Using patients as educators for communication skills: Exploring dental students' and patients' views

TITLE

A qualitative study to explore the issues for patients and students when giving feedback on the communication of dental students.

OBJECTIVES

The Department of Health and National Institute for Health Research are committed to involving patients in improving clinical education, research and service delivery. Yet, there is a limited body of evidence on the perceptions of patients when asked to be involved in this way, and specifically when asked to provide feedback on the communication skills of dental students. This study seeks to address this gap and heighten the understanding of the issues faced by patients when asked to be involved in clinical education.

METHODS

Data were collected using focus groups with dental students (n=10) and patients (n=8) being treated by these students. Both groups were asked about their thoughts, feelings and beliefs about patients being asked to provide feedback on the communication skills of dental students. Data analysis involved inductive thematic analysis of transcribed audio recordings.

RESULTS

Four themes emerged from the data: "legitimacy," "co-educators," "maintaining the equilibrium of the patient-student relationship" and the "timing of patient feedback." Support for involving patients in giving feedback on students' communication skills was established, with patients considering they were best placed to comment on the communication skills of dental students. Patients and students do not want to provide feedback alone and want support to assist them, especially if feedback was negative. Issues of anonymity, confidentiality and ownership of the feedback process were worrisome, and the positioning of patient feedback in the programme was seen as critical.

CONCLUSIONS

Patients and students are willing to engage in patient feedback on students' communication skills, and with support and training, the concerns around this are not insurmountable and the benefits could potentially profit both groups. These findings have resonance with other healthcare educators when using patients as educators in the development of communication skills.

Quality and safety impact on the provision of parenteral nutrition through introduction of a nutrition support team

BACKGROUND/OBJECTIVES

Parenteral nutrition (PN) should be provided to the malnourished patient if enteral feeding is insufficient or unsafe. A nutrition support team (NST) may improve PN services. We compared the use and complications of hospital PN before and after the implementation of an NST.

SUBJECTS/METHODS

All inpatients referred for PN outside of the intensive care unit and the intestinal failure unit were prospectively included from 2009 to 2012. The NST was introduced in 2010. Quality improvement methodology was applied.

RESULTS

In 2009, a mean of 16 (limits of normal variation 4-28) patients were referred for PN each month. After introduction of the NST, this rose to 26 (10-42) referrals per month. The percentage of referrals where PN was not initiated increased from 5.3% in 2009 to 10.1% in 2012 (P=0.03). This increase was restricted to teams that infrequently referred for PN, and enteral nutrition could replace PN in 31 of 51 patients (61%) as compared with 8 of 32 (25%) patients referred from teams that frequently referred for PN (P=0.001). The frequency of PN started owing to an insufficient oral or enteral intake decreased from 11% to 3% (P=0.01). The catheter-related bloodstream infection rate dropped from 6.7 to 0.7 episodes per 1000 catheter days (P<0.001).

CONCLUSIONS

Introduction of an NST increased both the total PN use and the percentage of referrals where enteral nutrition could replace PN. Medical specialty influenced the referral pattern and the likelihood that a referral resulted in PN being initiated. Safety of PN catheters improved significantly following NST introduction.

A measurement and comparison of the fluid intake in people with and without back pain

BACKGROUND

The aim of this study was to investigate and compare fluid intake of people with and without chronic back pain (BP). The research hypothesis was that fluid intake is lower in people with chronic BP.

METHOD

A diary to record fluid intake in the general public was piloted. Seventy-seven people with chronic BP and 88 without BP were recruited from outpatient clinics and asked to record their fluid intake using this diary for nine consecutive days. Data were analysed to compare the intake of fluid in the two groups.

RESULTS

T-tests showed that there is a higher fluid intake among the cohort with BP for the total daily fluid intake 2344 +/- 669 mL (P = 0.008), and daily fluid intake excluding alcohol 2065 +/- 658 mL (P = 0.039).

CONCLUSIONS

This study found that a sample of people with BP drank more fluid than a similar group with no BP.

Cost-effectiveness of first- v. second-generation antipsychotic drugs: results from a randomised controlled trial in schizophrenia responding poorly to previous therapy

BACKGROUND

There are claims that the extra costs of atypical (second-generation) antipsychotic drugs over conventional (first-generation) drugs are offset by improved health-related quality of life.

AIMS

To determine the relative costs and value of treatment with conventional or atypical antipsychotics in people with schizophrenia.

METHOD

Cost-effectiveness acceptability analysis integrated clinical and economic randomised controlled trial data of conventional and atypical antipsychotics in routine practice.

RESULTS

Conventional antipsychotics had lower costs and higher quality-adjusted life-years (QALYs) than atypical antipsychotics and were more than 50% likely to be cost-effective.

CONCLUSIONS

The primary and sensitivity analyses indicated that conventional antipsychotics may be cost-saving and associated with a gain in QALYs compared with atypical antipsychotics.

Randomised controlled trials of conventional antipsychotic versus new atypical drugs, and new atypical drugs versus clozapine, in people with schizophrenia responding poorly to, or intolerant of, current drug treatment

OBJECTIVES

To determine the clinical and cost-effectiveness of different classes of antipsychotic drug treatment in people with schizophrenia responding inadequately to, or having unacceptable side-effects from, their current medication.

DESIGN

Two pragmatic, randomised controlled trials (RCTs) were undertaken. The first RCT (band 1) compared the class of older, inexpensive conventional drugs with the class of new atypical drugs in people with schizophrenic disorders, whose current antipsychotic drug treatment was being changed either because of inadequate clinical response or owing to side-effects. The second RCT (band 2) compared the new (non-clozapine) atypical drugs with clozapine in people whose medication was being changed because of poor clinical response to two or more antipsychotic drugs. Both RCTs were four-centre trials with concealed randomisation and three follow-up assessments over 1 year, blind to treatment.

SETTING

Adult mental health settings in England.

PARTICIPANTS

In total, 227 participants aged 18-65 years (40% of the planned sample) were randomised to band 1 and 136 (98% of the planned sample) to band 2.

INTERVENTIONS

Participants were randomised to a class of drug. The managing clinician selected the individual drug within that class, except for the clozapine arm in band 2. The new atypical drugs included risperidone, olanzapine, quetiapine and amisulpride. The conventional drugs included older drugs, including depot preparations. As in routine practice, clinicians and participants were aware of the identity of the prescribed drug, but clinicians were asked to keep their participating patient on the randomised medication for at least the first 12 weeks. If the medication needed to be changed, the clinician was asked to prescribe another drug within the same class, if possible.

MAIN OUTCOME MEASURES

The primary outcome was the Quality of Life Scale (QLS). Secondary clinical outcomes included symptoms [Positive and Negative Syndrome Scale (PANSS)], side-effects and participant satisfaction. Economic outcomes were costs of health and social care and a utility measure.

RESULTS

Recruitment to band 1 was less than anticipated (40%) and diminished over the trial. This appeared largely due to loss of perceived clinical equipoise (clinicians progressively becoming more convinced of the superiority of new atypicals). Good follow-up rates and a higher than expected correlation between QLS score at baseline and at follow-up meant that the sample as recruited had 75% power to detect a difference in QLS score of 5 points between the two treatment arms at 52 weeks. The recruitment to band 2 was approximately as planned. Follow-up assessments were completed at week 52 in 81% of band 1 and 87% of band 2 participants. Band 1 data showed that, on the QLS and symptom measures, those participants in the conventional arm tended towards greater improvements. This suggests that the failure to find the predicted advantage for new atypicals was not due to inadequate recruitment and statistical power in this sample. Participants reported no clear preference for either class of drug. There were no statistically significant differential outcomes for participants entering band 1 for reasons of treatment intolerance to those entering because of broadly defined treatment resistance. Net costs over the year varied widely, with a mean of 18,850 pounds sterling in the conventional drug group and 20,123 pounds sterling in the new atypical group, not a statistically significant difference. Of these costs, 2.1% and 3.8% were due to antipsychotic drug costs in the conventional and atypical group, respectively. There was a trend towards participants in the conventional drug group scoring more highly on the utility measure at 1 year. The results for band 2 showed an advantage for commencing clozapine in quality of life (QLS) at trend level (p = 0.08) and in symptoms (PANSS), which was statistically significant (p = 0.01), at 1 year. Clozapine showed approximately a 5-point advantage on PANSS total score and a trend towards having fewer total extrapyramidal side-effects. Participants reported at 12 weeks that their mental health was significantly better with clozapine than with new atypicals (p < 0.05). Net costs of care varied widely, but were higher than in band 1, with a mean of 33,800 pounds sterling in the clozapine group and 28,400 pounds sterling in the new atypical group. Of these costs, 4.0% and 3.3%, respectively, were due to antipsychotic drug costs. The increased costs in the clozapine group appeared to reflect the licensing requirement for inpatient admission for commencing the drug. There was a trend towards higher mean participant utility scores in the clozapine group.

CONCLUSIONS

For band 1, there is no disadvantage in terms of quality of life and symptoms, or associated costs of care, over 1 year in commencing conventional antipsychotic drugs rather than new atypical drugs. Conventional drugs were associated with non-significantly better outcomes and lower costs. Drug costs represented a small proportion of the overall costs of care (<5%). For band 2, there is a statistically significant advantage in terms of symptoms but not quality of life over 1 year in commencing clozapine rather than new atypical drugs, but with increased associated costs of care. The results suggest that conventional antipsychotic drugs, which are substantially cheaper, still have a place in the treatment of patients unresponsive to, or intolerant of, current medication. Further analyses of this data set are planned and further research is recommended into areas such as current antipsychotic treatment guidance, valid measures of utility in serious mental illness, low-dose 'conventional' treatment in first episode schizophrenia, QLS validity and determinants of QLS score in schizophrenia, and into the possible financial and other mechanisms of rewarding clinician participation in trials.

Index for predicting mortality in elderly surgical patients

Background

The aim of the study was to validate a mortality index for use in patients over 65 years of age undergoing operative treatment or conservative management.

Methods

From a study conducted more than 20 years ago of elderly patients admitted with a surgical condition, 11 variables were identified as being significant in predicting mortality: age, white cell count, serum urea concentration, pulse rate, mean blood pressure, type of admission, urgency of operation, complexity of surgery, conservative management, and diagnostic categories of vascular disease and malignancy. Using multivariate logistic regression analysis, a mortality index was devised. This index was validated in a separate study of comparable patients treated in 1999–2001.

Results

Comparison of the derivation and validation data sets showed similarity in the distribution of variables with no significant difference in mortality (overall mortality rate 9·3 per cent for the derivation set versus 9·6 per cent for the validation set; χ2 = 0·084, 1 d.f., P = 0·771). Tests of calibration and discrimination showed no significant difference in predicted to actual deaths, and the receiver–operator characteristic plots of the two data sets showed good discrimination.

Conclusion

This mortality index was derived specifically for patients over 65 years of age receiving either operative or conservative treatment. It could be of use when counselling patients and their relatives about the possible outcome of treatment.

Short term arterial remodelling in the aortae of cholesterol fed New Zealand white rabbits shown in vivo by high-resolution magnetic resonance imaging — implications for human pathology

High-resolution, non-invasive imaging methods are required to monitor progression and regression of atherosclerotic plaques. We investigated the use of MRI to measure changes in plaque volume and vessel remodelling during progression and regression of atherosclerosis in New Zealand White rabbits. Atherosclerotic lesions were induced in the abdominal aorta by balloon injury and cholesterol feeding. MR images (2D) of the abdominal aorta were acquired with cardiac and respiratory gating using a fast spin echo sequence with and without fat-suppression. In an initial study on rabbits treated for 30 weeks we imaged the aortae with a spatial resolution of 250x250 micrometers with a slice thickness of 2 mm and achieved a close correlation between MRI-derived measurements and those made on perfusion pressure-fixed histological sections (r(1) = 0.83, slope p(1) < 0.01). We subsequently imaged 18 rabbits before and periodically during 12 weeks of cholesterol feeding (progression) followed by 12 weeks on normal diet (regression). Aortic wall (atherosclerotic lesion) volume increased significantly during progression and decreased during regression. In contrast, lumen volume increased during progression and did not change during regression. In conclusion, this study confirms that non-invasive, high-resolution MRI can be used to monitor progression and regression of atherosclerosis, each within 3 months and shows, for the first time in a short-term model, that positive remodelling occurs early during progression and persists through regression of atherosclerotic lesions.

Pediatric cochlear implantation: the parents' perspective

OBJECTIVE

To analyze parental views on cochlear implantation, before and in the years following implantation, to determine whether the results from the intervention met their expectations.

DESIGN

Prospective longitudinal study to assess parental perspectives of an unselected group of children with cochlear implantation.

SETTING

Tertiary referral pediatric cochlear implant center in the United Kingdom.

SUBJECTS

Forty-three parents of children with cochlear implantation.

INTERVENTION

A specifically designed questionnaire was administered to assess preimplant expectations and observed changes and concerns at 1, 2, and 3 years following implantation. Three key domains were evaluated: (1) communication with others, (2) listening to speech without lipreading, and (3) the development of speech and language.

RESULTS

Preoperative expectations were met or surpassed at each of the follow-up intervals. In the area of communication, 35 (81%) parents expected a definite improvement preoperatively, and 3 years following implantation, 42 (98%) actually saw such an improvement. The respective numbers in the area of listening to speech were 15 (35%) and 38 (88%), and for speech development, 37 (86%) and 37 (86%). Speech development was the major area of concern at all intervals.

CONCLUSION

This study demonstrates the ability of cochlear implantation to meet or surpass parental expectations in 3 important outcome domains: communication, listening to speech, and the development of speech and language.

Acute withdrawal of nasal CPAP in obstructive sleep apnea does not cause a rise in stress hormones

We hypothesized that withdrawal of nasal continuous positive airway pressure (CPAP) in patients with sleep apnea would produce a measurable stress response. To test this hypothesis, we ceased CPAP in eight patients regularly using nasal CPAP long term and measured the effect on sleep apnea as well as plasma and urinary levels of the stress hormones, noradrenaline, cortisol and adrenocorticotropic hormone (ACTH). CPAP withdrawal led to an immediate recurrence of sleep apnea with increases in apnea index, arousal index and oxygen desaturation (all p < .0001) but no change in levels of noradrenaline, cortisol or ACTH. We conclude that acute withdrawal of CPAP in patients with sleep apnea does not lead to a classic stress response.

The tunable dye laser--introducing new technology into the working environment

As we are all aware, the pace of change in all aspects of specialised critical care is constant, and finding time to understand and incorporate new technological advances into our nursing practice is not easy. Theatre nursing is demanding enough with the increasing demand for theatre sessions, staff shortages and financial limitations, but the obvious benefits of medical advances for patients easily outweigh these as this article will hopefully illustrate. We are all willing to embrace positive change but do feel the need to incorporate it safely into our practice, a dilemma recognised by Evans.

Volunteer blood donors who fail the copper sulfate screening test. What does failure mean, and what should be done?

Volunteers attending blood donor sessions who fail the copper sulfate screening test merit an explanation of why they are considered ineligible to donate. During a 30-month period, 0.24 percent of men and 2.8 percent of women attending blood donor sessions in the northern region of England failed this test. Their hematologic status was determined by performing complete blood counts on a venous blood specimen and measuring ferritin as an indication of iron stores in a representative sample of approximately 10 percent. Normal blood counts were found in some donors, while others had severe degrees of anemia, and such discrepancies could be clarified only by hemoglobin determinations. Iron deficiency was very common in deferred donors, including 36 of the 88 with normal blood counts in whom ferritin assays were performed. Microcytic blood cells, a hallmark of iron deficiency, were found to be a relatively insensitive measure of low iron stores, except at low levels of hemoglobin. By a check of a venous sample, the hematologic status of most volunteers failing the copper sulfate screening test can be ascertained, and appropriate review, investigation, and treatment can be undertaken.

t(9;11)(p22;q24) in a patient with acute monocytic leukemia

A case of t(9;11)(p22;q24) in a patient with acute monocytic leukemia is described. The difficulties of establishing the precise breakpoints involved in this emerging association are discussed.

Methylxanthines modulate adenosine release from slices of cerebral cortex

Using slices of mouse or rat cerebral cortex incubated with [3H]adenosine or [3H]adenine and/or [14C]GABA we have examined factors affecting the release of these compounds, and especially the influence of methylxanthines. Although release of purines and GABA could be induced by ouabain (10(-4) M), or p-hydroxymercuribenzoate (5 x 10(-4) M) no release was produced by ethacrynic acid (10(-3) or 10(-4) M) phenytoin (10(-3) M), noradrenaline or SC 13504. Release is probably not therefore related to (Na+, K+) ATPase or Mg2+-ATPase inhibition. At concentrations of 10(-3) and 10(-4) M, caffeine, theophylline, aminophylline and isobutyl-methylxanthine (IBMX) markedly depressed the release of purines evoked by ouabain. Non-xanthine inhibition of phosphodiesterase had much weaker though statistically significant effects. The methylxanthines had no significant effect on GABA release. It is suggested that the results can be explained on the basis of a positive feedback system in which released adenosine activates membranal adenylate cyclase, and the increased concentration of cyclic AMP which results form or origin of much of the adenosine released subsequently. However, we cannot exclude the existence of an intracellular receptor for methylxanthines which causes directly the inhibition of purine release.

Neuronal (Na+,K+)-ATPase and the release of purines from mouse and rat cerebral cortex

Slices of mouse or rat cerebral cortex were incubated with [3H]adenine or [3H]adenosine, and [14C]GABA. Purines and GABA could subsequently be released by ouabain. The release of purines previously shown to occur on restoring elevated K+ levels to normal was not mimicked by noradrenaline at concentrations which activate (Na+,K+)-ATPase. Potassium-free solutions evoked no release of purine during the test period, but resulted in a large release when K+ was restored to normal. K+-free solutions evoked an immediate release of GABA. It is concluded that (Na+,K+)-ATPase is not involved in purine release.