Online patient safety education programme for junior doctors: is it worthwhile?

BACKGROUND: Increasing demand exists for blended approaches to the development of professionalism. Trainees of the Royal College of Physicians of Ireland participated in an online patient safety programme. AIMS: Study aims were: (1) to determine whether the programme improved junior doctors' knowledge, attitudes and skills relating to error reporting, open communication and care for the second victim and (2) to establish whether the methodology facilitated participants' learning. METHODS: 208 junior doctors who completed the programme completed a pre-online questionnaire. Measures were "patient safety knowledge and attitudes", "medical safety climate" and "experience of learning". Sixty-two completed the post-questionnaire, representing a 30 % matched response rate. RESULTS: Participating in the programme resulted in immediate (p < 0.01) improvement in skills such as knowing when and how to complete incident forms and disclosing errors to patients, in self-rated knowledge (p < 0.01) and attitudes towards error reporting (p < 0.01). Sixty-three per cent disagreed that doctors routinely report medical errors and 42 % disagreed that doctors routinely share information about medical errors and what caused them. Participants rated interactive features as the most positive elements of the programme. CONCLUSIONS: An online training programme on medical error improved self-rated knowledge, attitudes and skills in junior doctors and was deemed an effective learning tool. Perceptions of work issues such as a poor culture of error reporting among doctors may prevent improved attitudes being realised in practice. Online patient safety education has a role in practice-based initiatives aimed at developing professionalism and improving safety.

A theory-based method for the evaluation of individual quality of life: the SEIQoL.

Few reports about methods of evaluating quality of life (QoL) among the thousands published since medical interest in the subject slowly began nearly 40 years ago are based upon theory. This paper, prepared in response to a request to furnish an exception (Meadows KA. Introduction to an Advanced Seminar: Assessing Health-Related Quality of Life. What can the Cognitive Sciences Contribute? Hull University, October 9, 2000) describes the origins of the Schedule for the Evaluation of Individual Quality of Life (SEIQoL). This derives its cognitive aspects from theoretical studies of perception by Egon Brunswik, their extension to Social Judgment Theory (SJT) by Kenneth Hammond and the application of these ideas to QoL by the present authors and their colleagues.

Understanding adherence to hand hygiene recommendations: the theory of planned behavior.

BACKGROUND: Most health care workers (HCWs) are aware of the rationale for hand hygiene procedures, yet failure to adhere to guidelines is common. Little is known about factors that motivate HCWs to practice hand hygiene. PURPOSE: The purposes of this study were to (1) estimate adherence to hand hygiene recommendations; (2) describe relationships among motivational factors, adherence, and intensity of nursing unit activity; and (3) test an explanatory model for adherence to hand hygiene guidelines based on the theory of planned behavior (TPB). METHOD: A longitudinal, observational design was used to collect data from 120 registered nurses employed in critical care and postcritical care units. Nurses provided information about motivational factors and intentions and a self-report of the proportion of time they followed guidelines. At least 2 weeks later, the nurses' hand hygiene performance was observed while they provided patient care. Structural equation modeling was used to test the TPB-based model. RESULTS: Rate of adherence to recommendations for 1248 hand hygiene indications was 70%. The correlation between self-reported and observed adherence to handwashing recommendations was low (r = 0.21). TPB variables predicted intention to handwash, and intention was related to self-reported hand hygiene. Intensity of activity in the nursing unit, rather than TPB variables, predicted observed adherence to hand hygiene recommendations. CONCLUSIONS: The limited association between self-reported and observed hand hygiene scores remains an enigma to be explained. Actual hand hygiene behavior may be more sensitive to the intensity of work activity in the clinical setting than to internal motivational factors.

Nurses' motivation to wash their hands: a standardized measurement approach.

Handwashing is a simple procedure that is critical to prevention and control of infections, yet many health care workers (HCWs) do not practice hand hygiene according to recommended guidelines. The Handwashing Assessment Inventory (HAI) is a self-report instrument that is designed to measure the motivational schema of HCWs for handwashing.

Quality-of-life measurement in advanced cancer: assessing the individual.

PURPOSE: Despite the increasing importance of assessing quality of life (QoL) in patients with advanced cancer, relatively little is known about individual patient's perceptions of the issues contributing to their QoL. The Schedule for the Evaluation of Individual Quality of Life (SEIQoL) and the shorter SEIQoL-Direct Weighting (SEIQoL-DW) assess individualized QoL using a semistructured interview technique. Here we report findings from the first administration of the SEIQoL and SEIQoL-DW to patients with advanced incurable cancer. PATIENTS AND METHODS: QoL was assessed on a single occasion using the SEIQoL and SEIQoL-DW in 80 patients with advanced incurable cancer. RESULTS: All patients were able to complete the SEIQoL-DW, and 78% completed the SEIQoL. Of a possible score of 100, the median QoL global score was as follows: SEIQoL, 61 (range, 24 to 94); SEIQoL-DW, 60.5 (range, 6 to 95). Psychometric data for SEIQoL indicated very high levels of internal consistency (median r =.90) and internal validity (median R(2) = 0.88). Patients' judgments of their QoL were unique to the individual. Family concerns were almost universally rated as more important than health, the difference being significant when measured using the SEIQoL-DW (P =.002). CONCLUSION: Patients with advanced incurable cancer were very good judges of their QoL, and many patients rated their QoL as good. Judgments were highly individual, with very high levels of consistency and validity. The primacy given to health in many QoL questionnaires may be questioned in this population. The implications of these findings are discussed with regard to clinical assessment and advance directives.

Continuous subcutaneous infusion of morphine vs. hydromorphone: a controlled trial.

Seventy-four patients were included in a double-blind, randomized, controlled trial comparing the analgesic efficacy and adverse effects of hydromorphone and morphine delivered by continuous subcutaneous infusion. Patients completed the Memorial Pain Assessment Card and a checklist of opioid-related adverse effects immediately before commencing subcutaneous infusion and 24, 48, and 72 hours later. An assessment tool was developed for the 60 patients who were too ill to complete their own questionnaire. The tool demonstrated excellent inter-rater reliability. Thirty-four percent of patients in the hydromorphone group and 27% of those in the morphine group died before completion of the study (P = 0.66). The hydromorphone group required more analgesia for breakthrough pain in the first 24 hours of the study (P = 0.03) and had a greater improvement in the behavior of frowning on movement and the comfort visual analogue scale (P = 0.08) over the course of the study. Adverse effects were rare and similar in both groups. This study found hydromorphone to be at least as effective as morphine when delivered by continuous subcutaneous infusion.

Dementia carer education and patient behaviour disturbance.

OBJECTIVE: To evaluate the impact of a dementia Carer Education Programme on carer quality of life (QoL), burden, and well-being. DESIGN: Single group before-after intervention study. The group was subdivided by perceived status post-programme for intragroup analysis. SETTING: Hospital memory clinic. PARTICIPANTS: Convenience sample of 32 dementia carers. INTERVENTION: Eight weekly 2 h education and support sessions run by a psychogeriatric clinical team. MEASURES: Pre-programme and 6 months post-programme data were obtained. Measures included individually perceived QoL, burden, well-being, managing problem behaviour, appraisal of social support, knowledge of dementia, and perception of the programme. Patients were characterized in terms of cognition, behaviour disturbance and functional status. RESULTS: Twelve carers reported their situation post-programme as 'better', 12 as 'worse', and four as 'no change'. There were no significant baseline differences. For 'better/no change' carers the only significant change over time was increased knowledge about dementia. For 'worse' carers knowledge also increased, but there was evidence of poorer QoL, increased burden, a poorer appraisal of social support, and increased patient behaviour disturbance. Only patient behaviour disturbance significantly discriminated 'no change/better' from 'worse' carers (F = 4.08, p = 0.055). CONCLUSIONS: The programme increased carers' knowledge about dementia, but had no significant impact on QoL, burden, or well-being. Increased patient behaviour disturbance appeared to be a major factor when the carer's situation worsened over time. Despite high carer satisfaction the efficacy of a group-based education approach to the management of behaviour disturbance in dementia appears limited. More intensive or individually tailored interventions may be necessary alternatives.

Quality of life issues in palliative medicine.

The assessment of patient's quality of life is assuming increasing importance in medicine and health care. Illnesses, diseases and their treatments can have significant impacts on such areas of functioning as mobility, mood, life satisfaction, sexuality, cognition, and ability to fulfil occupational, social and family roles. The emerging quality of life construct may be viewed as a paradigm shift in outcome measurement since it shifts the focus of attention from symptoms to functioning. This holistic approach more clearly establishes the patient as the centre of attention and subsumes many of the traditional measures of outcome. Quality of life assessment is particularly relevant to patients with progressive conditions, particularly in the later phases of the disease. Despite the fact that current definitions of palliative medicine include quality of life as a central concern, relatively little research has been conducted on the impact of palliative care on patient quality of life. This paper introduces the concept of quality of life and describes the significant difficulties in definition, measurement and interpretation that must be addressed before such measures can be used as reliable and valid indicators of disease impact and treatment outcomes. It is argued that the unique individual perspective of the patient on his or her own quality of life must be incorporated into outcome assessments aimed at improving the quality of health care delivery in progressive diseases.

Development of a direct weighting procedure for quality of life domains.

The Schedule for the Evaluation of Individual Quality of Life allows individuals to nominate the domains they consider most important to their quality of life and to use their own value system when describing the functional status and relative importance of those domains. The weights for domain importance are derived through a procedure called judgement analysis. As judgement analysis is impractical for individuals with cognitive impairment and in many clinical situations, a shorter, direct weighting procedure has been developed. To test the new procedure, 40 healthy individuals completed both direct and judgement analysis weightings, at t1 and 7-10 days later (t2). After a further 7-10 days (t3), they were asked to identify the weight profiles they had previously produced using each method. The weights produced by the two methods differed on average by 7.8 points at t1 and 7.2 points at t2. The direct weights changed on average by 4.5 points from t1 to t2, while the judgement analysis weights changed by 8.4 points. At t2, 55% of individuals were able to identify the direct weights they had previously produced. The new procedure demonstrates stability and validity but is not interchangeable with judgement analysis. The most appropriate ways of using and interpreting both procedures are discussed.

Behaviour disturbance and other predictors of carer burden in Alzheimer's disease.

OBJECTIVE: To investigate predictors of carer burden in Alzheimer's disease (AD). DESIGN: Two cohorts were formed, one comprising AD patients, the other comprising their primary carers. The relationship of patient and carer variables to carer burden was investigated. SETTING: An urban hospital memory clinic. PARTICIPANTS: A convenience sample of 50 patients meeting NINCDS-ADRDA for probable AD, age range 60-87, and their primary carers, age range 31-84. MEASURES: The Cambridge Cognitive Examination (CAMCOG), the Mini-Mental State Examination (MMSE), the Baumgarten et al. Dementia Behaviour Disturbance Scale, the Blessed-Roth Dementia Scale, the Personal Self-Maintenance Scale, the Zarit Burden Interview and the Vaux et al. Social Support Appraisals (SS-A) and Social Support Behaviours (SS-B) Scales. RESULTS: Daughters were particularly prone to burden. Neither patient cognitive nor functional status predicted burden. Behaviour disturbance in particular, and informal support were significant, but independent, predictors of carer burden. CONCLUSIONS: In this study increased carer burden was related independently to increased levels of patient behaviour disturbance and decreased levels of informal social support. This may have relevance to appropriate interventions for carers. As the study was based on a convenience sample of memory clinic attenders, replication in less highly selected samples is desirable.

General practitioner and public health nurse views of nutritional risk factors in the elderly.

A number of risk factors for malnutrition in the elderly have been identified, but their relative importance has yet to be established. General practitioners and public health nurses were interviewed to elicit the relative weights placed on 6 major risk factors when assessing nutritional risk in the elderly (living alone, recent bereavement, denture problems, mobility problems, psychiatric morbidity and multiple medication use). Participants rated risk for 35 hypothetical cases, described by their status on the 6 risk factors. Multiple regression models of these judgments revealed a consistently high weight for psychiatric morbidity compared to the other factors. Little group variation in diagnostic policies was observed between general practitioners and public health nurses or by case gender. These policies may reflect the perception that psychiatric problems pervade many areas of life functioning related to nutritional intake and are therefore more likely to cause malnutrition than other, more specific risk factors.

Measuring the quality of later life.

This paper examines quality of life as a scientific construct with a wide range of applications. The assessment of patients' quality of life is assuming increasing importance in medicine and health care. Illnesses, diseases and their treatments can have significant impacts on such areas of functioning as mobility, mood, life satisfaction, sexuality, cognition and ability to fulfil occupational, social and family roles. The emerging quality of life construct may be viewed as a paradigm shift in outcome measurement since it shifts the focus of attention from symptoms to functioning. This holistic approach more clearly establishes the patient as the centre of attention and subsumes many of the traditional measures of outcome. Quality of life assessment is particularly relevant to ageing populations both for healthy elderly and for those who develop chronic diseases where maintenance of quality of life rather than cure may be the primary goal of treatment. This paper introduces the concept of quality of life and describes the significant difficulties in definition, measurement and interpretation that must be addressed before such measures can be used as reliable and valid indicators of disease impact and treatment outcomes. It is argued that approaches to quality of life assessment in the elderly should incorporate advances in knowledge about the psychological adaptation to ageing. Consequently, the unique perspective of the individual on his or her own quality of life must be incorporated into outcome assessments aimed at improving the quality of health care. Incorporating measures of subjective outcome such as quality of life into policy decisions on resource allocation in health care will prove one of the major challenges for health services over the next decade.

A new short form individual quality of life measure (SEIQoL-DW): application in a cohort of individuals with HIV/AIDS.

Quality of life is an increasingly important outcome measure in medicine and health care. Many measures of quality of life present patients with predetermined lists of questions that may or may not be relevant to the individual patient. This paper describes a brief measure, the SEIQoL-DW, which is derived from the schedule for evaluation of individual quality of life (SEIQoL). The measure allows respondents to nominate the areas of life which are most important, rate their level of functioning or satisfaction with each, and indicate the relative importance of each to their overall quality of life. Given its practicality and brevity, the measure should prove particularly useful in clinical situations where patient generated data on quality of life is important. This article describes the first clinical application of the measure, assessing the quality of life of a cohort of patients with HIV/AIDS managed in general practice.

Individual quality of life in the healthy elderly.

Quality of life research with the elderly has usually focused on the impact of decline in function, and used a pre-determined model of quality of life in old age. The Schedule for the Evaluation of Individual Quality of Life (SEIQoL) allows individuals to nominate, weigh and assess those domains of greatest relevance to their quality of life. The SEIQoL was administered to 56 healthy elderly community residents at baseline and 12 months later. Quality of life levels were significantly higher at baseline (t = -2.04; p = 0.04) than that of a previously studied sample of healthy adults below 65 years of age, and did not change significantly over the study period. The domains nominated by both samples as relevant to their quality of life differed notably. Health status was not correlated with the perceived importance of health at baseline, and showed only a low correlation (r = 0.27) at 12 months. The weight placed on health did not increase over the study period despite a significant decline in health status. The value of allowing the individual to define personal quality of life values in a research context is explored.

Communication skills training in undergraduate medicine: attitudes and attitude change.

The importance of communication skills training in undergraduate medical education is now widely accepted. However little is known about student attitudes towards their own communication skills and whether their attitudes changes as a result of participating in communication skills courses. The aim of the present study was to identify these attitudes prior to commencing such a course and to further evaluate changes in these attitudes on completion of the course. Results demonstrated an improvement in perceived confidence regarding a number of specific communication skills. The study provides further evidence of the value of such courses in undergraduate medical training.

Individual quality of life in patients undergoing hip replacement.

Quality of life (QoL) assessment is becoming increasingly important for measuring the impact of illnesses, diseases, and their treatment and for deciding priorities when allocating resources. We developed a novel method to measure QoL from the perspective of the individual patient. The schedule for the evaluation of individual quality of life (SEIQoL) was devised from the technique known as judgment analysis to measure patients' level of functioning in five self-nominated facets of life and the relative weight or importance attached to these areas. We applied this method, together with traditional measures of health status, in a prospective intervention study of 20 patients undergoing unilateral total hip-replacement surgery with six-month follow-up by comparison with matched, non-patient controls. Health status was significantly improved by hip replacement on the McMaster health index questionnaire (p less than 0.001) and the arthritis impact measurement scales (p less than 0.001). Individually measured QoL was significantly increased after surgery when measured by SEIQoL (p less than 0.02). The individual nature of QoL was reflected in the variety of life areas nominated as important by individual patients, the differences in relative weights attached to these areas, and the complex nature of the changes that occurred postoperatively. Our data not only highlight such individuality but also show that SEIQoL provides a means by which this can be assessed scientifically.

Assessment of quality of life in surgery.

The concept of patients' quality of life is assuming increasing importance in modern medicine and surgery. Interventions are increasingly being assessed in terms of their impact on such areas of functioning as mobility, mood, cognitive function, ability to fulfil occupational and social roles, and general life satisfaction. This paper discusses the theoretical underpinnings of the quality-of-life paradigm and its practical relevance for modern surgery.

Assessing the quality of life of the individual: the SEIQoL with a healthy and a gastroenterology unit population.

Current methods of measuring quality of life (QoL) impose an external value system on individuals, rather than allowing them to describe their lives in terms of those factors which they consider important. The Schedule for the Evaluation of Individual Quality of Life (SEIQoL) was developed to overcome such limitations. The QoL of 42 healthy attenders at an international immunization clinic was assessed using SEIQoL. Judgement reliability was high (r = 0.74) and individuals' judgement policies accounted for a large percentage of the variance in overall QoL (R2 = 0.75) demonstrating the construct validity of judgement analysis in this context. In a second study of QoL of out-patient suffering from irritable bowel syndrome (IBS) (N = 20) or peptic ulcer disease (PUD) (N = 20) was assessed using SEIQoL. Judgement reliability was lower (r = 0.54) although statistically highly significant (P less than 0.01), and the variance in overall QoL judgements explained was high (R2 = 0.74). SEIQoL is an acceptable, reliable and valid technique for measuring individual QoL that takes greater account of individual perspectives than traditional measurement approaches.