Using Patient Simulation to Promote Best Practices in Fall Prevention and Postfall Assessment in Nursing Homes.

BACKGROUND: Fall-related injuries rise with age and are of particular concern for frail populations living in nursing homes. LOCAL PROBLEM: The Perley and Rideau Veterans' Health Centre is a large nursing home in Ontario, Canada. In 2019, we conducted internal audits of our Falls Prevention Program and identified notable variations in staff's response to a resident fall. INTERVENTIONS: We developed an in situ patient simulation program of a resident fall. METHODS: This was a mixed-methods evaluation of participants' perspectives of a simulation-based interprofessional education program for fall prevention. RESULTS: Participants indicated high-level support for simulation-based learning, with more than 80% of the participants expressing that they will apply these skills in the future when caring for a resident who falls. CONCLUSIONS: Our findings indicate that simulation-based training is well received by frontline workers in a nursing home setting and can be conducted as part of a typical shift with minimal disruption to resident care.

Lessons from Long-Term Care Home Partners during the COVID-19 Pandemic.

Rapid response to a quickly evolving pandemic was critical to keep residents and those who provide care in long-term care (LTC) safe. Two Ontario-based LTC homes, Perley Health and peopleCare Communities, share key aspects of their pandemic response that left both homes well positioned to partner in the Strengthening Pandemic Preparedness in Long-Term Care rapid response research program (HEC 2022a). To share lessons learned and generate evidence around practical solutions to mitigate future outbreaks, Perley Health and peopleCare Communities identify key considerations to enhance quality of care and quality of life for LTC residents now and in the future.

Testing Pediatric Emergency Telemedicine Implementation Strategies Using Quality Improvement Methods.

Background: Despite the recognized benefits of telemedicine use for pediatric emergency consultations, there are barriers to the widespread uptake of this technology. Quality improvement methods can be used to rapidly test implementation strategies. Our objective was to test telemedicine implementation strategies in real-world application using quality improvement methods. Our quality improvement aim was to achieve high rates of telemedicine use for pediatric transfer consultations. Methods: A multidisciplinary multisite improvement team identified that key drivers of increasing telemedicine use included telemedicine resource awareness, streamlined telemedicine workflow, provider buy-in, and data transparency. Interventions focused on telemedicine trainings, disseminating telemedicine uptake data, telemedicine reminders, telemedicine test calls, and preparing for telemedicine use for every transfer consultation. The outcome measure was percentage of pediatric emergency transfer consultations that used telemedicine. The balancing measure was time (minutes) from the initial transfer center call to completion of the consultation. Results: Multiple plan-do-study-act cycles were associated with special cause variation, with an upward shift in mean percentage of telemedicine use from 5% to 22%. Time from initial call to consultation completion remained unchanged. Conclusion: Our study supports the use of quality improvement methods to test telemedicine implementation strategies for pediatric telemedicine emergency consultations.

Establishing an educational value unit to promote teaching in an academic unit.

Background: In academic health centers, education remains an incompletely supported and funded mandate. In an attempt to promote education and better support educational endeavors of faculty, some academic health centers and departments have conceived of a metric, the educational value unit (eVU), to begin to "quantify" teaching. What goes into this metric, its intended goals and the logistics of its implementation vary considerably among centers. Lessons Learned: This practical advice paper highlights the various lessons learned from a review of the limited published literature on eVU systems supplemented with our personal experience in implementing a successful eVU system in the Department of Pediatrics at our institution, to help guide others who may be interested in doing that same. Even in limited-resource settings, our hope is that these lessons can serve as a guide on how to better quantify and reward teaching, whether through monetary or nonfiscal incentives and recognition.

Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center.

The COVID-19 pandemic has created multiple, complex and intense demands on hospitals, including the need for surge planning in the many locations outside epicenters such as northern Italy or New York City. We here describe such surge planning in an Academic Health Center that encompasses a children's hospital. Interprofessional teams from every aspect of inpatient care and hospital operations worked to prepare for a COVID-19 surge. In so doing, they successfully innovated ways to integrate pediatric and adult care and maximize bed capacity. The success of this intense collaborative effort offers an opportunity for ongoing teamwork to enhance efficient, effective, and high-quality patient care.

Illuminating exemplary professionalism using appreciative inquiry dialogues between students and mentors.

PURPOSE: To explore the types of exemplary professional behaviors and the facilitators and barriers to professional behavior discussed by student-mentor dyads during appreciative inquiry (AI) dialogs. MATERIALS AND METHODS: We conducted a qualitative analysis of AI narratives discussing exemplary professional practice written by third-year medical students following a dialog with mentors. Narratives were thematically analyzed using directed content analysis to explore the types of exemplary professional behaviors discussed and the facilitators and barriers to professional practice. Narratives were coded independently by two investigators; codes were finalized, themes were derived, and a model on how exemplary professional behaviors are nurtured and reinforced was developed. RESULTS: Themes addressed humanism toward others and excellence, with altruism being an underlying implicit guiding principle behind professional behavior. Humanism toward self was infrequently discussed as an aspect of professionalism, but when discussed, was perceived to foster resilience. Principle-based attitudes and emotional intelligence facilitated professional behaviors. Programmatic scaffolds facilitated professional behavior and included curricula on reflective practice, mentorship, promoting learner autonomy and connectedness, and a safe environment. CONCLUSIONS: AI is an effective strategy that can be used to stimulate learner reflection on professionalism, humanism, and wellness and promote learner acknowledgement of positive aspects of the learning environment.

Establishing an integrated model of subacute care for the frail elderly.

The current health system in Ontario is not designed to meet the needs of frail older adults. This is particularly true for older adults hospitalized due to exacerbation of chronic illness or medical crisis. This article describes the Subacute Care Unit for the Frail Elderly (SAFE) program, one which is designed to serve frail older patients who are at risk of deconditioning or disability associated with prolonged hospitalization but who may safely return home or to a retirement home following up to 4 weeks of subacute care in a restorative environment. The program centres on an intense restorative and integrated care delivery model. The patient population is medically complex, requiring medical supervision and regular adjustment to the care plan to optimize medical status. Individuals are no longer acutely ill and are considered stable or stabilizing. Care and services are designed to improve outcomes for hospitalized frail older adults by proactively addressing the conditions that contribute to alternate level of care before the deconditioning associated with prolonged hospitalization is experienced.

Challenges of interprofessional team training: a qualitative analysis of residents' perceptions.

BACKGROUND: Simulation-based interprofessional team training is thought to improve patient care. Participating teams often consist of both experienced providers and trainees, which likely impacts team dynamics, particularly when a resident leads the team. Although similar team composition is found in real-life, debriefing after simulations puts a spotlight on team interactions and in particular on residents in the role of team leader. The goal of the current study was to explore residents' perceptions of simulation-based interprofessional team training. METHODS: This was a secondary analysis of a study of residents in the pediatric residency training program at the University of California, San Francisco (United States) leading interprofessional teams in simulated resuscitations, followed by facilitated debriefing. Residents participated in individual, semi-structured, audio-recorded interviews within one month of the simulation. The original study aimed to examine residents' self-assessment of leadership skills, and during analysis we encountered numerous comments regarding the interprofessional nature of the simulation training. We therefore performed a secondary analysis of the interview transcripts. We followed an iterative process to create a coding scheme, and used interprofessional learning and practice as sensitizing concepts to extract relevant themes. RESULTS: 16 residents participated in the study. Residents felt that simulated resuscitations were helpful but anxiety provoking, largely due to interprofessional dynamics. They embraced the interprofessional training opportunity and appreciated hearing other healthcare providers' perspectives, but questioned the value of interprofessional debriefing. They identified the need to maintain positive relationships with colleagues in light of the teams' complex hierarchy as a barrier to candid feedback. DISCUSSION: Pediatric residents in our study appreciated the opportunity to participate in interprofessional team training but were conflicted about the value of feedback and debriefing in this setting. These data indicate that the optimal approach to such interprofessional education activities deserves further study.

Transition to Residency Courses: Recommendations for Creation and Implementation.

Transition to Residency (TTR) courses help ease the critical transition from medical school to residency, yet there is little guidance for developing and running these courses. In this perspective, the authors use their expertise as well as a review of the literature to provide guidance and review possible solutions to challenges unique to these courses. TTR courses should be specialty-specific, allow for flexibility, and utilize active learning techniques. A needs assessment can help guide course content, which should focus on what is necessary to be ready for day one of residency. The use of residents in course planning and delivery can help create a sense of community and ensure that content is practical. While course assessments are largely formative, instructors should anticipate the need for remediation, especially for skills likely to be performed with limited supervision during residency. Additionally, TTR courses should incorporate learner self-assessment and goal setting; this may be valuable information to share with learners' future residency programs. Lastly, TTR courses should undergo continuous quality improvement based on course evaluations and surveys. These recommendations are essential for effective TTR course implementation and improvement.

Understanding self-assessment as an informed process: residents' use of external information for self-assessment of performance in simulated resuscitations.

Self-directed learning requires self-assessment of learning needs and performance, a complex process that requires collecting and interpreting data from various sources. Learners' approaches to self-assessment likely vary depending on the learner and the context. The aim of this study was to gain insight into how learners process external information and apply their interpretation of this information to their self-assessment and learning during a structured educational activity. The study combined quantitative performance data with qualitative interview data. Pediatric residents led video-recorded simulated resuscitations and rated their crisis resource management skills on a validated 6-item instrument. Three independent observers rated the videos using the same instrument. During semi-structured interviews, each resident reviewed the video, rerated performance, discussed the self-assessment process, and interpreted feedback and observer scores. Transcripts were analyzed for themes. Sixteen residents participated. Residents' self-assessed scores ranged widely but usually fell within two points of the observers. They almost universally lowered their scores when self-assessing after the video review. Five major themes emerged from qualitative analysis of their interviews: (1) residents found self-assessment important and useful in certain contexts and conditions; (2) residents varied in their self-directed learning behaviors after the simulated resuscitation; (3) quantitative observer assessment had limited usefulness; (4) video review was difficult but useful; and (5) residents focused on their weaknesses and felt a need for constructive feedback to enhance learning. The residents in our study almost uniformly embraced the importance of self-assessment for all medical professionals. Even though video review had a negative impact on their self-assessment scores and was perceived as painful, residents saw this as the most useful aspect of the study exercises residents. They were less accepting of the quantitative assessment by observers. Residents explained their tendency to focus on weaknesses as a way to create an incentive for learning, demonstrating that self-assessment is closely linked to self-directed learning. How learners can use video review and external assessment most effectively to guide their self-directed learning deserves further study.

Promoting self-directed learning through portfolios in undergraduate medical education: the mentors' perspective.

BACKGROUND: Medical students need to acquire self-directed learning (SDL) skills for effective lifelong learning. Portfolios allow learners to reflect on their progress, diagnose learning needs and create learning plans, all elements of SDL. While mentorship is deemed to be essential for successful portfolio use, it is not known what constitutes effective mentorship in this process. In-depth understanding of the SDL construct seems a prerequisite. AIMS: The aim of this study was to examine how portfolio mentors perceive and approach SDL. METHODS: Interviews with faculty members who mentored medical students in portfolio were audio-recorded, transcribed and analysed for themes. RESULTS: Eight mentors participated. Qualitative analysis revealed six major themes around mentors' definitions of SDL, their perception of innate SDL abilities of medical students, their own approach to SDL, their understanding of the value of learning plans, their perceptions of students' engagement with the portfolio and the impact of the portfolio process on the mentoring relationship. CONCLUSIONS: This study revealed tensions between mentors' beliefs regarding the importance of SDL, their own approach to SDL and their perceptions of students' SDL skills. Based on our analysis of these tensions, we recommend both explicit faculty development and institutional culture change for successful integration of SDL in medical education.

Educational Relative Value Units as a Measure of Academic Productivity: A Systematic Review.

INTRODUCTION: Academic Health Centers (AHCs) have complex, often competing missions. Many have developed mission-based management (MBM) systems to support their clinical and non-clinical missions. There are limited data on MBM use for their educational missions. Our scoping review explored how AHCs employed such systems.  Materials and methods: Arksey and O'Malley's six-stage framework guided our review. Based on pre-defined criteria, English language articles from PubMed, EMBASE, SCOPUS, and the Healthcare Administration Database published between 2010 and 2020 were loaded into a reference manager. The search included all health professions education schools. Articles were excluded if they were review articles, commentaries, or clearly did not involve funding for education. From the final list of selected articles, data were extracted using a data extraction sheet we developed. Two researchers reviewed each article again to ensure extracted data were reported consistently and with sufficient detail.  Results: Of the 1729 manuscripts identified, 35 met inclusion criteria. Sixteen (46%) contained data in some form but did not have a formal methods section describing the specific approach to data collection and analysis. Moreover, there was marked variability in how educational effort was quantified, what counted as educational effort (educational scholarship versus teaching) and the impacts of such quantification (departmental funding versus individual faculty incentives). None of the studies reported on the impact on faculty promotion. Faculty satisfaction with the system was reported in seven studies (20%) and was generally positive. CONCLUSIONS: A systematic description of how systems were developed to support the educational mission was lacking. Clear goals, methods of development, uniform data on educational productivity and quality, and program evaluation were not defined by most articles. This lack of process clarity presents a challenge, but more importantly an opportunity for academic health centers to unify efforts and continue to further their educational mission.

Corrigendum to "Exploring social movement concepts and actions in a knowledge uptake and sustainability context: A concept analysis" [Int J Nurs Sci 9/4 (2022) 411-421].

[This corrects the article DOI: 10.1016/j.ijnss.2022.08.003.].

Program Evaluation of SeeMe™: Understanding Frailty Together.

Background: Perley Health has implemented SeeMe™: Understanding frailty together (www.perleyhealth.ca), a comprehensive approach to care that integrates the assessment and management of frailty, with an emphasis on goals of care planning. Methods: Program evaluation over the first year of SeeMe™ used a mixed-methods approach involving quantitative data from surveys, goals of care preferences, hospital transfers, and qualitative data from interviews. Results: The SeeMe™ training is an effective way to educate nurses and physicians in long-term care about frailty. For residents with documented care preferences prior to SeeMe™, there was a 15% reduction in the number of residents who preferred to be transferred to hospital post-SeeMe™ implementation. There was no significant decrease in hospital transfers during the first year the program was introduced. Conclusion: After the roll-out of SeeMe™, nurses, physicians, and families reported high satisfaction with the program, and nurses reported an increase in knowledge and confidence. There was also a reduction in the number of residents and families selecting to transfer to hospital. This suggests that the education from SeeMe™ influenced residents and families to choose less invasive interventions in the context of frailty and quality of life goals.

Exploring social movement concepts and actions in a knowledge uptake and sustainability context: A concept analysis.

Objectives: To share a concept analysis of social movement aimed at advancing its application to evidence uptake and sustainability in health-care. Methods: We applied Walker and Avant method to clarify the concept of social movement in the context of knowledge uptake and sustainability. Peer-reviewed and grey literature databases were systematically searched for relevant reports that described how social movement action led to evidence-based practice changes in health and community settings. Titles, abstracts and full texts were reviewed independently and in duplicate, resulting in 38 included articles. Results: Social movement action for knowledge uptake and sustainability can be defined as individuals, groups, or organizations that, as voluntary and intrinsically motivated change agents, mobilize around a common cause to improve outcomes through knowledge uptake and sustainability. The 10 defining attributes, three antecedents and three consequences that we identified are dynamic and interrelated, often mutually reinforcing each other to fortify various aspects of the social movement. Examples of defining attributes include an urgent need for action, collective action and collective identity. The concept analysis resulted in the development of the Social Movement Action Framework. Conclusions: Social movement action can provide a lens through which we view implementation science. Collective action and collective identity - concepts less frequently canvassed in implementation science literature - can lend insight into grassroots approaches to uptake and sustainability. Findings can also inform providers and change leaders on the practicalities of harnessing social movement action for real-world change initiatives. By mobilizing individuals, groups, or organizations through social movement approaches, they can engage as powered change agents and teams that impact the individual, organizational and health systems levels to facilitate knowledge uptake and sustainability.

Validation of a self-efficacy instrument and its relationship to performance of crisis resource management skills.

Self-efficacy is thought to be important for resuscitation proficiency in that it influences the development of and access to the associated medical knowledge, procedural skills and crisis resource management (CRM) skills. Since performance assessment of CRM skills is challenging, self-efficacy is often used as a measure of competence in this area. While self-efficacy may influence performance, the true relationship between self-efficacy and performance in this setting has not been delineated. We developed an instrument to measure pediatric residents' self-efficacy in CRM skills and assessed its content validity, internal structure, and relationship to other variables. After administering the instrument to 125 pediatric residents, critical care fellows and faculty, we performed an exploratory factor analysis within a confirmatory factor analysis as well as a known group comparison. The analyses specified four factors that we defined as: situation awareness, team management, environment management, and decision making. Pediatric residents reported lower self-efficacy than fellows and faculty in each factor. We also examined the correlation between self-efficacy and performance scores for a subset of 30 residents who led video recorded simulated resuscitations and had their performances rated by three observers. We found a significant, positive correlation between residents' self-efficacy in situation awareness and environment management and their overall performance of CRM skills. Our findings suggest that in a specific context, self-efficacy as a form of self-assessment may be informative with regards to performance.

Entrustable Professional Activity-Based Assessments in Undergraduate Medical Education: A Survey of Pediatric Educators.

OBJECTIVE: To explore the use of entrustable professional activities (EPAs) in undergraduate medical education (UME), characterization of EPAs by pediatric educators, and opportunities and challenges with an EPA framework. METHODS: In 2020, 9 survey questions were administered to members of the Council on Medical Student Education in Pediatrics, a national pediatric UME group. Clark's Commitment and Necessary Effort model on motivation served as the theoretical framework for our study. Quantitative and qualitative data were analyzed using descriptive statistics and conventional content analysis, respectively. RESULTS: One hundred and sixty-seven (31%) of 479 recipients, representing 75% of accredited schools responded. Eigty-three percent agreed that they understood what EPAs were, yet a minority reported using EPAs. Eighty-five percent of EPA users expressed satisfaction with EPAs in providing a shared framework and an opportunity to track student competence; dissatisfaction was expressed toward faculty resource needs. Among nonusers, barriers hindering implementation included faculty development challenges and faculty time. Qualitative analyses revealed a rich understanding of EPAs: that they offer a framework to measure learner competence by assessing performance in workplace-based tasks that can be used for entrustment decisions and for program evaluation. CONCLUSIONS: Although most pediatric UME educators report understanding EPAs (contributing to self-efficacy) and recognize their benefits (value), a minority report actually using EPAs. EPAs, while providing a valuable framework, pose challenges from contextual factors affecting personal agency, which could affect educator commitment in implementation. For more widespread adoption of the EPAs, efforts should focus on minimizing these perceived barriers.

Essential yet Ill-defined: leadership roles to support fourth-year medical students in pediatrics.

BACKGROUND: Few studies have been published about specialty-specific fourth-year medical student leadership in any discipline. This paper provides insight from pediatric educators about the current status and recommendations for pediatric-specific fourth-year leaders. OBJECTIVE: To identify the prevalence of pediatric fourth-year medical student directors across the US and Canada and to compare current and ideal responsibilities for this role. METHODS: Five multi-part questions were written and submitted for the 2019 Council on Medical Student Education in Pediatrics (COMSEP) Annual Survey and subsequently disseminated to all COMSEP member physicians. Anonymous responses were collected and results analyzed. The study was IRB exempt. RESULTS: The program-level survey response rate was 79%. Of 115 respondent medical schools, 37% reported having a pediatric fourth-year director separate from the clerkship director, with an average of 9.8% full-time equivalent (FTE) protected time for the role. In contrast, individuals indicated 20% FTE would be ideal for fourth-year director responsibilities. The most common role identified for pediatric fourth-year directors was directing sub-internships. Respondents indicated it would be ideal for pediatric fourth-year directors to have an increased level of involvement in all areas queried in the survey, especially directing a pediatric residency preparatory course/boot camp, faculty development for educators of fourth-year students, and remediating fourth-year students. CONCLUSIONS: As specialty-specific experiences have grown in the fourth year of medical school, there is an increasing demand for faculty leadership separate from direction of the pediatric clerkship. In this national survey, pediatric educators expressed a need for additional protected time to lead fourth-year specific activities. Similar findings in other disciplines would support advocating for more protected time and expanded roles for specialty-specific fourth-year directors nationally.