A new framework for Australian specialty colleges and other healthcare leaders to address bullying, discrimination, and harassment that involves doctors.

Bullying, discrimination, and harassment (BDH) within healthcare teams is a global issue that risks healthcare worker wellbeing, patient safety, public health, and industry reputations. Collectively, fragmented regulation, weak detection and correction processes, conflicts of interest, and fear of retribution for complainants create an environment that enables perpetrators. Specialty training Colleges and other stakeholders can collaborate to address this issue more effectively. This paper examines Australian processes and proposes that the existing disparate mechanisms should be replaced with a national BDH framework that is supported by an independent investigation body. The authors seek to stimulate discussion to reform practice in Australia and in other countries with similar health systems.

Informing the development of a scoring system for National Health Service Clinical Impact Awards; a Delphi process and simulated scoring exercise.

Objectives: To establish principles informing a new scoring system for the UK's Clinical Impact Awards and pilot a system based on those principles. Design: A three-round online Delphi process was used to generate consensus from experts on principles a scoring system should follow. We conducted a shadow scoring exercise of 20 anonymised, historic applications using a new scoring system incorporating those principles. Setting: Assessment of clinical excellence awards for senior doctors and dentists in England and Wales. Participants: The Delphi panel comprised 45 members including clinical excellence award assessors and representatives of professional bodies. The shadow scoring exercise was completed by 24 current clinical excellence award assessors. Main outcome measures: The Delphi panel rated the appropriateness of a series of items. In the shadow scoring exercise, a novel scoring system was used with each of five domains rated on a 0-10 scale. Results: Consensus was achieved around principles that could underpin a future scoring system; in particular, a 0-10 scale with the lowest point on the scale reflecting someone operating below the expectations of their job plan was agreed as appropriate. The shadow scoring exercise showed similar levels of reliability between the novel scoring system and that used historically, but with potentially better distinguishing performance at higher levels of performance. Conclusions: Clinical excellence awards represent substantial public spending and thus far the deployment of these funds has lacked a strong evidence base. We have developed a new scoring system in a robust manner which shows improvements over current arrangements.

Policies on doctors' declaration of interests in medical organisations: a thematic analysis.

OBJECTIVES: There has been growing concern about doctors' conflicts of interests (COIs) but it is unclear what processes and tools exist to enable the consistent declaration and management of such interests. This study mapped existing policies across a variety of organisations and settings to better understand the degree of variation and identify opportunities for improvement. DESIGN: Thematic analysis. SETTING: We studied the COI policies of 31 UK and international organisations which set or influence professional standards or engage doctors in healthcare commissioning and provision settings. PARTICIPANTS: 31 UK and international organisations. MAIN OUTCOME MEASURES: Organisational policy similarities and differences. RESULTS: Most policies (29/31) referred to the need for individuals to apply judgement when deciding whether an interest is a conflict, with just over half (18/31) advocating a low threshold. Policies differed on the perception of frequency of COI, the timings of declarations, the type of interests that needed to be declared, and how COI and policy breaches should be managed. Just 14/31 policies stated a duty to report concerns in relation to COI. Only 18/31 policies advised COI would be published, while three stated that any disclosures would remain confidential. CONCLUSIONS: The analysis of organisational policies revealed wide variation in what interests should be declared, when and how. This variation suggests that the current system may not be adequate to maintain a high level of professional integrity in all settings and that there is a need for better standardisation that reduces the risk of errors while addressing the needs of doctors, organisations and the public.

Practical Issues of Medical Experts in Assessing Persons With Mental Illness Asking for Assisted Dying in Switzerland.

With about 65,000 deaths per year in Switzerland, about 1,000 assisted suicides of Swiss citizens are carried out with the help of assisted dying organizations per year. Assisted suicide, which is carried out without selfish motives on the side of the helping person, only remains unpunished if there is a free will decision by the person willing to die who has the capacity of judgement and to act independently. While this is usually accepted as an option for somatically terminally ill patients in society at large, this procedure is controversial for psychiatrically ill patients. In Switzerland the topic of assisted dying is highly debated between medical professionals. In 2018, the Swiss Academy of Medical Sciences (SAMS) put revised guidelines into force, which are in discrepancy to the current rules of the Swiss Medical Association (FMH). This article gives an overview of the past and current development of the Code of Professional Conduct and medical-ethical guidelines as well as current Swiss criminal and medical law on this topic. Practical implications for the assessment of assessing persons with mental illness in this circumstances are discussed. It is to be concluded, that persons with a mental illness seem to face extra obstacles in relation with somatically ill persons as the assessment of the prerequisites comprises additional requirements. Among other issues there is an urgent need for the elaboration of contents to be assessed and standards of procedures. The procedures and guidelines to be elaborated should be scientifically accompanied in order to gain a more reliable basis for decision-making. Multidisciplinary assessments would help to avoid biases and blind spots of a mono-disciplinary assessments. In addition, even in the case of mentally ill people, their right to self-determined suicide should not be restricted by excessive hurdles in the assessment process. Lastly, reliable funding should be secured, as it is otherwise to be expected that the complex assessment of prerequisites through multi-professional-teams or just one assessor cannot be sustained. The exercise of fundamental rights must be possible for all persons to the same extent, regardless of their financial resources.

Future healthcare providers and professionalism on social media: a cross-sectional study.

BACKGROUND: Nowadays, social media have become central in the daily lives of people, including healthcare professionals. Fears arise that the accelerated growth of these social platforms was not accompanied by the appropriate training of the healthcare students and workers on the professional use of social media. This study primarily aimed to assess the awareness of the healthcare students at Beirut Arab University, Lebanon on the professional standards of social media. It also aimed to assess the presence of differences in the practices and attitudes of healthcare students according to gender and major. METHODS: A cross-sectional study was designed, and a paper-based questionnaire was distributed to healthcare students. Chi-Square test was used to analyse certain findings. RESULTS: Out of 1800 students approached, 496 participated in the questionnaire. All participants used social media. Only 19.5% (96/496) of them had received a structured education on the professional use of social media during their university study. The majority of students (349/488, 71.5%) thought that the professional standards on social media are distinct from those established in face-to-face interactions. Female students were more likely to get adequate answers in accordance with international guidelines. There were statistically significant differences in the practices and attitudes of students belonging to different majors (p value < 0.05). CONCLUSION: The line between what is professional on social media, and what is not, remains blurred for healthcare students. This study uncovered the need for clear and updated evidence-based guidelines assisting students in making the most appropriate decisions in the various online scenarios faced in healthcare practice.

Using social media in contemporary nursing: risks and benefits.

Social media has become incorporated into the practice of contemporary nursing. It must be acknowledged by the nurse and the nursing profession that social media has the power to enable the nurse to network with colleagues and share research findings through both private and open forums. However, it also has the potential to negatively influence patient care. This article discusses the use of social media and the dilemmas both ethical and legal. It highlights the need for the nurse and the nursing profession to remain vigilant regarding its use within both their personal and professional lives, to ensure that no boundaries are inadvertently crossed.

Registered nurses understanding of academic honesty and the perceived relationship to professional conduct: Findings from a cross-sectional survey conducted in Southeast Asia.

BACKGROUND: Academic dishonesty is increasing in prevalence in universities globally. Concerns exist that engagement in academic dishonesty by nursing students may transfer to professional misconduct in the clinical setting, thereby jeopardising the quality of patient care. OBJECTIVES: To determine the type and prevalence of academic dishonesty engaged in by post-registration nursing students and their understanding of the relationship between academic honesty and professional conduct. DESIGN: An exploratory quantitative study employing a cross sectional survey. SETTINGS AND PARTICIPANTS: A convenience sample of undergraduate students enrolled in an Australian post-registration nursing degree program delivered in a Southeast Asian country. METHODS: An online anonymous survey comprising 38 Likert-style items was completed by 179 voluntary participants. Descriptive statistics were used to analyse data pertaining to the frequency and type of academic dishonesty. Chi-square tests were used to identify associations between issues such as frequency of engagement to academically dishonest activities and perceptions of professional misconduct. Responses to open-ended questions was undertaken using descriptive summative content analysis. RESULTS: Almost 96% (n = 153) of participants agreed that academic dishonesty constitutes a breach of professional codes of conduct with 97.5% (n = 156) stating it should be viewed as professional misconduct. Findings revealed 44.1% (n = 79) of participants reported engagement with at least one type of academic dishonesty. Of these, 55 (69%) reported involvement in two or more types. CONCLUSIONS: Academic dishonesty continues to be an issue in nursing education with serious ramifications for professional conduct and patient outcomes. Educators must take a targeted approach to educating students about the importance of academic integrity and its relationship to professional conduct. This includes supporting students to develop academic skills such as referencing. Appropriate penalties and reporting of students who engage in academic dishonest behaviour to academic and professional regulatory authorities are also essential actions required to prevent academic dishonesty.

Client experiences and confidence in nutrition advice delivered by registered exercise professionals.

OBJECTIVES: The aims of this cross-sectional study were to describe the client experiences of registered exercise professionals (REP) in regard to nutrition advice, and to identify factors considered important when selecting a REP. DESIGN: A convenience sample of fitness facility-users were recruited. Participants completed a 46 item online questionnaire. METHOD: Frequency distributions were calculated for nutrition advice received from a REP, confidence in the nutrition advice received, and factors considered when selecting a REP. The effect of sex and level of education on participant responses were investigated. RESULTS: A total of 455 individuals participated, of which 55.6% had worked with a REP. Participants working with a REP had received nutrition advice on body fat loss (77.4%), muscle gain (78.7%), and clinical nutrition (51.9%). Sex and level of education did not influence confidence in nutrition advice, with 60.7% of participants reporting being 'very or extremely confident' in the nutrition advice. Over half of participants (58.3%) prefer to work with a REP who offers nutrition advice. Basic and personal professional conduct were identified as 'very or extremely important' by >70% of participants when selecting a REP. CONCLUSION: Clients of REP prefer to work with a REP who provides nutrition advice and are generally confident in this advice. Educating fitness facility-users on the nutrition scope of practice of REP and promoting the role of accredited nutrition professionals should be advocated. Encouraging REP to work collaboratively with nutrition professionals will help ensure clients receive appropriate nutrition care, while better allowing REP to remain within their scope of practice.

Contribuições técnicas e socioculturais da prevenção quaternária para a atenção primária à saúde: caminhos e desafios / Technical and socio-cultural contributions of quaternary prevention for primary health care: paths and challenges / Contribuciones técnicas y socioculturales de prevención cuaternaria para la atención primaria de salud: caminos y desafíos

Introdução: No contexto do Sistema Único de Saúde, o conceito da prevenção quaternária adentra timidamente os níveis de atenção à saúde, no entanto, sofre expansão significativa no âmbito da atenção primária à saúde. Objetivo: Identificar por meio da sistematização de evidências científicas, as contribuições técnicas e socioculturais da prevenção quaternária no âmbito da atenção primária à saúde no Brasil. Métodos: Trata-se de uma revisão integrativa de estudos presentes nas bases de dados científicas da Scientific Electronic Library Online, Biblioteca Virtual em Saúde, biblioteca virtual da Comissão de Aperfeiçoamento de Pessoal do Nível Superior e MEDLINE via PubMed com a utilização dos descritores "prevenção quaternária" e "atenção primária à saúde", em inglês e português. Resultados: O corpus de análise foi composto por 22 artigos, sendo que a produção científica sobre o tema se deu de forma mais intensa a partir do ano de 2015 e, em sua maioria, possuíam como abordagem metodológica ensaios teóricos. Dentre as contribuições técnicas destacaram-se a introdução do ensino da prevenção quaternária de modo continuado aos graduandos e profissionais; a construção de protocolos e documentos de amparo profissional; a utilização de modelos explicativos dinâmicos na socialização do quadro clínico; a conduta profissional com os usuários e as contribuições socioculturais envolvendo mudanças na percepção profissional e comunitária sobre o fenômeno saúde-doença, assim como o incentivo a práticas de desmedicalização sociocultural em relação à dor, incapacidade, desconforto, envelhecimento, nascimento e morte. Conclusão: Apesar do reconhecimento das potencialidades da prevenção quaternária, faz-se necessário fortalecer estratégias que possibilitem o desenvolvimento de políticas públicas para fomentar e gerenciar alianças estratégicas com tomadores de decisão, profissionais de saúde e cidadãos, para fomentar a redução de diagnósticos e tratamentos excessivos, contribuindo com a qualidade do cuidado.

Introduction: In the context of the Unified Health System, the concept of quaternary prevention shyly enters the levels of health care, however, undergoes significant expansion in the scope of primary health care. Objective: To identify, through the systematization of scientific evidence, the technical and socio-cultural contributions of quaternary prevention within the scope of primary health care in Brazil. Methods: This is an integrative review of studies present in the scientific databases of the Scientific Electronic Library Online, Regional Portal of the Virtual Health Library of the Latin American and Caribbean Center on Health Sciences Information of the Pan American Health Organization, virtual library of the Higher Education Personnel Improvement Commission, and MEDLINE through PubMed using the descriptors "quaternary prevention" and "primary health care", in English and Portuguese. Results: The corpus of analysis consisted of 22 articles, and the scientific production on the topic took place more intensively from the year 2015 and, for the most part, had theoretical essays as methodological approach. Among the technical contributions, we highlight the introduction of teaching on quaternary prevention in a continuous way to undergraduates and professionals; the construction of protocols and documents of professional support; the use of dynamic explanatory models in the socialization of the clinical picture and professional conduct with users and socio-cultural contributions involve changes in the professional and community perception about the phenomenon of illness and health conception, as well as the incentive to practices of socio-cultural demedicalization in relation to pain, disability, discomfort, aging, birth, and death. Conclusion: Despite the recognition of the potential of quaternary prevention, it is necessary to strengthen strategies that enable the development of public policies to foster and manage strategic alliances with decision makers, health professionals and citizens, to promote the reduction of excessive diagnoses and treatments, contributing to the quality of care.

Introducción: En el contexto del Sistema Único de Salud, el concepto de prevención cuaternaria entra tímidamente en los niveles de atención de salud, sin embargo, experimenta una expansión significativa en el alcance de la Atención Primaria de Salud. Objetivo: Identificar, a través de la sistematización de evidencia científica, las contribuciones técnicas y socioculturales de la prevención cuaternaria en el ámbito de la Atención Primaria de Salud en Brasil. Métodos: Esta es una revisión integradora de estudios presentes en las bases de datos científicas de la Biblioteca Electrónica Científica en línea, Portal Regional de la Biblioteca Virtual en Salud del Centro Latinoamericano y del Caribe de Información en Ciencias de la Salud de la Organización Panamericana de la Salud, biblioteca virtual de la Comisión de Mejoramiento del Personal de Educación Superior y MEDLINE a través de PubMed utilizando los descriptores de prevención cuaternaria y atención primaria de salud, en inglés y portugués. Resultados: El corpus de análisis estuvo conformado por 22 artículos, siendo la producción científica sobre el tema más intensiva desde 2015 y, en su mayor parte, tuvo ensayos teóricos como abordaje metodológico. Entre los aportes técnicos, destacamos la implantación de la docencia en prevención cuaternaria de forma continua a estudiantes de pregrado y profesionales; construcción de protocolos y documentos de apoyo profesional, uso de modelos explicativos dinámicos en la socialización del cuadro clínico y conducta profesional con los usuarios y los aportes socioculturales implican cambios en la percepción profesional y comunitaria sobre el fenómeno de la enfermedad y la concepción de la salud, así como el incentivo a prácticas de desmedicalización sociocultural en relación al dolor, discapacidad, malestar, envejecimiento, nacimiento y muerte. Conclusión: A pesar del reconocimiento del potencial de la prevención cuaternaria, es necesario fortalecer estrategias que permitan el desarrollo de políticas públicas para fomentar y gestionar alianzas estratégicas con los tomadores de decisiones, profesionales de la salud y ciudadanos, para promover la reducción de diagnósticos y tratamientos excesivos, contribuyendo a la calidad de la atención.

The quality and safety of locum doctors: a narrative review.

Locum doctors are often perceived to present greater risks of causing harm to patients than permanent doctors. After eligibility and quality assessment, eight empirical and 34 non-empirical papers were included in a narrative synthesis to establish what was known about the quality and safety of locum medical practice. Empirical literature was limited and weak methodologically. Locums enabled healthcare organisations to maintain appropriate staffing levels and allowed staffing flexibility, but they also gave rise to concerns about continuity of care, patient safety, team function and cost. There was some evidence to suggest that the way locum doctors are recruited, employed and used by organisations, may result in a higher risk of harm to patients. A better understanding of the quality and safety of locum working is needed to improve the use of locum doctors and the quality and safety of patient care that they provide.

Understanding the factors influencing doctors' intentions to report patient safety concerns: a qualitative study.

OBJECTIVES: To investigate doctors' intentions to raise a patient safety concern by applying the socio-psychological model 'Theory of Planned Behaviour'. DESIGN: Qualitative semi-structured focus groups and interviews. SETTING: Training venues across England (North West, South East and South West). PARTICIPANTS: Sampling was purposeful to include doctors from differing backgrounds and grades. MAIN OUTCOME MEASURES: Perceptions of raising a patient safety concern. RESULTS: While raising a concern was considered an appropriate professional behaviour, there were multiple barriers to raising a concern, which could be explained by the Theory of Planned Behaviour. Negative attitudes operated due to a fear of the consequences, such as becoming professionally isolated. Disapproval for raising a concern was encountered at an interpersonal and organisational level. Organisational constraints of workload and culture significantly undermined the raising of a concern. Responses about concerns were often side-lined or not taken seriously, leading to demotivation to report. This was reinforced by high-profile cases in the media and the negative treatment of whistle-blowers. While regulator guidance acted as an enabler to justify raising a concern, doctors felt disempowered to raise a concern about people in positions of greater power, and ceased to report concerns due to a perceived lack of action about concerns raised previously. CONCLUSIONS: Intentions to raise a concern were complex and highly contextual. The Theory of Planned Behaviour is a useful model to aid understanding of the factors which influence the decision to raise a concern. Results point to implications for policymakers, including the need to publicise positive stories of whistle-blowers and providing greater support to doctors.

Describing the Attributional Nature of Academic Dishonesty.

There is strong evidence that dishonesty occurs amongst medical students, and other allied health students and growing evidence that it occurs amongst medical academics. We believe that accidental dishonesty (or not knowing about the rules of regulations governing academic integrity) is a common attribution describing engagement in dishonesty; however, we believe that dishonest action is more often influenced and determined according to circumstance. In this paper, we aim to work through the literature that frames dishonest action with a focus on medical education, research and publication. We argue that the implications for medical education are far reaching and the root causes of many instances of dishonesty need to be more fully understood so that comprehensive, case-by-case ameliorative strategies can be developed.

Fostering Students' Collaborative Learning Competencies and Professional Conduct in the Context of Two Gross Anatomy Courses in Veterinary Medicine.

Collaborative learning has been used in anatomy courses to support students' learning of challenging topics but the success of group work depends significantly on the students' ability to communicate in a professional manner. Veterinary students' experiences with tasks related to collaborative learning and professional conduct were studied by comparing learning collaborative competences and pedagogy, as well as perceived positive and challenging aspects, in two gross anatomy courses. Both qualitative and quantitative data were collected from students' experiences of course assignments and collaboration, as well as from self-evaluated collaboration competence development. Trying things out oneself, practical application and professional conduct were positively highlighted particularly in the first-year course (myology and arthrology) group work and learning from others more in the second year (topographical anatomy). Various group work challenges, often relating to practical matters or communication, were the key concerns for students. The main difference between the two courses in learning of collaborative knowledge work competencies appeared to relate to the nature of the group work assignment. The topography course included the element of collaboration in preparing a presentation and teaching session for the rest of the class. Interestingly, students on the myology and arthrology course gave more positive comments on professional conduct than the students on the topography course despite the fact that the latter course included more practical elements relating to their future profession.

Indigenous clients intersecting with mainstream nursing: a reflection.

CONTEXT: Mental health care for Australian Aboriginal and Torres Strait Islander people living in rural and remote locations is delivered primarily by nurses. Culturally safe therapeutic interventions can promote understanding and improve care. Reflective knowledge thinking, writing and practice can support nurses to practice cultural safety. ISSUES: Two instances of mental health care for Australian Aboriginal and Torres Strait Islander clients are described in this reflective piece of writing. The care provided in both instances was culturally inappropriate and/or inadequate. I was an agent or observer in both cases, which happened during my employment as a mental health nurse in Australia. The first story, 'the traumatisation of Client A' describes an instance where I, from a place of ignorance, acted without cultural sensitivity and knowledge. I restrained and observed a client in a way that accorded with workplace policy but, at the same time, failed to take into account the circumstances and cultural safety of my client. The second story, 'the misunderstandings about Client B', occurred much later in my career. This time, I engaged with the client, acted with cultural safety, listened to his story and was able to clear up misunderstandings surrounding his presentation to hospital. LESSONS LEARNED: The two events described in this article led me to discover the nurse I was then and the nurse I have become now. In comparing the two events and my level of awareness and understanding of Aboriginal peoples, along with my own actions, I reflect on my own journey of discovery, which has informed and shaped my awareness as a culturally safe and more sensitive nurse.

Women's health care: the experiences and behaviors of rural and urban lesbians in the USA.

INTRODUCTION: Previous research has consistently demonstrated that, in comparison to their cisgender heterosexual counterparts, lesbians face a multitude of women's healthcare-related disparities. However, very little research has been conducted that takes an intersectionality approach to examining the potential influences of rural-urban location on the health-related needs and experiences of lesbians. The purpose of this study was to quantitatively compare rural and urban lesbians' access to women's health care, experiences with women's healthcare providers (WHCPs), and preventive behavior using a large, diverse sample of lesbians from across the USA. METHODS: A total of 895 (31.1% rural and 68.9% urban) lesbian-identified cisgender women (ie not transgender) from the USA participated in the current online study. As part of a larger parent study, participants were recruited from across the USA through email communication to lesbian, gay, bisexual, and transgender (LGBT)-focused organizations and online advertisements. Participants were asked to complete a series of questions related to their women's healthcare-related experiences and behaviors (ie access to care, experiences with WHCPs, and preventive behavior). A series of χ2 analyses were utilized in order to examine rural-urban differences across dependent variables. RESULTS: An examination of sexual risks revealed that relatively more rural lesbians reported at least one previous male sexual partner in comparison to the urban sample of lesbians (78.1% vs 69.1%, χ2(1, N=890)=7.56, p=0.006). A similarly low percentage of rural (42.4%) and urban (42.9%) lesbians reported that they have a WHCP that they see on a regular basis for preventive care. In terms of experiences with WHCP providers, relatively fewer rural lesbians indicated that their current WHCP had discussed/recommended the human papillomavirus (HPV) vaccination in comparison to urban lesbians (27.5% vs. 37.2%; χ2 (1, N=796)=7.24, p=0.007). No other rural-urban differences in experiences with WHCPs emerged - few rural and urban lesbians had been asked about their sexual orientation by their WHCP (38.8% and 45.0%, respectively), been provided with appropriate safe-sex education by their WHCP (21.4% and 25.3%), had their last HIV/sexually transmitted infection screening instigated by their WHCP (if applicable; 15.7% and 19.5%), and reported that their WHCP seems knowledgeable about lesbian health concerns (56.5% vs 54.6%). In terms of preventive behavior, significantly fewer rural lesbians aged 40 years or more had received a mammogram in the past 3 years (63.2% vs 83.2%; χ2(1, N=163)=8.36, p=0.004) when compared to their urban counterparts. No other significant rural-urban differences in preventive behaviors emerged. A similarly low percentage of rural and urban lesbians indicated that they have received the HPV vaccination (22.8% and 29.0%, respectively) and/or have had a HIV/STI screening (43.0% and 47.8%), Pap test (62.0% and 64.5%) or breast exam (59.2% and 62.8%), in the past 3 years. CONCLUSIONS: The current findings highlight that rural lesbians in the USA, in comparison to urban lesbians, may experience elevated health risks related to being more likely to have at least one previous male sexual partner, less likely to be recommended the HPV vaccination by a WHCP, and, for those 40 or older, less likely to receive routine mammogram screenings. Furthermore, rural lesbians appear to engage in similarly low rates of HPV vaccination and regular HIV/STI screenings, Pap tests, and clinical breast exams as their urban counterparts. Given the increased cervical and breast cancer risks associated with rural living, the current findings underscore the dire need for health promotion efforts aimed at increasing rural lesbians' engagement in routine pelvic and breast exams.

Developing a grounded theory for interprofessional collaboration acquisition using facilitator and actor perspectives in simulated wilderness medical emergencies.

CONTEXT: Interprofessional collaboration is a complex process that has the potential to transform patient care for the better in urban, rural and remote healthcare settings. Simulation has been found to improve participants' interprofessional competencies, but the mechanisms by which interprofessionalism is learned have yet to be understood. A rural wilderness medicine conference (WildER Med) in northern Ontario, Canada with simulated medical scenarios has been demonstrated to be effective in improving participants' collaboration without formal interprofessional education (IPE) curriculum. ISSUES: Interprofessionalism may be taught through rural and remote medical simulation, as done in WildER Med where participants' interprofessional competencies improved without any formal IPE curriculum. This learning may be attributed to the informal and hidden curriculum. Understanding the mechanism by which this rural educational experience contributed to participants' learning to collaborate requires insight into the events before, during and after the simulations. The authors drew upon feedback from facilitators and patient actors in one-on-one interviews to develop a grounded theory for how collaboration is taught and learned. LESSONS LEARNED: Sharing emerged as the core concept of a grounded theory to explain how team members acquired interprofessional collaboration competencies. Sharing was enacted through the strategies of developing common goals, sharing leadership, and developing mutual respect and understanding. Further analysis of the data and literature suggests that the social wilderness environment was foundational in enabling sharing to occur. Medical simulations in other rural and remote settings may offer an environment conducive to collaboration and be effective in teaching collaboration. When designing interprofessional education, health educators should consider using emergency response teams or rural community health teams to optimize the informal and hidden curriculum contributing to interprofessional learning.

Validating competencies for an undergraduate training program in rural medicine using the Delphi technique.

INTRODUCTION: Worldwide, half the population lives in rural or remote areas; however, less than 25% of doctors work in such regions. Despite the continental dimensions of Brazil and its enormous cultural diversity, only some medical schools in this country offer students the opportunity to acquire work experience focused on medicine in rural or remote areas. The objective of the present study was to develop a framework of competencies for a longitudinal medical training program in rural medicine as an integrated part of medical training in Brazil. METHODS: Two rounds of a modified version of the Delphi technique were conducted. Initially, a structured questionnaire was elaborated, based on a literature review. This questionnaire was submitted to the opinion of 20 panelists affiliated with the Rural Medicine Working Party of the Brazilian Society of Family and Community Medicine. The panelists were asked to evaluate the relevance of the competencies using a five-point Likert-type scale. In this study, the consensus criterion for a competency to be included in the framework was it being deemed 'very important' or 'indispensable' by a simple majority of the participants, while the criterion for excluding a competency was that a simple majority of the panel members considered that it 'should not be included' or was 'of little importance'. When a consensus was not reached regarding a given competency, it was submitted to a second round to enable the panelists to re-evaluate the now dichotomized questions. RESULTS: Compliance in responding to the questionnaire was better among the panelists predominantly involved in teaching activities (85%; n=12) compared to those working principally in patient care (45%; n=8). The questionnaire consisted of 26 core competencies and 165 secondary competencies. After evaluation by the specialists, all the 26 core competencies were classified as relevant, with none being excluded and only eight secondary competencies failing to achieve a consensus. No new competencies were suggested. Of the competencies that failed to reach a consensus in the first round, seven were excluded from the framework in the second round, with most of these being associated with hospital procedures. CONCLUSIONS: A framework of competencies for a program in rural medicine was developed and validated. It consists of 26 core competencies and 158 secondary competencies that should be useful when constructing competency-based curricula in rural medicine for medical education in Brazil.

Outreach programs: an adjunct for improving dental education.

INTRODUCTION: An important objective of education is to improve clinical competence and hence confidence of students. Ample evidence on effectiveness of medical outreach programs is available but data pertaining to effectiveness of dental outreach, especially from developing countries, are still limited. The present study was undertaken to assess effectiveness of outreach placements on clinical confidence and communication skills of Indian dental students. METHODS: A non-randomized trial was conducted in three randomly selected dental colleges of Bangalore city, India, amongst 89 students pursuing internship programs. Subjects were put into two groups: outreach (study group) and dental school based only (control group). A pre-tested, self-administered questionnaire was used to evaluate the change in clinical confidence and communication skills of both groups from baseline and after 3 months of follow-up via global self-assessment test, then-test and transition judgment. Outcome measures were analysed using t-test. RESULTS: Global assessment revealed outreach group confidence level was higher in comparison to dental school based group only (4.37±0.49 vs 4.04±0.21, p<0.001), while using then-test their baseline confidence was observed to be lower (3.42±0.75 vs 3.72±0.72, p=0.04). Transition judgement rated an increase in their confidence significantly higher than the dental school based group only (4.24±0.91 vs 2.54±0.66, p<0.001). The outreach group rated increase in communication skills to be higher for the transition judgement. CONCLUSIONS: The present trial supports the concept of outreach programs to be incorporated in the existing dental curricula in order to supplement the traditional school-based dental education to achieve an overall professionally trained dentist.