A Scoping Review of Retrieval Practice (Test-Enhanced Learning) in Nursing Education.

AIM: The aim of this study was to determine the status of retrieval practice in original research of nursing education. BACKGROUND: The science of learning is an emerging interdisciplinary field that offers evidence-based strategies to improve learning. One of the most highly effective strategies is retrieval practice, which involves recalling previously learned information from long-term memory prior to additional study. METHOD: Searching PubMed, CINAHL, Scopus, Psych INFO, and ERIC, an interprofessional team followed a formal scoping review framework and utilized the PRISMA Extension for Scoping Reviews to report the findings. RESULTS: The review included 25 research studies, with all but one at the prelicensure level. Quantitative designs were most common, and outcomes reflected objective and subjective measures. If present, terms were varied and inconsistent with supporting research. Documentation of many characteristics was lacking. CONCLUSION: Retrieval practice is an increasingly common strategy being studied at the prelicensure level. Opportunities for improvement include consistent use of standard terminology, documentation of important characteristics, and more attention to subjective outcomes and to graduate and continuing education levels.

Science of Learning Strategy Series: Article 3, Interleaving.

ABSTRACT: Interleaving is an evidence-based, learning-science strategy that is relevant to the planning and implementation of continuing professional development (CPD). Mixing related but different areas of study forces the brain to reconcile the relationship between the areas while understanding each area well. By doing so, interleaving increases the likelihood of mastery and memory. Research from cognitive psychology and neuroscience provides the rationale for interleaving, and examples of its implementation in health profession education have begun to appear in the literature. If utilized appropriately, some common CPD interventions can leverage interleaving. Through increased understanding, CPD participants can benefit from interleaving by making more-informed educational choices, and CPD planners can benefit in efforts to improve educational activities.

Educational needs assessment identifying opportunities to improve sepsis care.

INTRODUCTION: In 2015, the Centers for Medicare and Medicaid Services developed a national quality bundle for the management of patients with severe sepsis and septic shock (SEP-1). Despite performance improvement measures, compliance remains low. This needs assessment is the first stage of a quality improvement initiative to improve SEP-1 compliance. Using a conceptual outcomes framework, this needs assessment analyses SEP-1 compliance data, knowledge, and competence to identify gaps in care and educational opportunities. METHODS: The needs assessment began with a review of national and statewide SEP-1 compliance data to identify a need for improvement. The needs assessment proceeded with a retrospective chart review to evaluate process measures and identify which providers would most likely benefit from educational interventions. A focus group provided perspective on the chart review findings. RESULTS: During the period of 1 April 2017-31 March 2018, national SEP-1 compliance was 51% and compliance at the studied institution was 19%. The chart review included 51 patients (66.7% severe sepsis, 33.3% septic shock). Frequently missed SEP-1 measures included administration of intravenous fluids (0% severe sepsis, 58.8% septic shock), repeat lactate levels (52.6% severe sepsis, 60% septic shock), documentation of volume and tissue perfusion assessment (58.8%), vasopressor administration (73.3%) and administration of broad-spectrum antibiotics (76.5%, severe sepsis). Focus group perceptions identified themes related to gaps in declarative and dispositional knowledge. CONCLUSIONS: This educational needs assessment highlights gaps in SEP-1 clinician performance, competence and knowledge. A multifaceted education programme is the next step for this performance improvement project. Education should include a series of meetings, activities, and workshops that include declarative knowledge, procedural knowledge and dispositional knowledge. Simulation activities can provide an opportunity for providers to demonstrate competence. Point-of-care prompts and performance measurement and feedback of patient care data can support clinician performance. This needs assessment underscores the need for a multifaceted approach to clinician education and performance to improve SEP-1 compliance.

Scoping Review of Distributed Practice in Nursing Education.

AIM: The aim of this study was to describe the status of distributed practice in research of nursing education. BACKGROUND: The science of learning has compiled evidence-based strategies that should be integral to nursing education. One long-standing strategy, distributed practice, involves spacing, placing cognitive breaks between study or practice sessions with priority information. METHOD: Reviewing literature published over 20 years at every level of nursing education, the authors conducted a scoping review to determine the extent to which research of nursing education includes attention to distributed practice. RESULTS: In the 13 articles meeting criteria, distributed practice was most common in continuing professional development, with an emphasis in learning psychomotor skills. Study authors used a variety of terms and descriptions in referring to the strategy. CONCLUSION: By way of research, distributed practice appears underutilized in nursing education, especially at prelicensure and graduate levels, and could benefit from clear and consistent use of terminology.

Science of Learning Strategy Series: Article 2, Retrieval Practice.

ABSTRACT: Retrieval practice is an evidence-based, science of learning strategy that is relevant to the planning and implementation of continuing professional development (CPD). Retrieval practice requires one to examine long-term memory to work with priority information again in working memory. Retrieval practice improves learning in two ways. It improves memory for the information itself (direct benefit), and retrieval practice provides feedback about what needs additional effort (indirect). Both benefits contribute significantly to durable learning. Research from cognitive psychology and neuroscience provides the rationale for retrieval practice, and examples of its implementation in health professions education are increasingly available in the literature. Through appropriate utilization, CPD participants can benefit from retrieval practice by making more-informed educational choices, and CPD planners can benefit in efforts to improve educational activities.

Science of Learning Strategy Series: Article 1, Distributed Practice.

ABSTRACT: Distributed practice is an evidence-based, learning-science strategy that is relevant to the planning and implementation of continuing professional development (CPD). Spacing-out study or practice over time allows the brain multiple opportunities to process new and complex information in an efficient way, thus increasing the likelihood of mastery and memory. Research from cognitive psychology and neuroscience provide the rationale for distributed practice, and examples of its implementation in health professions education have begun to appear in the literature. If used appropriately or extended creatively, some common CPD interventions can fully leverage distributed practice. Through increased understanding, CPD planners can benefit from distributed practice in efforts to improve educational activities, and CPD participants can benefit by making more informed educational choices.

Definitions of Physician Certification Used in the North American Literature: A Scoping Review.

INTRODUCTION: The authors sought to identify how physician specialty certification is defined in the North American literature. METHODS: A rigorous, established six-stage scoping review framework was used to identify the North American certification literature published between January 2006 and May 2016 relating to physician specialty certification. Data were abstracted using a charting form developed by the study team. Quantitative summary data and qualitative thematic analysis of the purpose of certification were derived from the extracted data. RESULTS: A two stage screening process identified 88 articles that met predefined criteria. Only 14 of the 88 articles (16%) contained a referenced purpose of certification. Eighteen definitions were identified from these articles. Definitional concepts included lifelong learning and continuous professional development, assessment of competence and performance, performance improvement, public accountability, and professional standing. DISCUSSION: Most articles identified in this scoping review did not define certification or describe its purpose or intent. Future studies should provide a definition of certification to further scholarly examination of its intent and effects and inform its further evolution.

Learning science as a potential new source of understanding and improvement for continuing education and continuing professional development.

Learning science is an emerging interdisciplinary field that offers educators key insights about what happens in the brain when learning occurs. In addition to explanations about the learning process, which includes memory and involves different parts of the brain, learning science offers effective strategies to inform the planning and implementation of activities and programs in continuing education and continuing professional development. This article provides a brief description of learning, including the three key steps of encoding, consolidation and retrieval. The article also introduces four major learning-science strategies, known as distributed learning, retrieval practice, interleaving, and elaboration, which share the importance of considerable practice. Finally, the article describes how learning science aligns with the general findings from the most recent synthesis of systematic reviews about the effectiveness of continuing medical education.

Integrating Essential Components of Quality Improvement into a New Paradigm for Continuing Education.

Continuing education (CE) that strives to improve patient care in a complex health care system requires a different paradigm than CE that seeks to improve clinician knowledge and competence in an educational setting. A new paradigm for CE is necessary in order to change clinician behavior and to improve patient outcomes in an increasingly patient-centered, quality-oriented care context. The authors assert that a new paradigm should focus attention on an expanded and prioritized list of educational outcomes, starting with those that directly affect patients. Other important components of the paradigm should provide educational leaders with guidance about what interventions work, reasons why interventions work, and what contextual factors may influence the impact of interventions. Once fully developed, a new paradigm will be helpful to educators in designing and implementing more effective CE, an essential component of quality improvement efforts, and in supporting policy trends and in promoting CE scholarship. The purpose of this article is to rekindle interest in CE theory and to suggest key components of a new paradigm.

What Is Implementation Science and What Forces Are Driving a Change in Medical Education?

Evidence-based interventions to improve health care and medical education face multiple complex barriers to adoption and success. Implementation science focuses on the period following research dissemination, which is necessary but insufficient to address important gaps in clinician performance and patient outcomes. This article describes the forces on health care institutions, medical schools, physician clinicians, and trainees that have created the imperative to design educational interventions to address the gap between evidence and practice. These forces include accreditation, certification, licensure, and regulatory and research funding initiatives focused on improving the quality of health professions education and clinical practice. Medical educators must expand their focus on "what to change" to include "how to change" in order to prepare health care professionals and institutions to effectively adopt new evidence-based practices to improve patient, and ultimately population, outcomes.

Description and Impact Evaluation of a Statewide Collaboration to Reduce Preventable Hospital Readmissions.

This article describes how a Medicare-funded Quality Improvement Organization collaborated with a hospital association and multiple cross-continuum partners on a statewide effort to reduce hospital readmissions. Interventions included statewide education on quality improvement strategies and community-specific technical assistance on collaboration approaches, data collection and analysis, and selection and implementation of interventions. Fifteen communities, comprising 16 acute care hospitals, 119 nursing homes, 70 home health agencies, and 32 other health care or social service providers, actively participated over a 4.5-year period. Challenges included problems with end-of-life discussions (80.0%), physician engagement (70.0%), staffing (70.0%), and communication between settings (60.0%). Thirty-day all-cause readmission rates in fee-for-service Medicare patients decreased in most hospital service areas across the state (22/24), and the aggregate statewide readmission rate dropped from 15.2/1000 to 12.1/1000, a relative decrease of 20.3% ( P < .001). Despite these positive findings, the specific impact of this collaboration could not be determined because of multiple confounding interventions.

Key Features of Academic Detailing: Development of an Expert Consensus Using the Delphi Method.

BACKGROUND: Academic detailing is an outreach education technique that combines the direct social marketing traditionally used by pharmaceutical representatives with unbiased content summarizing the best evidence for a given clinical issue. Academic detailing is conducted with clinicians to encourage evidence-based practice in order to improve the quality of care and patient outcomes. The adoption of academic detailing has increased substantially since the original studies in the 1980s. However, the lack of standard agreement on its implementation makes the evaluation of academic detailing outcomes challenging. OBJECTIVE: To identify consensus on the key elements of academic detailing among a group of experts with varying experiences in academic detailing. METHODS: This study is based on an online survey of 20 experts with experience in academic detailing. We used the Delphi process, an iterative and systematic method of developing consensus within a group. We conducted 3 rounds of online surveys, which addressed 72 individual items derived from a previous literature review of 5 features of academic detailing, including (1) content, (2) communication process, (3) clinicians targeted, (4) change agents delivering intervention, and (5) context for intervention. Nonrespondents were removed from later rounds of the surveys. For most questions, a 4-point ordinal scale was used for responses. We defined consensus agreement as 70% of respondents for a single rating category or 80% for dichotomized ratings. RESULTS: The overall survey response rate was 95% (54 of 57 surveys) and nearly 92% consensus agreement on the survey items (66 of 72 items) by the end of the Delphi exercise. The experts' responses suggested that (1) focused clinician education offering support for clinical decision-making is a key component of academic detailing, (2) detailing messages need to be tailored and provide feasible strategies and solutions to challenging cases, and (3) academic detailers need to develop specific skill sets required to overcome barriers to changing clinician behavior. CONCLUSION: Consensus derived from this Delphi exercise can serve as a useful template of general principles in academic detailing initiatives and evaluation. The study findings are limited by the lack of standard definitions of certain terms used in the Delphi process.

Characteristics of Academic Detailing: Results of a Literature Review.

BACKGROUND: Academic detailing is an evidence-based strategy to improve patient care. Efforts to understand the intervention and to use it strategically require an understanding of its important characteristics. A recent systematic review and a subsequent reporting framework call for more accurate and complete reporting of continuing medical education interventions. OBJECTIVES: Building on a previously published systematic review of 69 studies, we sought to determine how an expanded set of 106 academic detailing studies, including many recently published articles, fared with respect to reporting of important data about this intervention. METHODS: We conducted a search of MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (clinical) database, and Scopus, from which we identified 38 additional randomized controlled trials published from August 2007 through March 2013. Including the original 69 studies, we abstracted 106 available English-language studies and quantitatively analyzed information about 4 important characteristics of academic detailing: content of visits, clinicians being visited, communication process underlying visits, and outreach workers making visits. RESULTS: We found considerable variation (36.5%-100%) in the extent of reporting intervention characteristics, especially about the communication process underlying visits and the outreach workers making visits. The best overall documentation of intervention characteristics of any single study was 68%. Results also demonstrate wide variation in the approach to academic detailing. CONCLUSIONS: This study demonstrates the need for a standardized approach to collecting and reporting data about academic detailing interventions. Our findings also highlight opportunities for using academic detailing more effectively in research and quality-improvement efforts.

Process Evaluation of a Quality Improvement Project to Decrease Hospital Readmissions From Skilled Nursing Facilities.

OBJECTIVE: To describe and evaluate the impact of quality improvement (QI) support provided to skilled nursing facilities (SNFs) by a Quality Improvement Organization (QIO). DESIGN: Retrospective, mixed-method, process evaluation of a QI project intended to decrease preventable hospital readmissions from SNFs. SETTING: Five SNFs in Connecticut. PARTICIPANTS: SNF Administrators, Directors of Nursing, Assistant Directors of Nursing, Admissions Coordinators, Registered Nurses, Certified Nursing Assistants, Receptionists, QIO Quality Improvement Consultant. INTERVENTION: QIO staff provided training and technical assistance to SNF administrative and clinical staff to establish or enhance QI infrastructure and implement an established set of QI tools [Interventions to Reduce Acute Care Transfers (INTERACT) tools]. MEASUREMENTS: Baseline SNF demographic, staffing, and hospital readmission data; baseline and follow-up SNF QI structure (QI Committee), processes (general and use of INTERACT tools), and outcome (30-day all-cause hospital readmission rates); details of QIO-provided training and technical assistance; QIO-perceived barriers to quality improvement; SNF leadership-perceived barriers, accomplishments, and suggestions for improvement of QIO support. RESULTS: Success occurred in establishing QI Committees and targeting preventable hospital readmissions, as well as implementing INTERACT tools in all SNFs; however, hospital readmission rates decreased in only 2 facilities. QIO staff and SNF leaders noted the ongoing challenge of engaging already busy SNF staff and leadership in QI activities. SNF leaders reported that they appreciated the training and technical assistance that their institutions received, although most noted that additional support was needed to bring about improvement in readmission rates. CONCLUSION: This process evaluation documented mixed clinical results but successfully identified opportunities to improve recruitment of and provision of technical support to participating SNFs. Recommendations are offered for others who wish to conduct similar projects.

Terminology in Continuing Education: A Hybrid Methodology for Improving the Use and Reporting of Interventions in Continuing Education.

Researchers and leaders working in quality improvement and continuing education have a variety of interventions available to change clinician behavior and to improve patient outcomes. Evidence from systematic reviews and meta-analyses of such interventions is often mixed, with methodological weaknesses contributing to challenges in summarizing and interpreting evidence. Confusion and inconsistency surrounding many of the terms contributes to this challenge. This international study was commissioned by the Society for Academic Continuing Medical Education to use expert opinion to improve the consistency of important educational terminology by describing the essential components of a set of educational interventions, such as educational meetings. This article will describe how this project uses the literature and an expert consensus process to improve precision around the conceptualization and implementation of educational interventions. This article will offer an in-depth description of a hybrid methodology that blends the Chaffee framework for concept explication with a modified Delphi technique that constitutes a novel expert consensus process. This article concludes with recommendations for other scholars replicating this process.

Society for Academic Continuing Medical Education Intervention Guideline Series: Guideline 1, Performance Measurement and Feedback.

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, to standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, performance measurement and feedback, which is a common intervention in health professions education. In the form of a summary report, performance measurement and feedback is an opportunity for clinicians to view data about the care they provide compared with some standard and often with peer and benchmark comparisons. Based on a review of recent evidence and a facilitated discussion with the US and Canadian experts, we describe proper terminology for performance measurement and feedback and other important information about the intervention. We encourage leaders and researchers to consider and build on this guideline as they plan, implement, evaluate, and report efforts with performance measurement and feedback. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of performance measurement and feedback.

Society for Academic Continuing Medical Education Intervention Guideline Series: Guideline 2, Practice Facilitation.

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, practice facilitation, which is a common strategy in primary care to help practices develop capacity and infrastructure to support their ability to improve patient care. Based on a review of recent evidence and a facilitated discussion with US and Canadian experts, we describe practice facilitation, its terminology, and other important information about the intervention. We encourage leaders and researchers to consider and build on this guideline as they plan, implement, evaluate, and report practice facilitation efforts. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of practice facilitation.

Society for Academic Continuing Medical Education Intervention Guideline Series: Guideline 3, Educational Meetings.

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, to standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, educational meetings, which is a common intervention in health professions' education. An educational meeting is an opportunity for clinicians to assemble to discuss and apply important information relevant to patient care. Based on a review of recent evidence and a facilitated discussion with US and Canadian experts, we describe proper educational meeting terminology and other important information about the intervention. We encourage leaders and researchers to consider and to build on this guideline as they plan, implement, evaluate, and report educational meeting efforts. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of educational meetings.

Conceptualization and Reporting of Context in the North American Continuing Medical Education Literature: A Scoping Review Protocol.

Within continuing medication education (CME), it has been argued that an "authentic" clinical context should be built into CME activities for knowledge to be effectively translated into clinical practice. However, although context is considered significant in the success (or lack thereof) of an intervention, there is a lack of consensus on what exactly context is. This scoping review arises from concerns surrounding the opaque, complex, and potentially problematic relationship between context and the effective design and implementation of CME interventions. In this article, we present a protocol for examining how context is discussed within the CME literature. The specific purpose of this scoping review is to summarize the breadth of existing evidence on context within the North American CME literature. The scoping review methodology will also highlight gaps in the current literature, which can inform future research endeavors.