Reflections on the physical, executive developmental and systems applied framework in child neuropsychological rehabilitation.

This paper describes the influence of the Physical, Executive, Developmental and Systems (PEDS) framework on the delivery of community-based child neuropsychological rehabilitation and how it has been enhanced by the proliferation of neuroscientific, neuropsychological and psychosocial research and evidence-base in childhood brain injury and rehabilitation over the past decade. The paper signposts to some of the key models, theories and concepts currently shaping service delivery. Application of the PEDS framework in a clinical case is described.

Continuing bonds after suicide bereavement in childhood.

It has been argued that the grieving process after suicide bereavement has unique properties (e.g.,J. R.Jordan, 2001). A qualitative study was conducted to explore one aspect of the grieving process--continuing bonds--after suicide bereavement in childhood. Data were collected through semi-structured interviews with 10 suicide-bereaved children and analyzed using Interpretative Phenomenological Analysis (Smith & Osborn, 2003). Three themes are discussed: thinking about the deceased, coping strategies, and ongoing connections to the deceased. The findings highlight potentially unique qualities of continuing bonds after childhood suicide bereavement and factors that might influence their adaptiveness. Theoretical and clinical implications are outlined.

Ambulance officers' use of online clinical evidence.

BACKGROUND: Hospital-based clinicians have been shown to use and attain benefits from online evidence systems. To our knowledge there have been no studies investigating whether and how ambulance officers use online evidence systems if provided. We surveyed ambulance officers to examine their knowledge and use of the Clinical Information Access Program (CIAP), an online evidence system providing 24-hour access to information to support evidence-based practice. METHODS: A questionnaire was completed by 278 ambulance officers in New South Wales, Australia. Comparisons were made between those who used CIAP and officers who had heard of, but not used CIAP. RESULTS: Half the sample (48.6%) knew of, and 28.8% had used CIAP. Users were more likely to have heard of CIAP from a CIAP representative/presentation, non-users from written information. Compared to ambulance officers who had heard of but had not used CIAP, users were more likely to report better computer skills and that their supervisors regarded use of CIAP as a legitimate part of ambulance officers' clinical role. The main reasons for non-use were lack of access(49.0%) and training(31.4%). Of users, 51.3% rated their skills at finding information as good/very good, 67.5% found the information sought all/most of the time, 87.3% believed CIAP had the potential to improve patient care and 28.2% had directly experienced this. Most access to CIAP occurred at home. The databases frequently accessed were MIMS (A medicines information database) (73.8%) and MEDLINE(67.5%). The major journals accessed were Journal of Emergency Nursing(37.5%), American Journal of Medicine(30.0%) and JAMA(27.5%). CONCLUSION: Over half of ambulance officers had not heard of CIAP. The proportion who knew about and used CIAP was also low. Reasons for this appear to be a work culture not convinced of CIAP's relevance to pre-hospital patient care and lack of access to CIAP at work. Ambulance officers who used CIAP accessed it primarily from home and valued it highly. Lack of access to CIAP at central work locations deprives ambulance officers of many of the benefits of an online evidence system.

The impact of an online evidence system on confidence in decision making in a controlled setting.

OBJECTIVE: To examine the impact of online evidence retrieval on clinicians' decision-making confidence and to determine if this differs for experienced doctors and nurses. METHODS: A sample of 44 doctors and 31 clinical nurse consultants (CNCs) answered 8 clinical scenarios (600 scenario answers) before and after the use of online evidence resources. Clinicians rated their confidence in scenario answers and in the evidence they found using the information system. RESULTS: Prior to using online evidence, 37% of doctors and 18% of CNCs answered the scenarios correctly. These clinicians were more confident (56% very confident or confident) in their answers than those with incorrect (34%) answers. Doctors with incorrect answers prior to searching rated their confidence significantly higher than did nurses who were incorrect. After searching, both groups answered 50% of scenarios correctly. Clinicians with correct answers had greater confidence in the evidence found compared to those with incorrect answers. Doctors were more confident in evidence found confirming an initially correct answer than were nurses. More than 50% of clinicians who persisted with an incorrect answer after searching reported that they were confident or very confident in the evidence found. Clinicians who did not know scenario answers before searching placed equal confidence in evidence that led them to a correct or incorrect answer. CONCLUSIONS: The information obtained from an online evidence system influenced clinicians' confidence in their answers to the clinical scenarios. The relationship between confidence in answers and correctness is complex. Both existing knowledge and professional role were mediating factors. The finding that many clinicians placed confidence in information that led them to incorrect answers warrants further investigation.

Do online information retrieval systems help experienced clinicians answer clinical questions?

OBJECTIVE: To assess the impact of clinicians' use of an online information retrieval system on their performance in answering clinical questions. DESIGN: Pre-/post-intervention experimental design. MEASUREMENTS: In a computer laboratory, 75 clinicians (26 hospital-based doctors, 18 family practitioners, and 31 clinical nurse consultants) provided 600 answers to eight clinical scenarios before and after the use of an online information retrieval system. We examined the proportion of correct answers pre- and post-intervention, direction of change in answers, and differences between professional groups. RESULTS: System use resulted in a 21% improvement in clinicians' answers, from 29% (95% confidence interval [CI] 25.4-32.6) correct pre- to 50% (95% CI 46.0-54.0) post-system use. In 33% (95% CI 29.1-36.9) answers were changed from incorrect to correct. In 21% (95% CI 17.1-23.9) correct pre-test answers were supported by evidence found using the system, and in 7% (95% CI 4.9-9.1) correct pre-test answers were changed incorrectly. For 40% (35.4-43.6) of scenarios, incorrect pre-test answers were not rectified following system use. Despite significant differences in professional groups' pre-test scores [family practitioners: 41% (95% CI 33.0-49.0), hospital doctors: 35% (95% CI 28.5-41.2), and clinical nurse consultants: 17% (95% CI 12.3-21.7; chi(2) = 29.0, df = 2, p < 0.01)], there was no difference in post-test scores. (chi(2) = 2.6, df = 2, p = 0.73). CONCLUSIONS: The use of an online information retrieval system was associated with a significant improvement in the quality of answers provided by clinicians to typical clinical problems. In a small proportion of cases, use of the system produced errors. While there was variation in the performance of clinical groups when answering questions unaided, performance did not differ significantly following system use. Online information retrieval systems can be an effective tool in improving the accuracy of clinicians' answers to clinical questions.

General practitioners' use of online evidence during consultations.

BACKGROUND: Clinicians have many unanswered questions during clinical encounters which may impact on the quality and outcomes of decisions made. Provision of online evidence at the point of care is one strategy that provides clinicians with easy access to up-to-date evidence in clinical settings to support evidence-based decision-making. AIM: To determine if and when general practitioners use an online evidence system in routine clinical practice, the type of questions for which clinicians seek evidence and the extent to which the system provides clinically useful answers. DESIGN OF STUDY: A prospective cohort study which involved a 4-week clinical trial of Quick Clinical, an online evidence system specifically designed around the needs of general practitioners. SETTING: Two hundred and twenty-seven clinicians who had a computer with Internet access in their consulting rooms. METHODS: Computer logs and survey analysis. RESULTS: One hundred and ninety-three general practitioners used the online evidence system to conduct on average 8.7 searches/month. The majority of these (81%) were conducted from consulting rooms and carried out between 9a.m. and 7p.m. (83%). The most frequent searches conducted related to diagnosis (40%) and treatment (35%). 83% of clinicians believed that Quick Clinical (QC) had the potential to improve patient care, and one in four users reported direct experience of improvements in care. In 73% of queries with clinician feedback participants reported that they were able to find clinically useful information during their routine work. CONCLUSION: General practitioners will use an online evidence retrieval system in routine practice, and report that its use improves the quality of patient care.

Clinicians' assessments of the usefulness of online evidence to answer clinical questions.

Family physicians' experience of using an online evidence retrieval system in routine clinical work was measured. Participants' assessments regarding the usefulness of the online evidence to answer their clinical questions were determined using three feedback channels: voluntary online feedback during the trial; randomized prompted feedback during a specific online evidence search; and responses in a post-trial survey. Using an analysis of the web logs, search outcome was related to patterns of searching in terms of number of searches and documents viewed. The majority of clinicians' searches were related to patient care and information retrieved was rated as useful in answering these questions. On average clinicians conducted two searches and viewed one document per clinical question. Search sessions which resulted in "completely answering" a clinical question involved significantly fewer searches than less successful searches. The three feedback channels provided different information but consistent overall results. The findings indicate that clinicians' assessments of online evidence use are linked to search patterns and online feedback is useful for measuring the effectiveness of systems.

Nurses' use of online clinical evidence.

BACKGROUND: The 'information explosion' presents a significant challenge to the nursing profession. One way to assist access to information is to provide electronic information resources at the point of care. A large-scale survey of nurses working in the public health system in New South Wales, Australia, was undertaken as part of a 2-year evaluation of the Clinical Information Access Program (CIAP). This is a website which provides 24 hour, online access to a range of evidence sources at the point of care. AIM: This paper reports a study to investigate factors influencing nurses' use of online evidence available at the point of care and to examine differences between nurses in different roles. METHOD: Nurses from 65 randomly selected hospitals were surveyed. A convenience sample representing 25% of nursing staff at these hospitals was sought. Eighty-four per cent of the survey quota was met and 3128 questionnaires were completed and returned. RESULTS: The results showed that 58% of nurses had heard of the CIAP and, of those, 70% had used the website's resources. Senior nurses had greater awareness and use than others. The most frequent reasons for use were to fill a knowledge gap and for personal education. Lack of training was the most frequently cited reason for not using the website. Use of online evidence, particularly amongst senior staff, was higher than reported in previous studies. CONCLUSION: Use of online evidence was associated with nursing role, and with managerial and organizational support. Diffusion of innovation theory can help to explain some of the patterns observed. The use and impact of online evidence should be interpreted in the context of nursing practice and culture.

Allied health professionals' use of online evidence: a survey of 790 staff working in the Australian public hospital system.

OBJECTIVE: To measure the impact of a state health department policy to provide allied health professional staff with access to a point-of-care, 24h, online evidence system in terms of awareness, use and clinical impact of the system on clinical practice; to identify perceived barriers to use, and differences in measures between seven professional groups (physiotherapists, occupational therapists, speech pathologists, dieticians, clinical psychologists, pharmacists and social workers). METHOD: A convenience sample of 790 allied health professionals from 65 randomly selected hospitals in New South Wales, Australia. A self-administered questionnaire was distributed. Rates of use, frequency and types of resources accessed were calculated. Comparisons between professional groups were undertaken using Chi-square analyses and t-tests. RESULTS: The results showed that 82% of allied health professionals had heard of the online evidence system, and of those 76% had used it. Pharmacists had the highest rates of use and social workers the lowest. Of users, 90% agreed that use of the system had the potential to improve patient care and 45% reported direct experience of this. Computer skills and easy access were significantly associated with use and frequency of use. Among non-users, lack of specific training in the use of the online evidence system and lack of time were the most frequently reported reasons for not using the system. However, among users there was no relationship between this training and the frequency or effectiveness of use, i.e. the ability to find the information required. CONCLUSIONS: Allied health professionals will use an online evidence system when it is provided, however there are marked differences in use by professional groups. General training aimed at improving computer skills appears more important in encouraging use of an online evidence system, than specific system-based training. Perceptions of organisational and professional support for allied health professionals to use online evidence as a legitimate part of their work play an important role in influencing system use.

Do clinicians use online evidence to support patient care? A study of 55,000 clinicians.

OBJECTIVES: To determine clinicians' (doctors', nurses', and allied health professionals') "actual" and "reported" use of a point-of-care online information retrieval system; and to make an assessment of the extent to which use is related to direct patient care by testing two hypotheses: hypothesis 1: clinicians use online evidence primarily to support clinical decisions relating to direct patient care; and hypothesis 2: clinicians use online evidence predominantly for research and continuing education. DESIGN: Web-log analysis of the Clinical Information Access Program (CIAP), an online, 24-hour, point-of-care information retrieval system available to 55,000 clinicians in public hospitals in New South Wales, Australia. A statewide mail survey of 5,511 clinicians. MEASUREMENTS: Rates of online evidence searching per 100 clinicians for the state and for the 81 individual hospitals studied; reported use of CIAP by clinicians through a self-administered questionnaire; and correlations between evidence searches and patient admissions. RESULTS: Monthly rates of 48.5 "search sessions" per 100 clinicians and 231.6 text hits to single-source databases per 100 clinicians (n = 619,545); 63% of clinicians reported that they were aware of CIAP and 75% of those had used it. Eighty-eight percent of users reported CIAP had the potential to improve patient care and 41% reported direct experience of this. Clinicians' use of CIAP on each day of the week was highly positively correlated with patient admissions (r = 0.99, p < 0.001). This was also true for all ten randomly selected hospitals. CONCLUSION: Clinicians' online evidence use increases with patient admissions, supporting the hypothesis that clinicians' use of evidence is related to direct patient care. Patterns of evidence use and clinicians' self-reports also support this hypothesis.

Clinical team functioning and IT innovation: a study of the diffusion of a point-of-care online evidence system.

OBJECTIVES: To investigate the association between clinical team functioning and diffusion (awareness, use, and impact) of a 24-hour online evidence retrieval system. To examine the relationships between clinical team characteristics and the adoption of the online evidence system. DESIGN: 18 clinical teams, consisting of 180 clinicians from three Australian hospitals, were identified and studied. Teams were categorized as small ( 15). MEASUREMENTS: Clinical team functioning was assessed using the Team Climate Inventory (TCI). Awareness, use, and impact of an online evidence retrieval system were measured using a self-administered questionnaire. The relationships between TCI scores and awareness, use, and impact were examined using t-tests and one-way ANOVAs. Chi square analyses were used to examine differences between small and large teams. RESULTS were interpreted within a diffusion of innovations framework. RESULTS: Clinical team functioning was not related to awareness or use of the online evidence retrieval system. However, clinical team functioning was significantly associated with the impact of online evidence in terms of reported experience of improved patient care following system use. Clinicians in small teams ( 15) teams. CONCLUSIONS: Team functioning had the greatest impact on the fourth stage of innovation diffusion, the effective use of online evidence for clinical care. This supports Rogers' diffusion of innovation theory, to the effect that different types of communication about an innovation are important at different stages in the diffusion process. Members of small teams were more aware of the system than members of large teams. Team functioning is amenable to improvement through interventions. The findings suggest that the role of team climate in the diffusion of information systems is a promising area for future research.

Variation in the use of online clinical evidence: a qualitative analysis.

OBJECTIVE: To investigate factors influencing variations in clinicians' use of an online evidence retrieval system. SETTING: Public hospitals in New South Wales, Australia. METHOD: Web log analysis demonstrated considerable variation in rates of evidence use by clinicians at different hospitals. Focus groups and interviews were held with 61 staff from three hospitals, two with high rates of use and one with a low rate of use, to explore variation in evidence use. RESULTS: Differences between hospitals' and professional groups' (doctors, nurses and allied health) use of online evidence could be explained by organizational, professional and cultural factors. These included the presence of champions, organizational cultures which supported evidence-based practice (EBP), and database searching skills of individual clinicians. Staff shortages, ease of access and time taken to use the online evidence system were cited as barriers to use at the low use site, but no objective differences in these measures were found between the high and low use sites. CONCLUSION: Social and cultural factors were found to be better discriminators of high and low evidence use than technical factors.