Dynamic occupancy modelling reveals a hierarchy of competition among fishers, grey foxes and ringtails.

Determining how species coexist is critical for understanding functional diversity, niche partitioning and interspecific interactions. Identifying the direct and indirect interactions among sympatric carnivores that enable their coexistence is particularly important to elucidate because they are integral for maintaining ecosystem function. We studied the effects of removing nine fishers (Pekania pennanti) on their population dynamics and used this perturbation to elucidate the interspecific interactions among fishers, grey foxes (Urocyon cinereoargenteus) and ringtails (Bassariscus astutus). Grey foxes (family: Canidae) are likely to compete with fishers due to their similar body sizes and dietary overlap, and ringtails (family: Procyonidae), like fishers, are semi-arboreal species of conservation concern. We used spatial capture-recapture to investigate fisher population numbers and dynamic occupancy models that incorporated interspecific interactions to investigate the effects members of these species had on the colonization and persistence of each other's site occupancy. The fisher population showed no change in density for up to 3 years following the removals of fishers for translocations. In contrast, fisher site occupancy decreased in the years immediately following the translocations. During this same time period, site occupancy by grey foxes increased and remained elevated through the end of the study. We found a complicated hierarchy among fishers, foxes and ringtails. Fishers affected grey fox site persistence negatively but had a positive effect on their colonization. Foxes had a positive effect on ringtail site colonization. Thus, fishers were the dominant small carnivore where present and negatively affected foxes directly and ringtails indirectly. Coexistence among the small carnivores we studied appears to reflect dynamic spatial partitioning. Conservation and management efforts should investigate how intraguild interactions may influence the recolonization of carnivores to previously occupied landscapes.

Cost savings vary by length of stay for inpatients receiving palliative care consultation services.

BACKGROUND: Cost savings associated with palliative care (PC) consultation have been demonstrated for total hospital costs and daily costs after PC involvement. This analysis adds another approach by examining costs stratified by hospital length of stay (LOS). OBJECTIVE: To examine cost savings for patients who receive PC consultations during short, medium, and long hospitalizations. METHODS: Data were analyzed for 1815 PC patients and 1790 comparison patients from two academic medical centers between 2005 and 2008, matched on discharge disposition, LOS category, and propensity for a PC consultation. We used generalized linear models and regression analysis to compare cost differences for LOS of 1 to 7 days (38% of consults), 8 to 30 days (48%), and >30 days (14%). Comparisons were done for all patients in both hospitals (n=3605) and by discharge disposition: survivors (n=2226) and decedents (n=1379); analyses were repeated for each hospital. RESULTS: Significant savings per admission were associated with shorter LOS: For stays of 1 to 7 days, costs were lower for all PC patients by 13% ($2141), and for survivors by 19.1% ($2946). For stays of 8 to 30 days, costs were lower for all PC patients by 4.9% ($2870), and for survivors by 6% ($2487). Extrapolating the per admission cost across the PC patient groups with lower costs, these programs saved about $1.46 million for LOS under a week and about $2.5 million for LOS of 8 to 30 days. Patients with stays >30 days showed no differences in costs, perhaps due to preferences for more aggressive care for those who stay in the hospital more than a month. CONCLUSION: Cost savings due to PC are realized for short and medium LOS but not stays >30 days. These findings suggest savings can be achieved by earlier involvement of palliative care, and support screening efforts to identify patients who can benefit from PC services early in an admission.

Design, dissemination, and evaluation of an advanced communication elective at seven U.S. medical schools.

PURPOSE: To test educational methods that continue communication training into the fourth year of medical school. METHOD: The authors disseminated and evaluated an advanced communication elective in seven U.S. medical schools between 2007 and 2009; a total of 9 faculty and 22 fourth-year students participated. The elective emphasized peer learning, practice with real patients, direct observation, and applications of video technology. The authors used qualitative and quantitative survey methods and video review to evaluate the experience of students and faculty. RESULTS: Students reported that the elective was better than most medical school clerkships they had experienced. Their self-confidence in time management and in the use of nine communication skills improved significantly. The most valued course components were video review, repeated practice with real patients, and peer observation. Analysis of student videos with real patients and in role-plays showed that some skills (e.g., agenda setting, understanding the patient perspective) were more frequently demonstrated than others (e.g., exploring family and cultural values, communication while using the electronic health record). Faculty highly valued this learner-centered model and reported that their self-awareness and communication skills grew as teachers and as clinicians. CONCLUSIONS: Learner-centered methods such as peer observation and video review and editing may strengthen communication training and reinforce skills introduced earlier in medical education. The course design may counteract a "hidden curriculum" that devalues respectful interactions with trainees and patients. Future research should assess the impact of course elements on skill retention, attitudes for lifelong learning, and patients' health outcomes.

Faculty and student participation in online discussions of palliative care scenarios.

BACKGROUND AND OBJECTIVES: The use of online discussion is increasing in medical education curricula. Few studies have explored factors that affect patterns of participation in such an online learning environment. In this study, we examined how medical students interacted with one another in online discussions of end-of-life care during family medicine clerkships. METHODS: Based on factors that affect the quality of online discussions as identified in the literature, we developed a coding scheme for comments that facilitated social interactions (social presence) and learning (cognitive presence). Our study was based on available transcripts from discussions including two faculty and 42 students. RESULTS: Participants created social interactions by greeting one another, referring to students' names, and connecting their postings to previous comments. While faculty prompted student discussions and posed questions, they rarely highlighted learning points, corrected student errors, or summarized discussions. Students offered multiple perspectives on end-of-life issues based on personal and clinical experiences. However, they tended to share existing online resources without much interpretation or explanation. CONCLUSIONS: Most comments by students lacked critical thinking skills in linking evidence from the literature with ongoing discussions. Students may need direct modeling by faculty to learn how to use existing resources to support statements, pose critical questions, and justify proposed solutions.

Breaking the cycles of violence.

Violence begets violence and it is important to understand how cycles of violence are perpetuated if we are to find solutions to the global problems they present. A multi-disciplinary group of The International Work Group on Death, Dying and Bereavement has developed a model of the cyclical events that perpetuate violence at all levels including the family, community, nation, and world. This includes the Violent Act(s), the Perception of the Violent Act(s), the Immediate Response, Legitimising Authority, Destructive Codes, and Inflammatory/Polarising Strategies. It is possible at each point to break the cycle, examples are given and recommendations made.

Integrating communication training into a required family medicine clerkship.

Persistent evidence suggests that the communication skills of practicing physicians do not achieve desired goals of enhancing patient satisfaction, strengthening health outcomes and decreasing malpractice litigation. Stronger communication skills training during the clinical years of medical education might make use of an underutilized window of opportunity-students' clinical years-to instill basic and important skills. The authors describe the implementation of a novel curriculum to teach patient-centered communication skills during a required third-year, six-week family medicine clerkship. Curriculum development and implementation across 24 training sites in a five-state region are detailed. A faculty development effort and strategies for embedding the curriculum within a diverse collection of training sites are presented. Student and preceptor feedback are summarized and the lessons learned from the curriculum development and implementation process are discussed.

TNEEL workshop. Interactive methods for teaching end-of-life care.

Nurse educators have identified lack of end-of-life content as a serious deficit in undergraduate nursing education. TNEEL, a new software program with tools for teaching end-of-life topics, was created to help educators overcome this problem. The authors implemented an experiential workshop to help educators learn how to use TNEEL's wide variety of educational tools. Trainers provided information about TNEEL and coached participants (N = 94) as they practiced using laptop computers to increase their familiarity and comfort in using the toolkit. Workshop participants completed pre- and posttest evaluations addressing their opinions and beliefs about using this computer tool. Findings support the workshop as an effective way to facilitate adoption of this innovative educational resource and support the development of a nation-wide training plan for TNEEL with experiential workshops.

Developing a computerized data collection and decision support system for cancer pain management.

Contemporary nursing practice needs reengineering to deliver its service effectively and efficiently. Using computer technology to support clinicians' decision making may be a parsimonious way to provide high-quality, patient-centered, efficient care. The process of developing the PAINReportIt and PAINConsultN system is described, and the results of two pilot studies in which the system was tested are summarized. The feasibility of using the system to assess pain and provide decision support for clinicians is demonstrated. The findings show PAINReportIt to be promising as an effective, efficient way for patients to report their pain. Whether PAINConsultN is an effective answer to cancer pain management barriers warrants further evaluation with larger samples. The advantages of using the system, as compared with use of the traditional pain management process, are discussed.

Issues in end-of-life care: patient, caregiver, and clinician perceptions.

CONTEXT: Review of published research indicates the need to better incorporate patient and caregiver perceptions when providing end-of-life (EOL) care. Although considerable research regarding patient and caregiver experience of EOL has been done, little research has studied patients, caregivers, and clinicians as a connected system. OBJECTIVE: To study the perceptions of patients, caregivers, and physicians who are already connected with one another in an EOL care experience. DESIGN: Qualitative study consisting of in-depth, open-ended, face-to-face interviews and content analysis. SETTING: Community family practice residency programs in rural and urban settings in the Affiliated Family Practice Residency Network of the Department of Family Medicine, University of Washington School of Medicine. PARTICIPANTS: Forty-two patients and 39 caregivers facing EOL were interviewed either alone or together after referral by their physicians. Additionally, results of previously published findings from interviews with 39 family practice faculty were included. OUTCOME MEASURES: Perceptions of participants on EOL issues. RESULTS: Participants identified four primary issues related to their experience of EOL care: awareness of impending death, management/coping with daily living while attempting to maintain the management regimen, relationship fluctuations, and the personal experiences associated with facing EOL. Participants expected their physicians to be competent and to provide a caring relationship. CONCLUSIONS: Awareness of these crucial patient and caregiver EOL issues and expectations and how they differ from clinician perspectives can assist clinicians to appropriately explore and address patient/caregiver concerns and thereby provide better quality EOL care.

Technology survey of nursing programs: implications for electronic end-of-life teaching tool development.

From an online survey of current technological capabilities of US undergraduate nursing programs, we found almost universal use of Microsoft Windows-based computers and Microsoft Office Suite software. Netscape and Microsoft Internet Explorer were the most popular browsers for Internet access. The survey also assessed faculty preferences for end-of-life care teaching materials and found that nurse educators preferred simple easy-to-use tools provided on CD-ROM or the Internet, with instructions provided via CD-ROM, the Internet, and demonstration workshops. Our findings have numerous implications for the development of electronic teaching materials for nursing.

Technology available in nursing programs: implications for developing virtual end-of-life educational tools.

BACKGROUND: To overcome insufficient attention to end-of-life (EOL) care in nursing education, the authors are developing the "Toolkit for Nursing Excellence at End-of-Life Transition" (TNEEL). METHOD: An evidence-based design process was used to create a computerized (CD-ROM) multimedia toolkit of instructional aides. An online survey of all U.S. undergraduate nursing programs was conducted to identify their current technologic infrastructures available for innovative teaching aides. Expert review process guided pedagogic decisions. RESULTS: Survey findings enabled TNEEL development to be responsive to nurse educators' needs and preferences. CONCLUSION: Educators can use TNEEL to actively engage students in meaningful learning about EOL care.

Defining effective clinician roles in end-of-life care.

OBJECTIVE: Our goal was to determine primary care clinician perceptions of what is important to the provision of quality end-of-life care. STUDY DESIGN: We used ethnography, a qualitative research method involving the use of open-ended semistructured interviews. POPULATION: We included 38 family practice residency faculty from 9 community residency programs of the Affiliated Family Practice Residency Network, Department of Family Medicine, University of Washington School of Medicine. OUTCOMES MEASURED: The roles described by interviewees when discussing their best practices while delivering end-of-life care were compiled. RESULTS: Primary care clinicians organize their delivery of quality end-of-life care predominantly through their relationships with patients and families. They play 3 roles when providing end-of-life care. As consultants, clinicians provide expert medical advice and treatment. As collaborators, they seek to understand the patient and family experience. Seasoned clinicians act as guides, using their personal intuitive knowledge of patient and family to facilitate everyone's growth when providing end-of-life care. CONCLUSIONS: Shifting clinician focus from skills and knowledge toward relationship, meaning, and roles provides new opportunities to improve end-of-life care for patients, families, and clinicians.