Theory in quality improvement and patient safety education: A scoping review

Systems-Based Practice in Graduate Medical Education: Evolving Toward an Ideal Future State

ABSTRACT

Systems-based practice (SBP) was first introduced as a core competency in graduate medical education (GME) in 2002 by the Accreditation Council for Graduate Medical Education as part of the Outcomes Project. While inclusion of SBP content in GME has become increasingly common, there have also been well-documented stumbling blocks, including perceptions that SBP has eroded the amount of curricular time available for more medically focused competencies, is not relevant for some practice contexts, and is not introduced early enough in training. As a result, SBP learning experiences often feel disconnected from medical trainees' practical reality. In this commentary, the authors provide guidance regarding potential changes that may facilitate the evolution of SBP toward an ideal future state where graduates bring a systems science mindset to all aspects of their work. Specific suggestions include the following: (1) expanding the SBP toolbox to reflect current-day health system needs, (2) evolve the teaching methodology, (3) broadening the scope of relevant SBP content areas, and (4) emphasizing SBP as an integrated responsibility for all health care team members. Levers to enact this transformation exist and must be used to influence change at the learner, faculty, program, and clinical learning environment levels.Physicians operate within an increasingly complex health care system that highlights the intersection of health care with complex social, environmental, and relational contexts. Consequently, the role of SBP in both physician work responsibilities and educational requirements continues to expand. To meet this growing demand, GME must adapt how it supports and trains the next generation of systems thinkers, ensuring they understand how levers in the health care system directly affect health outcomes for their patients, and integrate SBP into the foundation of GME curricula in an inclusive, holistic, and unrestrained way.

Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review

The quality of health care remains generally poor across primary health care settings, especially in low- and middle-income countries where tertiary care tends to take up much of the limited resources despite primary health care being the first (and often the only) point of contact with the health system for nearly 80 per cent of people in these countries. Evidence is needed on barriers and enablers of quality improvement initiatives. This systematic review sought to answer the question: What are the enablers of and barriers to quality improvement in primary health care in low- and middle-income countries? It adopted an integrative review approach with narrative evidence synthesis, which combined qualitative and mixed methods research studies systematically. Using a customized geographic search filter for LMICs developed by the Cochrane Collaboration, Scopus, Academic Search Ultimate, MEDLINE, CINAHL, PSYCHINFO, EMBASE, ProQuest Dissertations and Overton.io (a new database for LMIC literature) were searched in January and February 2023, as were selected websites and journals. 7,077 reports were retrieved. After removing duplicates, reviewers independently screened titles, abstracts and full texts, performed quality appraisal and data extraction, followed by analysis and synthesis. 50 reports from 47 studies were included, covering 52 LMIC settings. Six themes related to barriers and enablers of quality improvement were identified and organized using the model for understanding success in quality (MUSIQ) and the consolidated framework for implementation research (CFIR). These were: microsystem of quality improvement, intervention attributes, implementing organization and team, health systems support and capacity, external environment and structural factors, and execution. Decision makers, practitioners, funders, implementers, and other stakeholders can use the evidence from this systematic review to minimize barriers and amplify enablers to better the chances that quality improvement initiatives will be successful in resource-limited settings. PROSPERO registration: CRD42023395166.

Exploring the impact educational interventions have on nursing and medical students' attitudes and empathy levels towards people with disability. A systematic review

This systematic review aimed to explore the impact educational interventions have on undergraduate nursing and medical students' attitudes and empathy levels towards people with disability. There are over one billion people with some form of disability currently. A growing body of research reveals that nurses and doctors display negative attitudes including decreased empathy towards people with disability. A systematic review using narrative synthesis of chosen randomized controlled trials was employed. A comprehensive search was completed in June 2021 on six databases (CINAHL, Medline, Science Direct, Health Research Premium - PROQUEST, Scopus. Cochrane Library). The search strategy yielded 21,616 studies and only three randomised controlled trials fulfilled the eligibility criteria. These trials included 125 participants (n = 50 medical students and n = 75 nursing students) and evaluated the effectiveness of a disabled health course, disability education module with bedside teaching and wheelchair workshop intervention. Findings from one study revealed that a disabled health course using affective learning method based on a transformative learning theory significantly improves attitudes to disability amongst nursing students however there was no statistically significant difference in empathy levels. More high-quality randomised controlled trials with greater theoretical and methodological complexity are needed to identify more effective educational approaches that enhance attitude and empathy levels of these key stakeholders.

Transformative learning theory applications in health professional and nursing education: An umbrella review

OBJECTIVES

This review intended to synthesise existing evidence on the application of transformative learning theory in nursing education.

DESIGN

An umbrella review, or review of reviews.

DATA SOURCES

Six databases were systematically searched: CINAHL, Cochrane Reviews, Ebscohost, OVID, ProQuest Central, and PubMed. The structured framework of PCC: Population/Concept/Context was employed to identify relevant literature, published in English between 2012 and March 1st, 2022.

REVIEW METHODS

Elements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided this review. A modified version of the Johanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Synthesis was applied to determine final inclusions.

RESULTS

Sixteen (16) reviews were included. Most reviews were scoping reviews. Nursing featured in 10 of the 16, medicine in half (8/16) and various allied health disciplines were reported in seven reviews. Studies reported on differing scholarly approaches to transformative learning theory. Curricula design and evaluation, developing leadership skills and a professional identity were common applications. Critical reflection and learning experiences that challenge students' and professionals' existing ideologies also featured. Few reviews reported on studies of models and tools for educators to guide them in applying the theory in lesson design and teaching practice.

CONCLUSION

Applying transformative learning theory in curriculum design, program evaluation and healthcare professional education can be beneficial. There were reported successes and some critiques. Researchers should design more rigorous studies to evaluate the theory in practice and to develop and test frameworks that guide educators in teaching with transformative learning theory.