Challenges, coping and support during student placement abroad: A qualitative study.

BACKGROUND: During placements abroad, healthcare students are confronted with different personal and professional challenges, related to participation in practice. This study investigates when and how students respond to such challenges, and which coping and support mechanisms students use to overcome these. METHODS: Twenty-five international students shared their experiences about physiotherapy placement in The Netherlands. Using a critical incident technique, we asked participants to recall events where participation was affected by an unforeseen situation, in or outside the clinic. Further, we explored students' strategies of seeking support within their social network to overcome individual challenges. Two researchers applied thematic analysis to the interview data, following an iterative approach. Team discussions supported focused direction of data collection and analysis, before conceptualizing results. RESULTS: Participants described a wide range of challenges. The scope and impact level of challenges varied widely, including intercultural differences, language barriers and inappropriate behaviour in the workplace, students' personal context and wellbeing. Mechanisms employed by students to overcome these challenges depended on the type of event (personal or professional), making purposeful use of their available network. CONCLUSION: Students involve clinical staff, peers, family and friends during placement abroad, to make deliberate use of their support network to overcome challenges in participation, whereas the academic network remains distant. Findings may help reflect on the roles and responsibilities of academic staff and other professionals involved with placements abroad. Healthcare programmes should ensure support before, during and after placement is within students' reach.

Reliability and validity of assessment methods available in primary care for bladder outlet obstruction and benign prostatic obstruction in men with lower urinary tract symptoms: a systematic review.

OBJECTIVES: To systematically review the literature regarding the reliability and validity of assessment methods available in primary care for bladder outlet obstruction or benign prostatic obstruction in men with lower urinary tract symptoms (LUTS). DESIGN: Systematic review with best evidence synthesis. SETTING: Primary care. PARTICIPANTS: Men with LUTS due to bladder outlet obstruction or benign prostatic obstruction. REVIEW METHODS: PubMed, Ebsco/CINAHL and Embase databases were searched for studies on the validity and reliability of assessment methods for bladder outlet obstruction and benign prostatic obstruction in primary care. Methodological quality was assessed with the COSMIN checklist. Studies with poor methodology were excluded from the best evidence synthesis. RESULTS: Of the 5644 studies identified, 61 were scored with the COSMIN checklist, 37 studies were included in the best evidence synthesis, 18 evaluated bladder outlet obstruction and 17 benign prostatic obstruction, 2 evaluated both. Overall, reliability was poorly evaluated. Transrectal and transabdominal ultrasound showed moderate to good validity to evaluate bladder outlet obstruction. Measured prostate volume with these ultrasound methods, to identify benign prostatic obstruction, showed moderate to good accuracy, supported by a moderate to high level of evidence. Uroflowmetry for bladder outlet obstruction showed poor to moderate diagnostic accuracy, depending on used cut-off values. Questionnaires were supported by high-quality evidence, although correlations and diagnostic accuracy were poor to moderate compared with criterion tests. Other methods were supported by low level evidence. CONCLUSION: Clinicians in primary care can incorporate transabdominal and transrectal ultrasound or uroflowmetry in the evaluation of men with LUTS but should not solely rely on these methods as the diagnostic accuracy is insufficient and reliability remains insufficiently researched. Low-to-moderate levels of evidence for most assessment methods were due to methodological shortcomings and inconsistency in the studies. This highlights the need for better study designs in this domain.

Feasibility of a home-based interdisciplinary rehabilitation program for patients with Post-Intensive Care Syndrome: the REACH study.

BACKGROUND: Survivors of critical illness experience long-term functional challenges, which are complex, heterogeneous, and multifactorial in nature. Although the importance of rehabilitation interventions after intensive care unit (ICU) discharge is universally recognized, evidence on feasibility and effectiveness of home-based rehabilitation programs is scarce and ambiguous. This study investigates the feasibility of an interdisciplinary rehabilitation program designed for patients with Post-Intensive Care Syndrome (PICS) who are discharged home. METHODS: A mixed method, non-randomized, prospective pilot feasibility study was performed with a 6-month follow-up, comparing the intervention (REACH) with usual care. REACH was provided by trained professionals and included a patient-centered, interdisciplinary approach starting directly after hospital discharge. Primary outcomes were patient safety, satisfaction, adherence, referral need and health care usage. Secondary outcomes, measured at 3 timepoints, were functional exercise capacity, self-perceived health status, health-related quality of life (HRQoL), return to work and psychotrauma. Risk of undernutrition was assessed at baseline. RESULTS: 43 patients with a median mechanical ventilation duration of 8 (IQR:10) days, were included in the study and 79.1% completed 6-month follow-up. 19 patients received the intervention, 23 received usual care. Groups were similar for gender distribution and ICU length of stay. No adverse events occurred. REACH participants showed higher satisfaction with treatment and reported more allied health professional visits, while the usual care group reported more visits to medical specialists. Qualitative analysis identified positive experiences among REACH-professionals related to providing state-of-the-art interventions and sharing knowledge and expertise within an interprofessional network. Similar recovery was seen between groups on all secondary outcomes, but neither group reached reference values for HRQoL at 6 months. Larger return to work rates were seen in the REACH group. Prevalence of undernutrition at hospital discharge was high in both groups (> 80%), warranting the need for careful tuning of physical therapy and nutritional interventions. CONCLUSIONS: This study shows that providing early, home-based rehabilitation interventions for patients with PICS-related symptoms is feasible and perceived positively by patients and professionals. When provided in an interdisciplinary collaborative network state of the art, person-centered interventions can be tailored to individual needs potentially increasing patient satisfaction, adherence, and efficacy. Registered in the Dutch Trial register: NL7792: https://www.trialregister.nl/trial/7792 , registered 7-06-2019.

Initiation of student participation in practice: An audio diary study of international clinical placements.

BACKGROUND: Differences in professional practice might hinder initiation of student participation during international placements, and thereby limit workplace learning. This study explores how healthcare students overcome differences in professional practice during initiation of international placements. METHODS: Twelve first-year physiotherapy students recorded individual audio diaries during the first month of international clinical placement. Recordings were transcribed, anonymized, and analyzed following a template analysis approach. Team discussions focused on thematic interpretation of results. RESULTS: Students described tackling differences in professional practice via ongoing negotiations of practice between them, local professionals, and peers. Three themes were identified as the focus of students' orientation and adjustment efforts: professional practice, educational context, and individual approaches to learning. Healthcare students' initiation during international placements involved a cyclical process of orientation and adjustment, supported by active participation, professional dialogue, and self-regulated learning strategies. CONCLUSIONS: Initiation of student participation during international placements can be supported by establishing a continuous dialogue between student and healthcare professionals. This dialogue helps align mutual expectations regarding scope of practice, and increase understanding of professional and educational practices. Better understanding, in turn, creates trust and favors meaningful students' contribution to practice and patient care.

Preparing undergraduate students for clinical work in a complex environment: evaluation of an e-learning module on physiotherapy in the intensive care unit.

BACKGROUND: Intensive Care Units (ICUs) are daunting environments for physiotherapy (PT) students performing clinical rotations. To prepare students for this environment, a newly developed, evidence-based e-learning module was designed and implemented in the undergraduate curriculum. The aim of this study was to investigate whether e-learning is a feasible method in preparing PT students for clinical work in complex ICU environments, as perceived by students and experts. METHODS: A mixed methods proof of concept study was undertaken. Participants were final-year students of an international curriculum, and experts from didactic and clinical fields. An e-learning module consisting of 7 separate chapters based on the latest scientific evidence and clinical expertise was developed, piloted and incorporated into the undergraduate curriculum as a compulsory course to be completed prior to clinical ICU rotations. Data were collected through 3 focus group meetings and 5 semi-structured interviews; these meetings and interviews were audio recorded, transcribed verbatim and analyzed. RESULTS: The study sample comprised of 14 students and 5 experts. Thematic analysis revealed three themes: expected competencies of PT students in ICU, feeling prepared for ICU clinical work and dealing with local variety. The e-learning module enabled students to anticipate clinical situations and PT tasks in the ICU. Higher level clinical reasoning skills, handling of lines and wires and dealing with out-of-textbook situations could not be achieved with the e-learning module alone. CONCLUSIONS: An e-learning module can sufficiently prepare PT students for their clinical tasks in the ICU, as long as it is integrated with, or closely connected to, the students' clinical placement.

Finding your feet: student participation during initiation of international clinical placements : Student participation during initiation.

INTRODUCTION: International placements challenge students to find the right level of participation, as local practices, language and time pressure may affect their engagement in patient-related tasks or team activities. This study sought to unpack the initiation process during international clinical placements with the ultimate aim to achieve active student participation. METHODS: Following a constructivist grounded theory approach, we conducted two individual interviews with 15 undergraduate healthcare students (before departure and whilst on placement). To identify emerging themes, we applied an iterative process of data collection and constant comparative analysis. Several team discussions informed further analysis, allowing us to reach a more conceptual level of theory. RESULTS: From our findings we constructed a four-phase model of healthcare students' initiation of international clinical placements, which brings into focus how the phases of 'orientation', 'adjustment' and 'contribution to patient care' build up towards a 'sense of belonging'. We identified several factors that induced active student participation in practice, such as a favourable workplace setting, opportunities for learning and a local support network. DISCUSSION: Active student participation is aimed at different goals, depending on the four phases of initiation that eventually lead to a sense of belonging and support workplace learning.

Applicability of Progress Testing in Veterinary Medical Education.

A substantial part of graduate education in veterinary medicine is spent in clinical practice. During the clinical experiential phase, it is difficult to monitor students' actual knowledge development: they build individual records of experiences based on the cases they have to deal with, while mainly focusing on knowledge that is of direct, clinical relevance to them. As a result, students' knowledge bases may differ to such a degree that a single test alone may not be able to provide an adequate reflection of progress made. In these circumstances, progress testing, which is a method of longitudinal assessment independent of the curricular structure, may offer a viable solution. The purpose of this study, therefore, was to determine the extent to which progress tests (PT) can be used to monitor progress in knowledge development at a graduate level in veterinary medical education. With a 6-month interval, we administered two tests to students based on the Maastricht Progress Test format that covered a large variety of veterinary topics. Consequently, we analyzed students' progress in knowledge development. Based on a substantive appraisal of the questions and analysis of the test results, we concluded that the tests met the measurement criteria. They appeared sensitive enough to gauge the progress made and were appreciated by the students. Hence, in spite of the differences within the whole graduate group, the PT format can be used to monitor students' knowledge development.

Students' motives for using online formative assessments when preparing for summative assessments.

BACKGROUND: Formative assessments intend to provide feedback on student performance in order to improve and accelerate learning. Several studies have indicated that students using online formative assessments (OFAs), have better results on their exams. AIMS: The present study aims to provide insight in student reasons for using or not using available OFAs. METHOD: Three OFAs with feedback were available in a second year undergraduate course in physiology for biomedical sciences students (N = 147). First, students received an open questionnaire about why they did (not) complete the first two OFAs. Based on this data, a closed questionnaire was developed and distributed among students. Exploratory factor analysis (EFA) was applied. RESULTS: The results indicate reasons why students do (not) use the OFAs. The EFA for using the OFAs indicated three factors, that were interpreted as collecting (1) feed up, (2) feed forward, and (3) feed back information. The main reasons for not using the OFAs were lack of time and having completed the questions before. CONCLUSIONS: Students' reasons for using OFAs can be described in terms of collecting feed up, forward and back information and students' reasons for not using OFAs can be student-, teacher-, or mode-related.

Prevalence of histological prostatitis in men with benign prostatic hyperplasia or adenocarcinoma of the prostate presenting without urinary retention.

OBJECTIVE: To determine the prevalence of prostatitis on histopathological evaluation of prostatic tissue in men without urinary retention. DESIGN, SETTING AND SUBJECTS: The clinical data and histopathology reports of men seen from January 1999 through March 2009 at our institution were analysed using Student's t-test, the Mann-Whitney test and Fisher's exact test where appropriate. Values were expressed as means, medians and ranges (p<0.05 accepted as statistically significant). OUTCOME MEASURES: Data collected included patient age, duration of lower urinary tract symptoms and hospitalisation, findings on digital rectal examination, prostate volume, haemoglobin concentration, serum creatinine and prostate-specific antigen (PSA) levels, and histological findings. RESULTS: Prostatic tissue of 385 men without urinary retention at presentation was obtained via biopsy (48.3% of cases), transurethral prostatectomy (62.9%), retropubic prostatectomy (6.8%) or radical prostatectomy (28.3%). On histological examination, benign prostatic hyperplasia (BPH) was found to be present in 213 patients (55.3%) and adenocarcinoma of the prostate (ACP) in 172 (44.7%). Histological prostatitis was present in 130 patients (61.0%) with BPH and 51 (29.7%) with ACP (p<0.001). A previous study of 405 men presenting with urinary retention at our institution showed histological prostatitis in 98/204 (48.0%) with BPH and in 51/201 (25.4%) with ACP. The group of men with BPH alone had a significantly lower mean serum PSA at presentation (4.5 ng/ml, range 0.3 - 20.8 ng/ml) compared with the group with BPH and prostatitis (11.2 ng/ml, range 0.2 - 145 ng/ml, p=0.011). The mean PSA level at presentation did not differ significantly between the group with ACP only (40.9 ng/ml, range 0 - 255 ng/ml) and the group with ACP plus prostatitis (1 672 ng/ml, range 0.3 - 38 169 ng/ml, p=0.076). CONCLUSIONS: Among men presenting without urinary retention, histological prostatitis was significantly more prevalent in those with BPH than in those with ACP (61% v. 30%), similar to the previous study of men presenting with retention at our institution, in which histological prostatitis was significantly more prevalent in BPH than in ACP (48% v. 25%). This finding suggests that histological prostatitis is not significantly associated with the causation of ACP or urinary retention. Serum PSA at presentation was significantly higher in the group with BPH plus prostatitis compared with BPH alone, but not in the group with ACP plus prostatitis compared with ACP alone.

Significance of histological prostatitis in patients with urinary retention and underlying benign prostatic hyperplasia or adenocarcinoma of the prostate.

OBJECTIVE: To compare the clinical features of patients having urinary retention and benign prostatic hyperplasia (BPH) with those having adenocarcinoma of the prostate (ACP) and to evaluate the significance of histological prostatitis. PATIENTS AND METHODS: The clinical data and histopathology reports of patients with retention admitted to Tygerberg Hospital between September 1998 and June 2007 were evaluated. Statistical analysis was performed with Student's t-test, Mann-Whitney test and Fisher's exact test where appropriate and P < 0.05 was considered to indicate statistical significance. RESULTS: Prostatic histology was available in 405 patients, 204 with BPH and 201 with ACP. Comparing those with BPH and those with ACP showed statistically significant differences in mean age (69.5 vs 71.9 years), serum prostate-specific antigen (PSA) level (18.6 vs 899.5 ng/mL) and histological prostatitis (48 vs 25%) but not duration of catheterization, prostate volume or urinary tract infection (UTI). Comparing those with BPH only and those with BPH plus prostatitis showed significant differences in mean age (71.9 vs 67.1 year) and PSA level (14.6 vs 22.8 ng/mL) but not prostate volume, UTI or duration of catheterization. Comparing those with ACP only and those with ACP plus prostatitis showed significant differences in stage T4 cancer (68.1 vs 35.4%) and PSA level (1123.4 vs 232.4 ng/mL) but not age, prostate volume, UTI or duration of catheterization. CONCLUSIONS: Histological prostatitis was almost twice as common in patients with urinary retention associated with underlying BPH than in patients with ACP, but there was no significant difference in the duration of catheterization, prostatic volume or presence of UTI, suggesting that histological prostatitis more often contributes to the development of retention in patients with underlying BPH than in those with ACP. In patients with BPH, histological prostatitis was associated with urinary retention at a significantly younger age and with higher serum PSA levels. In patients with ACP, histological prostatitis was associated with urinary retention at an earlier stage of cancer.

An instructional model for training competence in solving clinical problems.

We examined the design of a course that aims to ease the transition from pre-clinical learning into clinical work. This course is based on the premise that many of the difficulties with which students are confronted in this transition result from a lack of experience in applying knowledge in real practice situations. It is focused on the development of competence in solving clinical problems; uses an instructional model with alternating clinical practicals, demonstrations, and tutorials; and extends throughout the last pre-clinical year. We used a "proof-of-concept" approach to establish whether the core principles of the course design are feasible with regard to achieving the intended results. With the learning functions and processes as a frame of reference, retrospective analysis of the course's design features shows that this design matches the conditions from theories of the development of competence in solving clinical problems and instructional design. Three areas of uncertainty in the design are identified: the quality of the cases (information, openness), effective teaching (student and teacher roles), and adjustment to the development of competence (progress, coherence).

Prospective comparison of a new visual prostate symptom score versus the international prostate symptom score in men with lower urinary tract symptoms.

OBJECTIVE: To evaluate the correlation between the International Prostate Symptom Score (IPSS) and a new Visual Prostate Symptom Score (VPSS) using pictures rather than words to assess lower urinary tract symptoms (LUTS). METHODS: Four IPSS questions related to frequency, nocturia, weak stream, and quality of life (QoL) were represented by pictograms in the VPSS. Men with LUTS were given the IPSS and VPSS to complete. Peak (Qmax.) and average (Qave.) urinary flow rates were measured. Statistical analysis was performed using Student's t, Fisher's exact, and Spearman's correlation tests. RESULTS: The educational level of the 96 men (mean age 64, range 33-85 years) evaluated August 2009 to August 2010 was school grade 8-12 (62%), grade 1-7 (28%), university education (6%), and no schooling (4%). The IPSS was completed without assistance by 51 of 96 men (53%) and the VPSS by 79 of 96 men (82%) (P<.001). Comparing education grade<7 vs grade>10 groups, the IPSS required assistance in 27 of 31 men (87%) vs 9 of 38 men (24%) (P<.001), and the VPSS required assistance in 10 of 31 men (32%) vs 3 of 38 men (8%) (P=.014). There were statistically significant correlations between total VPSS, Qmax. and Qave., total VPSS and IPSS, and individual VPSS parameters (frequency, nocturia, weak stream and QoL) vs their IPSS counterparts. CONCLUSIONS: The VPSS correlates significantly with the IPSS, Qmax. and Qave., and can be completed without assistance by a greater proportion of men with limited education, indicating that it may be more useful than the IPSS in patients who are illiterate or have limited education.

Propagation of nitric oxide pools during controlled mechanical ventilation.

OBJECTIVE: Infusing nitric oxide at a constant rate into a breathing circuit with intermittent mainstream flow causes formation of nitric oxide pools between successive breaths. We hypothesized that incomplete mixing of these pools can confound estimates of delivered nitric oxide concentrations. METHODS: Nitric oxide flowed at a constant rate into the upstream end of a standard adult breathing circuit connected to a lung model. One-milliliter gas samples were obtained from various sites within the breathing system and during various phases of the breathing cycle. These samples were aspirated periodically by a microprocessor controlled apparatus and analyzed using an electrochemical sensor. RESULTS: The pools of nitric oxide distorted into hollow parabolic cone shapes and remained unmixed during their propagation into the lungs. In our preparation, time-averaged nitric oxide concentrations were minimal 60 cm downstream of the infusion site (18 ppm) and maximal 15 cm upstream of the Y-piece (36 ppm). The concentrations were mid-range within the lung (23 ppm), yet were substantially less than predicted by assuming homogeneity of the gases (31 ppm). Generally, nitric oxide concentrations within the lung were different from all other sites tested. CONCLUSION: Incomplete mixing of nitric oxide confounds estimates of delivered nitric oxide concentrations. When nitric oxide is infused at a constant rate into a breathing circuit, we doubt that any sampling site outside the patient's lungs can reliably predict delivered nitric oxide concentrations. Strategies to ensure complete mixing and representative sampling of nitric oxide should be considered carefully when designing nitric oxide delivery systems.

Comparison of age, gender, number of aortic valve cusps, concomitant coronary artery bypass grafting, and magnitude of left ventricular-systemic arterial peak systolic gradient in adults having aortic valve replacement for isolated aortic valve stenosis.

Correlation of the structure of the operatively excised aortic valve with various clinical variables has received relatively little attention. This report describes certain observations in 115 patients aged >30 years (mean age 70) who had aortic valve replacement for aortic valve stenosis unassociated with mitral valve dysfunction. The operatively excised aortic valve was congenitally unicuspid in 3 patients (3%), congenitally bicuspid in 54 patients (47%), tricuspid in 57 patients (50%), and of uncertain structure in 1. Of the 87 patients (76%) aged > or =65 years (Medicare population), 36 (41%) had congenitally malformed valves (bicuspid in each), and of the 28 patients (24%) aged <65 years, 21 (75%) had congenitally malformed valves. A higher percentage of patients with congenitally malformed valves had peak systolic pressure gradients across the valve >50 mm Hg than did patients with tricuspid valves (57% vs 43%). Concomitant coronary artery bypass grafting (CABG) was performed in 52 patients (45%) (34 men and 18 women), and they had average peak systolic pressure gradients across the valve significantly lower than patients without coronary bypass (46 vs 64 mm Hg): 39% of the 57 patients with congenitally malformed valves and 53% of the 57 patients with tricuspid valves had concomitant coronary bypass (insignificant difference). Thus, in a relatively older population of 115 patients having aortic valve replacement for isolated aortic valve stenosis, with or without associated aortic regurgitation, one half had congenitally malformed valves (either unicuspid or bicuspid valves) and one half had tricuspid valves. Patients having concomitant CABG had significantly smaller gradients across the stenotic valves than those who had no CABG.