements was suboptimal. The students were encouraged to push themselves forward to practice clinical skills. This, however, did not suit all the students; the cautious ones risked becoming passive spectators. The intended learning outcomes were not frequently used; rather, the supervisors asked the students what they had learned, or the students focused on what seemed to be important on the ward. The students tried to adapt to their supervisors' working situation and not to be a burden to them. CONCLUSIONS: Our findings show that the transition from learning on campus was sometimes abrupt, as the students had to switch to a more active learning role. Ad hoc solutions in supervision occurred, which contributed to the experience that educational responsibilities were downgraded and the opportunities for clinical training varied. Rather than trying to change the circumstances, the students opted to adapt to the busy clinical learning environment.

Migrant physicians' choice of employment and the medical specialty general practice: a mixed-methods study.

OBJECTIVE: In many countries, migrant physicians (MP) tend to fill staff shortages in medical specialties perceived as low status. The aim of this study was to explore aspects that influence MPs', with a medical degree from outside EU/EEA, choice of employment and medical specialty in Sweden, and to explore and understand a potential over-representation in general practice (family medicine), a specialty suffering from staff shortages in Sweden. METHODS: A mixed-methods approach was applied. This included questionnaire data from 101 MPs training and working as medical specialists in Sweden and semi-structured interview data from four MPs specializing in general practice. RESULTS: Regardless of specialty, the most influential aspects when choosing employment were the ability to combine work with family, to develop one´s competence, and to have highly competent colleagues. Women scored higher on some aspects related to private life and the surroundings. More than half (55%) of the respondents specialized in general practice, and more women than men. The MPs in general practice scored higher on the aspect 'ability to have the same patients for a longer period' than MPs specializing in other specialties. No significant difference between MP general practitioner respondents and MPs in other medical specialties was found in relation to the item 'Was the specialty your first choice?'. Aspects identified in the interviews that influenced the choice to specialize in general practice related to job opportunities, positive experiences of primary health care, working conditions, and family conditions. CONCLUSION: Labour market conditions such as high competition, and the time-consuming recertification process, can influence the choice to specialize in general practice as this reduces the time to become a medical specialist. We however did not find any results indicating that MPs' decision to specialize in general practice and to work as general practitioners was any less voluntary than that of MPs who chose other specialties.

-A cross-sectional study of clinical learning environments across four undergraduate programs using the undergraduate clinical education environment measure.

BACKGROUND: The clinical learning environment (CLE) influences students' achievement of learning outcomes and the development of their professional behaviors. However, CLEs are not always optimal for learning because of clinical productivity expectations and a lack of support from supervisors. The purpose of this study was to describe and compare students' perceptions of their CLEs across four undergraduate programs. METHODS: This study is cross-sectional. In total, 735 students who were registered in the medical, nursing, physiotherapy, and speech-language pathology (SLP) programs were invited to participate. Data were collected using an online survey, which included demographics and the Undergraduate Clinical Education Environment Measure (UCEEM). The UCEEM consists of 26 items congregated into two overarching dimensions-experiential learning and social participation-with four subscales: opportunities to learn in and through work and quality of supervision, preparedness for student entry, workplace interaction patterns and student inclusion, and equal treatment. RESULTS: In total 280 students (median age 28; range: 20-52; 72% females) returned the questionnaire. The mean total UCEEM score was 98.3 (SD 18.4; range: 91-130), with physiotherapy students giving the highest scores and medical students the lowest. The mean scores for the dimensions experiential learning and social participation for all the students were 62.8 (SD 13.6; range 59-85) and 35.5 (SD 6.2; range 13-45), respectively. Medical students rated the lowest for all subscales. The items receiving the highest ratings concerned equal treatment, whereas those receiving the lowest ratings concerned supervisors' familiarity with the learning objectives. There were few statistically significant differences between the semesters within each program. CONCLUSIONS: The students generally hold positive perceptions toward their CLEs. However, the students from the medical and nursing programs rated their learning environment lower than did the students from the physiotherapy and SLP programs. Importantly, in several aspects, the medical students provided significantly lower ratings for their CLE compared with the students from the other programs. The medical students' low ratings for their supervisors' familiarity with the learning objectives underscore the need to ensure that the prerequisites for optimal supervision are met.

The use of complementary medicine in palliative care in France: an observational cross-sectional study.

PURPOSE: Palliative care for cancer deals with physical, psychosocial, and spiritual issues faced by cancer patients, their families, communities, and healthcare providers. Research on complementary medicine (CM) use in France is limited despite high rates of reported CM use in other countries including by palliative patients. This study describes the use of CM by individuals receiving palliative care in Lyon, France. DESIGN: This study employed an observational cross-sectional survey design. SETTING/PARTICIPANTS: The study was conducted in three palliative care centers in Lyon, France; two tertiary hospitals and one palliative care unit (3 sites). Inpatients and outpatients visiting the palliative care clinic with a primary diagnosis of cancer at each study site were invited to participate. RESULTS: Of 138 eligible patients, 100 completed the survey (RR 72.4%). The majority (90.7%) reported using CM in the previous 6 months or since their primary cancer diagnosis. Participant CM use was either the same (20.7%) or increased since their primary cancer diagnosis (33.7%). Average out-of-pocket expenses associated with CM use in the previous 6 months or since diagnosis were €157.40 (SD €330.15). The most common CM health professional visited was an aromatherapist (72.7%), a Coupeurs de feu (38.6%), osteopath (28.6%) and naturopath (15.3%). The most common CM used were aromatherapy oils (33.7%), homeopathy (30.0%), and vitamins (29.4%). CONCLUSION: This second survey on CM use in France; is the first conducted in palliative care centers. Results show people with cancer in Lyon, France, have a very high prevalence of CM utilization.

You say it, we say it, but how do we use it? Communities of practice: A critical analysis.

OBJECTIVES: As educational theories are increasingly used in medical education research there are concerns over how these theories are used, how well they are presented and what the authors intend. Communities of practice (CoP) is one example of an often-used theory and conceptual framework. This paper presents a critical analysis of how CoP theory is used in medical education research. METHODS: A critical literature analysis was undertaken of articles published between 1998 and 2018 in eight internationally recognised medical education journals. From a total of 541 articles, 80 articles met the inclusion criteria and were analysed and mapped according to various patterns of use. RESULTS: We discerned five categories of use, two misleading and cosmetic, off target and cosmeticising, and three functional, framing, lensing and transferring. A considerable number of articles either misrepresented the point of communities of practice or used it in a cosmetic fashion. The remainder used the theory to frame an ongoing study in relation to other work, as a lens through which to design the study and collect or analyse data, or as a way of discussing or demonstrating the transferability of the findings. CONCLUSIONS: We conclude that almost half of the reviewed articles did not offer a functional and rigorous definition of what is meant by CoP; instead, they used it in a potentially misleading or cosmetic manner. This study therefore calls on editors, reviewers and authors alike to increase clarity and quality in the application of CoP theory in medical education.

Benefits of Massive Open Online Course Participation: Deductive Thematic Analysis.

BACKGROUND: Massive open online courses (MOOCs), as originally conceived, promised to provide educational access to anyone with an internet connection. However, the expansiveness of MOOC education has been found to be somewhat limited. Nonetheless, leading universities continue to offer MOOCs, including many in the health sciences, on a number of private platforms. Therefore, research on online education must include thorough understanding of the role of MOOCs. To date, studies on MOOC participants have focused mainly on learners' assessment of the course. It is known that MOOCs are not reaching the universal audiences that were predicted, and much knowledge has been gained about learners' perceptions of MOOCs. However, there is little scholarship on what learners themselves gain from participating in MOOCs. OBJECTIVE: As MOOC development persists and expands, scholars and developers should be made aware of the role of MOOCs in education by examining what these courses do offer their participants. The objective of this qualitative synthesis of a set of MOOC evaluation studies was to explore outcomes for MOOC learners, that is, how the learners themselves benefit from participating in MOOCs. METHODS: To explore MOOC learners' outcomes, we conducted a qualitative synthesis in the form of a deductive thematic analysis, aggregating findings from 17 individual studies selected from an existing systematic review of MOOC evaluation methods. We structured our inquiry using the Kirkpatrick model, considering Kirkpatrick levels 2, 3, and 4 as potential themes in our analysis. RESULTS: Our analysis identified six types of Kirkpatrick outcomes in 17 studies. Five of these outcomes (learning/general knowledge, skills, attitudes, confidence, and commitment) fit into Kirkpatrick Level 2, while Kirkpatrick Level 3 outcomes concerning behavior/application were seen in four studies. Two additional themes were identified outside of the Kirkpatrick framework: culture and identity outcomes and affective/emotional outcomes. Kirkpatrick Level 4 was not represented among the outcomes we examined. CONCLUSIONS: Our findings point to some gains from MOOCs. While we can expect MOOCs to persist, how learners benefit from the experience of participating in MOOCs remains unclear.

Migrant physicians' entrance and advancement in the Swedish medical labour market: a cross-sectional study.

BACKGROUND: Worldwide, physicians are migrating to new countries and want to practise their profession. However, they may experience difficulties doing so. To optimise and accelerate their entrance into and advancement within the Swedish healthcare system, there is an urgent need to explore how they are currently doing so, as their competences should be put to use without any unnecessary delay. The aim of the study was to explore how migrant physicians with a medical degree from outside EU/EEA enter and advance within the medical labour market in Sweden and to identify perceived barriers and facilitating aspects in the process. The empirical findings are discussed in light of Bourdieu's concept symbolic capital as adapted in the Swedish medical field. METHODS: A cross-sectional study with a self-administrated questionnaire was disseminated. A sample of 498 migrant physicians were identified. Descriptive statistical analysis and qualitative thematic analysis were used to analyse the data. RESULTS: The response rate was 57% (n = 283). Respondents mainly found their first positions via spontaneous job applications, during internships, while participating in an educational intervention or via personal contacts. Perceived barriers to entering and advancing within the medical field in Sweden were mainly related to having a medical degree from and/or originating from another country, which could in turn represent discrimination and/or having one's competence undervalued as a result. Facilitating aspects included having or developing contacts in Swedish healthcare and gaining proficiency or fluency in the Swedish language. CONCLUSIONS: When MPs find their first positions, the contacts they have developed appear to play a role, and when advancing in their positions, the active development of a variety of contacts seems to be beneficial. MPs experience a variety of barriers to entering and advancing within the field that could be related to discrimination. Many MPs perceived having their competences undervalued due to their origin or to being educated abroad. Based on the respondents' experiences, our interpretation is that MPs as a group are hierarchically positioned lower in the Swedish medical field than physicians trained in the country. Facilitating aspects included educational interventions, having contacts and developing language skills. For optimal entry into the labour market, it is vitally important for MPs to learn the new language and obtain a job or internship in the field as soon as possible.

Twelve tips for conducting qualitative research interviews.

The qualitative research interview is an important data collection tool for a variety of methods used within the broad spectrum of medical education research. However, many medical teachers and life science researchers undergo a steep learning curve when they first encounter qualitative interviews, both in terms of new theory but also regarding new methods of inquiry and data collection. This article introduces the concept of qualitative research interviews for novice researchers within medical education, providing 12 tips for conducting qualitative research interviews.

Perceptions about trust: a phenomenographic study of clinical supervisors in occupational therapy.

BACKGROUND: Finding the best way to facilitate student learning in clinical practice can be challenging for clinical supervisors. While high levels of trust might jeopardize patient safety, low trust might hinder student learning; however, carrying out professional activities is necessary for students to develop professional competence. There is a dearth of scholarly literature regarding the concept of trust among clinical supervisors in occupational therapy education. A better understanding of how trust is created between the supervisor and student may thus aid in facilitating student learning. The aim of this study, therefore, was to explore occupational therapy clinical supervisors' perception of trust and how it is formed. METHODS: A qualitative method deploying a phenomenographic approach was chosen. Twelve clinical supervisors were interviewed, and the data were analyzed according to the seven-step phenomenographic approach. RESULTS: Three qualitatively different ways of thinking about trust were found: (1) that trust is about the student and is rather static; (2) trust as a dynamic process based on student performance; and (3) trust as something mutual and interrelated. The findings indicate that trust can be understood in various ways, such as being something inherent in the student or, alternatively, about the student, the supervisor, the relationship between them, and the surrounding context, including the tasks performed. Furthermore, the study shows that trust can be seen either as something static or as a dynamic process. CONCLUSIONS: This study contributes to a deeper understanding of the variation of ways in which the concept of trust is understood among clinical supervisors in occupational therapy. The study corroborates the prior research finding that trust can be understood as a multifaceted construct. It contributes novel insights about the role of the supervisor as an influential factor in the trust-building process. A deep understanding of the possible differences in the ways of conceptualizing something can help supervisors support learning by building on this understanding. The results from this study contribute to our knowledge of the drivers behind entrusted decisions in clinical education in various professional contexts. We suggest that the results be used in the continuing professional development of clinical supervisors.

Investigating psychometric properties and dimensional structure of an educational environment measure (DREEM) using Mokken scale analysis - a pragmatic approach.

BACKGROUND: Questionnaires and surveys are used throughout medical education. Nevertheless, measuring psychological attributes such as perceptions of a phenomenon among individuals may be difficult. The aim of this paper is to introduce the basic principles of Mokken scale analysis (MSA) as a method for the analysis of questionnaire data and to empirically apply MSA to a real-data example. METHODS: MSA provides a set of statistical tools for exploring the relationship between items and latent traits. MSA is a scaling method of item selection algorithms used to partition an array of items into scales. It employs various methods to probe the assumptions of two nonparametric item response theory models: the monotone homogeneity model and the double monotonicity model. The background and theoretical framework underlying MSA are outlined in the paper. MSA for polytomous items was applied to a real-life data example of 222 undergraduate students who had completed a 50-item self-administered inventory measuring the educational environment, the Dundee Ready Educational Measure (DREEM). RESULTS: A pragmatic and parsimonious approach to exploring questionnaires and surveys from an item response theory (IRT) perspective is outlined. The use of MSA to explore the psychometric properties of the Swedish version of the DREEM failed to yield strong support for the scalability and dimensional structure of the instrument. CONCLUSIONS: MSA, a class of simple nonparametric IRT models - for which estimates can be easily obtained and whose fit to data is relatively easily investigated - was introduced, presented, and tested. Our real-data example suggests that the psychometric properties of DREEM are not adequately supported. Thus, the empirical application depicted a potential and feasible approach whereby MSA could be used as a valuable method for exploring the behavior of scaled items in response to varying levels of a latent trait in medical education research.

Exploring chiropractic students' experiences of the educational environment in healthcare professional training: a qualitative study.

BACKGROUND: The educational environment has a significant impact on students' behavior, sense of well-being, and academic advancement. While various research methodologies have been used to explore the educational environment, there is a paucity of studies employing qualitative research methods. This study engages in an in-depth exploration of chiropractic students' experiences of the meaning of the educational environment. METHODS: A qualitative approach was employed by interviewing 26 students in four focus group interviews at two different points in time. A conventional manifest and latent content analysis was chosen to investigate and interpret the experiences of the educational environment in an undergraduate chiropractic training institution in Sweden. RESULTS: The analysis resulted in five overarching themes: Personal growth; Being part of a community; A place of meaningfulness; Trust in a regulated system; and Scaffolding relationships. Early in the training, the meaning of the educational environment was experienced as part of a vocational community and the scaffolding of intra-institutional relationships. In later stages, the environment was experienced in terms of personal growth - balancing academic pressures and progress within the professional community - thus laying the foundations for autonomy and motivation. During the clinical training, the environment was experienced as where learning happens, thus creating a place of meaningfulness. Throughout the training, the formal and clinical environments were experienced as isolating, with little bridging between the two. A regulated system - conveying an operative organization with clear communication regarding what to expect - was experienced as important for an apt educational environment. CONCLUSIONS: We found that experiences of an educational environment are dynamic and change over time. When restructuring or evaluating curriculums, educational managers can consider the emerged themes as constituting facets relating to the educational environment, and thus possible learning conditions. Likewise, researchers can consider these aspects of the educational environment when: interpreting results from quantitative and qualitative inquiries, constructing and refining instruments, or conceptualizing and framing the educational environment phenomenon.

Attitudes, skills and implementation of evidence-based practice: a national cross-sectional survey of licensed naprapaths in Sweden.

BACKGROUND: Evidence-based practice (EBP) is fundamental to the delivery of high-quality, safe and effective health care. Naprapaths, manual therapy providers that specialize in the treatment of musculoskeletal pain and dysfunction, became a Swedish licensed health profession in 1994. This study investigated the attitudes, skills and implementation of EBP among licensed naprapaths in Sweden. METHODS: Licensed naprapaths (n = 950) of Svenska Naprapatförbundet (the Swedish Naprapathy Association) were invited by email to take part in this cross-sectional anonymous online study using the Evidence-Based Practice Attitude and Utilisation Survey in February 2019. RESULTS: Fourteen percent (137/950) of invited naprapaths completed the survey. There was an approximately equal gender divide among responders; most were in the mid-career age range, practiced in city areas, and had a university or college certificate/diploma as their highest qualification. The majority of naprapaths agreed or strongly agreed that EBP was necessary in the practice of naprapathy, assisted them in making care decisions, and improved the quality of patient care. Naprapaths' self-reported skills in EBP were mostly in the moderate to moderate-high range. The majority of participating naprapaths reported infrequent implementation of EBP. Perceived minor or moderate barriers to EBP uptake included a lack of colleague support for EBP and a lack of relevant resources. Access to the internet and free online databases were reported as very useful enablers to improving EBP uptake. CONCLUSIONS: The licensed naprapaths participating in this survey reported positive attitudes toward EBP, moderate levels of EBP skills, and infrequent implementation of EBP.

Development and evaluation of the MAINTAIN instrument, selecting patients suitable for secondary or tertiary preventive manual care: the Nordic maintenance care program.

BACKGROUND: Chiropractic maintenance care (MC) has been found to be effective for patients classified as dysfunctional by the West Haven-Yale Multidimensional Pain Inventory (MPI). Although displaying good psychometric properties, the instrument was not designed to be used in clinical practice to screen patients for stratified care pathways. The aim was to develop a brief clinical instrument with the intent of identifying dysfunctional patients with acceptable diagnostic accuracy. METHODS: Data from 249 patients with a complete MPI dataset from a randomized clinical trial that investigated the effect and cost-effectiveness of MC with a 12-month follow-up was used in this cross-sectional analysis. A brief screening instrument was developed to identify dysfunctional patients, with a summary measure. Different cut-offs were considered with regards to diagnostic accuracy using the original instrument's classification of dysfunctional patients as a reference. Very good diagnostic accuracy was defined as an area under the curve (AUC) metric between 0.8 and 0.9. The instrument was then externally validated in 3 other existing datasets to assess model transportability across populations and medical settings. RESULTS: Using an explorative approach, the MAINTAIN instrument with 10 questions (0-6 Likert responses) capturing 5 dimensions (pain severity, interference, life control, affective distress, and support) was developed, generating an algorithm-based score ranging from - 12 to 48. Reporting a MAINTAIN score of 18 or higher, 146 out of the 249 patients were classified as dysfunctional with 95.8% sensitivity and 64.3% specificity. At a score of 22 or higher, 109/249 were classified as dysfunctional with 81.1% sensitivity and 79.2% specificity. AUC was estimated to 0.87 (95% CI 0.83, 0.92) and Youden's index was highest (0.70) at a score of 20. The diagnostic accuracy was similar and high across populations with minor differences in optimal thresholds for identifying dysfunctional individuals. CONCLUSION: The MAINTAIN instrument has very good diagnostic accuracy with regards to identifying dysfunctional patients and may be used as a decision aid in clinical practice. By using 2 thresholds, patients can be categorized into "low probability (- 12 to 17)", "moderate probability (18 to 21)", and "high probability (22 to 48)" of having a good outcome from maintenance care for low back pain. TRIAL REGISTRATION: Clinical trials.gov; NCT01539863; registered February 28, 2012; https://clinicaltrials.gov/ct2/show/NCT01539863 .

Complementary medicine visits by palliative care patients: a cross-sectional survey.

BACKGROUND: The paucity of empirical research examining complementary medicine (CM) use in palliative care in France compared with other countries results in a gap in scientific knowledge. This study aims to describe the frequency and the cause of palliative care patients consulting with a CM clinician along with the conventional physicians. METHODS: This study is an observational cross-sectional survey conducted in three palliative care centres in Lyon, France, between July 2017 and May 2018: two tertiary hospitals and one palliative care unit in a private hospital. Inpatients and outpatients visiting the palliative care clinics with a primary diagnosis of cancer were invited to participate in the study. Using a 19-item paper-based survey instrument, we collected data on the participants' personal characteristics, health service utilisation and attitudes towards CM. RESULTS: From the 138 participants meeting the inclusion criteria, 100 (72.4%) were included in the study. On average, they were 62.9 years old (SD 12.4) and the majority were women (60%). The primary cancer site was mostly colorectal (29.0%), breast (15.0%) and gynaecological (11.0%). The most commonly visited CM clinician was the aromatherapist (72.7%), recording more than six consultations (78.1%) for symptom management (21.9%). Visits to an osteopath were reported by 28.6% of patients, and 45.8% of osteopathy users reported visiting an osteopath more than six times for symptom management (62.5%). Participants visiting a naturopath (15.3%) reported less than four visits and indicated symptom management as the most common reason (76.9%). CONCLUSIONS: Our findings show a substantial proportion of palliative care patients visit CM clinicians and primarily seek symptom management from CM clinical care.

The nordic maintenance care program: patient experience of maintenance care-a qualitative study.

BACKGROUND: Low back pain is one of the major causes of disability world-wide. Most back pain sufferers experience pain that is recurrent or persistent, making management of this condition a priority. In a series of previous studies, chiropractic maintenance care has been found to be an effective way of reducing the number of days with pain, particularly for patients with a certain psychological profile. However, little is known about patients' experience of this kind of management plan. This study aimed to explore patient experiences and preferences by looking at barriers to and facilitators of engaging in and maintaining a care plan, and to contrast the data using psychological sub-groups. METHODS: In this qualitative study we performed semi-structured interviews with 24 patients who had previously participated in a Swedish trial evaluating maintenance care. They were purposefully selected to obtain richness, variation and breadth of data. The data were analyzed using inductive qualitative manifest and latent content analysis. We used the theory of planned behavior to deepen our understanding of the constructed themes. RESULTS: The analysis resulted in two overarching dimensions: "when maintenance care is of high value" and "when maintenance care is of low value". Four factors were jointly identified as obstacles to maintenance care by patients in all the psychological subgroups. These factors were: Cost demanding, A sense of low value, Perceived as unavailable and Fear of treatment. The one factor seen as facilitating maintenance care by patients in all the subgroups was Care that is patient-centered. CONCLUSIONS: The findings reveal a variance of both positive and negative experiences of MC in the psychological subgroups. These findings can deepen our understanding of how patients experience MC and can help clinicians to understand when patients might regard maintenance care as being of high value.

Selecting Instruments for Measuring the Clinical Learning Environment of Medical Education: A 4-Domain Framework.

Learning environments shape the experiences of learners and practitioners, making them an important component of program evaluation. However, educators find it challenging to decide whether to measure clinical learning environments with existing instruments or to design their own new instrument and, if using an existing instrument, which to choose. To assist educators with these decisions, the authors compared clinical learning environment instruments based on their characteristics, underlying constructs, and degree to which items reflect 4 domains (personal, social, organizational, material) from a recently developed model for conceptualizing learning environments in the health professions. Building on 3 prior literature reviews as well as a literature search, the authors identified 6 clinically oriented learning environment instruments designed for medical education. They collected key information about each instrument (e.g., number of items and subscales, conceptual frameworks, operational definitions of the learning environment) and coded items from each instrument according to the 4 domains. The 6 instruments varied in number of items, underlying constructs, subscales, definitions of clinical learning environment, and domain coverage. Most instruments focused heavily on the organizational and social domains and less on the personal and material domains (half omitted the material domain entirely). The variations in these instruments suggest that educators might consider several guiding questions. How will they define the learning environment and which theoretical lens is most applicable (e.g., personal vitality, sociocultural learning theory)? What aspects or domains of the learning environment do they most wish to capture (e.g., personal support, social interactions, organizational culture, access to resources)? How comprehensive do they want the instrument to be (and correspondingly how much time do they expect people to devote to completing the instrument and how frequently)? Whose perspective do they wish to evaluate (e.g., student, resident, fellow, attending, team, patient)? Each of these considerations is addressed.

Skills, attitudes and uptake of evidence-based practice: a cross-sectional study of chiropractors in the Swedish Chiropractic Association.

BACKGROUND: Evidence-based practice (EBP) is integral to the delivery of high-quality health care. Chiropractic has been a licensed health profession in Sweden since 1989, but little is known of the uptake of EBP in this professional group. This study explored the self-reported skills, attitudes and uptake of EBP, and the enablers and barriers of EBP uptake, among licensed chiropractors in Sweden. METHODS: Licensed chiropractors (n = 172) of the Swedish Chiropractic Association (Legitimerade Kiropraktorers Riksorganisation) were invited to participate in an anonymous online questionnaire, using the Evidence-Based Practice Attitude and Utilisation Survey (EBASE) in February 2019. RESULTS: Fifty-six (33%) chiropractors completed the survey. Participants were predominantly male, aged 30-49 years, held a Master's degree, and had received their highest qualification and practiced chiropractic for over a decade. Chiropractors rated their EBP skill-level mostly in the moderate to moderate-high range. The majority of chiropractors reported positive attitudes towards EBP, with most agreeing or strongly agreeing that EBP is necessary in the practice of chiropractic, and that EBP assists in making decisions about patient care. Chiropractors reported an average level of engagement in EBP activities. All participants indicated professional literature and research findings were useful in their day-to-day chiropractic practice. The main perceived enabler of EBP uptake was internet access in the workplace, whereas the main barrier to EBP uptake was lack of clinical evidence in chiropractic. CONCLUSIONS: Participating chiropractors of the Swedish Chiropractic Association were generally favourable of EBP, though only reported modest levels of EBP-related skills and engagement in EBP activities. Our findings suggest future studies investigating interventions focussed on improving chiropractors' skills and uptake of EBP are warranted.