Effectiveness of a game-based educational strategy e-EDUCAGUIA for implementing antimicrobial clinical practice guidelines in family medicine residents in Spain: a randomized clinical trial by cluster

BACKGROUND

Clinical practice guidelines (CPGs) have teaching potential for health professionals in training clinical reasoning and decision-making, although their use is limited. The objective was to evaluate the effectiveness of a game-based educational strategy e-EDUCAGUIA using simulated clinical scenarios to implement an antimicrobial therapy GPC compared to the usual dissemination strategies to improve the knowledge and skills on decision-making of family medicine residents. Additionally, adherence to e-EDUCAGUIA strategy was assessed.

METHODS

A multicentre pragmatic cluster-randomized clinical trial was conducted involving seven Teaching Units (TUs) of family medicine in Spain. TUs were randomly allocated to implement an antimicrobial therapy guideline with e-EDUCAGUIA strategy ( intervention) or passive dissemination of the guideline (control). The primary outcome was the differences in means between groups in the score test evaluated knowledge and skills on decision-making at 1 month post intervention. Analysis was made by intention-to-treat and per-protocol analysis. Secondary outcomes were the differences in mean change intrasubject (from the baseline to the 1-month) in the test score, and educational game adherence and usability. Factors associated were analysed using general linear models. Standard errors were constructed using robust methods.

RESULTS

Two hundred two family medicine residents participated (104 intervention group vs 98 control group). 100 medicine residents performed the post-test at 1 month (45 intervention group vs 55 control group), The between-group difference for the mean test score at 1 month was 11 ( 8.67 to 13.32) and between change intrasubject was 11,9 ( 95% CI 5,9 to 17,9). The effect sizes were 0.88 and 0.75 respectively. In multivariate analysis, for each additional evidence-based medicine training hour there was an increase of 0.28 points (95% CI 0.15-0.42) in primary outcome and in the change intrasubject each year of increase in age was associated with an improvement of 0.37 points and being a woman was associated with a 6.10-point reduction. 48 of the 104 subjects in the intervention group (46.2%, 95% CI: 36.5-55.8%) used the games during the month of the study. Only a greater number of evidence-based medicine training hours was associated with greater adherence to the educational game ( OR 1.11; CI 95% 1.02-1.21).

CONCLUSIONS

The game-based educational strategy e-EDUCAGUIA shows positive effects on the knowledge and skills on decision making about antimicrobial therapy for clinical decision-making in family medicin residents in the short term, but the dropout was high and results should be interpreted with caution. Adherence to educational games in the absence of specific incentives is moderate.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02210442 . Registered 6 August 2014.

"To get the baby out off the hook": a prospective, longitudinal, multicenter, observational study about decision making in vacuum-assisted operative vaginal delivery

Background

Since operative vaginal delivery may be risky for women and might cause neonatal complications, the aim of this study is to assess appropriateness of the procedure.

This is a prospective, longitudinal, multicenter, observational study and it was conducted in three Italian Obstetric Units (Pisa, Massa Carrara and Prato). All term pregnant women, either nulliparous and multiparous, with singleton pregnancy and a cephalic fetus, with spontaneous or induced labour, requiring vacuum-assisted delivery were enrolled.

Indications to operative vaginal delivery were grouped as alterations of fetal cardiotocography (CTG) patterns, delay/arrest of second stage of labour or elective shortening of second stage of labour. A board consisting of five among authors evaluated appropriateness of the procedure.

Results

Overall, 466 women undergoing operative vaginal deliveries were included. Cardiotocography, classified as ACOG category 2 or 3 was the indication for vacuum assisted delivery in 253 patients (54.29%). Among these, 66 women (26.1%) had an operative vaginal delivery which was then considered to be inappropriate, while in 114 cases (45.1%) CTG traces resulted to be unreadable.

Conclusion

Decision making process, which leads clinicians to go for operative vaginal delivery, is often influenced by shortness of time and complexity of the situation. Therefore, clinicians tend to intervene performing vacuum delivery without adopting critical analysis and without adequately considering the clinical situation.

Tweetable abstract

Operative vaginal delivery might be a risky procedure and should be performed only when clinically indicated and after adequate critical analysis.

Training Clinical Researchers with Design Thinking to To Develop Dementia Caregiving Research Initiatives

Training healthcare professionals with Design Thinking (DT) can support patient-centred care by recognizing patient/care provider needs through empathizing. This article explored the Design Thinking in improving clinical researchers' understanding of relatively unexplored and understudied dementia caregiving problems. Following the Double-Diamond, a Design Thinking process model, we conducted a series of workshops and invited family caregivers of patients with dementia as active participants to provide training to clinical researchers on Design Thinking. We then evaluated the benefit of the workshops in improving clinical researchers' understanding of the caregiving problem and solution space through pre- and post-surveys. Our findings revealed researchers' overall perception of Design Thinking, their clear insights on dementia caregivers' challenges, and speculating caregiver-specific interventions. Our paper contributed to the health design community by exploring the benefit of Design Thinking in understudied areas by 1) Recognizing urgent matters in healthcare, 2) Revealing implicit needs through collective expertise and knowledge exchange, and 3) Producing original health care research and contributions. We hope this study inspires and supports training healthcare researchers to advance dementia caregiving and healthcare research initiatives by adopting the Double-Diamond process model.

Out of the empirical box: A mixed-methods study of tool innovation among Congolese BaYaka forager and Bondongo fisher-farmer children

Tool innovation has played a crucial role in human adaptation. Yet, this capacity seems to arise late in development. Before 8 years of age, many children struggle to solve the hook task, a common measure of tool innovation that requires modification of a straight pipe cleaner into a hook to extract a prize. Whether these findings are generalizable beyond postindustrialized Western children remains unclear. In many small-scale subsistence societies, children engage in daily tool use and modification, experiences that theoretically could enhance innovative capabilities. Although two previous studies found no differences in innovative ability between children from Western and small-scale subsistence societies, these did not account for the latter's inexperience with pipe cleaners. Thus, the current study investigated how familiarity with pipe cleaners affected hook task success in 132 Congolese BaYaka foragers (57 girls) and 59 Bondongo fisher-farmers (23 girls) aged 4-12 years. We contextualized these findings within children's interview responses and naturalistic observations of how pipe cleaners were incorporated into daily activities. Counter to our expectation, prior exposure did not improve children's performance during the hook task. Bondongo children innovated significantly more hooks than BaYaka children, possibly because they participate in hook-and-line fishing. Observations and interviews showed that children imagined and innovated novel uses for pipe cleaners outside the experimental context, including headbands, bracelets, and suspenders. We relate our findings to ongoing debates regarding systematic versus unsystematic tool innovation, the importance of prior experience for the ontogeny of tool innovation, and the external validity of experimental paradigms.

Validation of the Italian Remote Associate Test

The scientific approach to the study of creative problem solving has shifted from using classic insight problems (e.g., the Nine-dots problem), towards sets of problems that have more robust psychometric properties, such as the Remote Associate Test (RAT). Because it is homogeneous, compact, quickly solvable, and easy to score, the RAT has been used more frequently in recent creativity studies. We applied the Item Response Theory (IRT) to develop an Italian version of this task. The final 51-item test was reliable (α = .89) and provided information over a wide range of ability levels, as revealed by the IRT analysis. The RAT correlated with five measures of creative performance: The Raven's Standard Progressive Matrices (SPM), three classic insight problems, a set of anagrams purposefully developed, the fluency and flexibility scores of the Alternative Uses Task (AUT), and the Creative Achievements Questionnaire (CAQ). The new measure provided is meant to encourage the study of creativity and problem solving in the Italian language.

Understanding Implementation of Complex Interventions in Primary Care Teams

BACKGROUND

The implementation of interventions to support practice change in primary care settings is complex. Pragmatic strategies, grounded in empiric data, are needed to navigate real-world challenges and unanticipated interactions with context that can impact implementation and outcomes.

OBJECTIVE

This article uses the example of the "5As Team" randomized control trial to explore implementation strategies to promote knowledge transfer, capacity building, and practice integration, and their interaction within the context of an interdisciplinary primary care team.

METHODS

We performed a qualitative evaluation of the implementation process of the 5As Team intervention study, a randomized control trial of a complex intervention in primary care. We conducted thematic analysis of field notes of intervention sessions, log books of the practice facilitation team members, and semistructured interviews with 29 interdisciplinary clinician participants. We used and further developed the Interactive Systems Framework for dissemination and implementation to interpret and structure findings.

RESULTS

Three themes emerged that illuminate interactions between implementation processes, context, and outcomes: (1) facilitating team communication supported collective and individual sense-making and adoption of the innovation, (2) iterative evaluation of the implementation process and real-time feedback-driven adaptions of the intervention proved crucial for sustainable, context-appropriate intervention impact, (3) stakeholder engagement led to both knowledge exchange that contributes to local problem solving and to shaping a clinical context that is supportive to practice change.

CONCLUSION

Our findings contribute pragmatic strategies that can help practitioners and researchers to navigate interactions between context, intervention, and implementation factors to increase implementation success. We further developed an implementation framework that includes sustained engagement with stakeholders, facilitation of team sense-making, and dynamic evaluation and intervention design as integral parts of complex intervention implementation.

TRIAL REGISTRATION

NCT01967797. 18 October 2013.

Can Intrinsic and Extrinsic Metacognitive Cues Shield Against Distraction in Problem Solving?

We investigated the capacity for two different forms of metacognitive cue to shield against auditory distraction in problem solving with Compound Remote Associates Tasks (CRATs). Experiment 1 demonstrated that an intrinsic metacognitive cue in the form of processing disfluency (manipulated using an easy-to-read vs. difficult-to-read font) could increase focal task engagement so as to mitigate the detrimental impact of distraction on solution rates for CRATs. Experiment 2 showed that an extrinsic metacognitive cue that took the form of an incentive for good task performance (i.e. 80% or better CRAT solutions) could likewise eliminate the negative impact of distraction on CRAT solution rates. Overall, these findings support the view that both intrinsic and extrinsic metacognitive cues have remarkably similar effects. This suggests that metacognitive cues operate via a common underlying mechanism whereby a participant applies increased focal attention to the primary task so as to ensure more steadfast task engagement that is not so easily diverted by task-irrelevant stimuli.

The Effectiveness of Problem-Solving Therapy for Primary Care Patients' Depressive and/or Anxiety Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

There is increasing demand for managing depressive and/or anxiety disorders among primary care patients. Problem-solving therapy (PST) is a brief evidence- and strength-based psychotherapy that has received increasing support for its effectiveness in managing depression and anxiety among primary care patients.

METHODS

We conducted a systematic review and meta-analysis of clinical trials examining PST for patients with depression and/or anxiety in primary care as identified by searches for published literature across 6 databases and manual searching. A weighted average of treatment effect size estimates per study was used for meta-analysis and moderator analysis.

RESULTS

From an initial pool of 153 primary studies, 11 studies (with 2072 participants) met inclusion criteria for synthesis. PST reported an overall significant treatment effect for primary care depression and/or anxiety (d = 0.673; P < .001). Participants' age and sex moderated treatment effects. Physician-involved PST in primary care, despite a significantly smaller treatment effect size than mental health provider only PST, reported an overall statistically significant effect (d = 0.35; P = .029).

CONCLUSIONS

Results from the study supported PST's effectiveness for primary care depression and/or anxiety. Our preliminary results also indicated that physician-involved PST offers meaningful improvements for primary care patients' depression and/or anxiety.

Probability or Reasoning: Current Thinking and Realistic Strategies for Improved Medical Decisions

A prescriptive model approach in decision making could help achieve better diagnostic accuracy in clinical practice through methods that are less reliant on probabilistic assessments. Various prescriptive measures aimed at regulating factors that influence heuristics and clinical reasoning could support clinical decision-making process. Clinicians could avoid time-consuming decision-making methods that require probabilistic calculations. Intuitively, they could rely on heuristics to obtain an accurate diagnosis in a given clinical setting. An extensive literature review of cognitive psychology and medical decision-making theory was performed to illustrate how heuristics could be effectively utilized in daily practice. Since physicians often rely on heuristics in realistic situations, probabilistic estimation might not be a useful tool in everyday clinical practice. Improvements in the descriptive model of decision making (heuristics) may allow for greater diagnostic accuracy.

Problem solving, loneliness, depression levels and associated factors in high school adolescents

Objectives:

To determine problem solving, loneliness, depression levels and associated factors in high school adolescents.

Methods:

This cross-sectional study was conducted in a city west of Turkey (Bursa) in a public high school and the population was 774 and the sampling was 394 students. Students to be included in the study were selected using the multiple sampling method. A personal Information Form with 23 questions, Problem Solving Inventory (PSI), Loneliness Scale (UCLA), Beck Depression Inventory (BDI) were used as data collection tools in the study. Basic statistical analyses, t-test, Kruskall Wallis-H, One Way Anova and Pearson Correlation test were used to evaluate the data. Necessary permissions were obtained from the relevant institution, students, parents and the ethical committee.

Results:

The study found significant differences between “problem solving level” and family type, health assessment, life quality and mothers’, fathers’ siblings’ closeness level; between “loneliness level” and gender, family income, health assessment, life quality and mothers’, fathers’, siblings’ closeness level; between “depression level” and life quality, family income, fathers’ closeness level.

Conclusion:

Unfavorable socio-economic and cultural conditions can have an effect on the problem solving, loneliness and depression levels of adolescents. Providing structured education to adolescents at risk under school mental health nursing practices is recommended.

The Effects of Family-Centered Problem-Solving Education on Relapse Rate, Self Efficacy and Self Esteem Among Substance Abusers

Background:

The success of drug abuse treatment and relapse prevention methods depends widely on not only pharmaceutical and non-pharmaceutical therapies but also self efficacy and self esteem promotion.

Objectives:

The current study attempted to clarify the effects of Problem Solving Education (PSE) on relapse rate, self efficacy and self esteem among drug abusers.

Patients and Methods:

This non-controlled clinical trial (quasi-experimental) assessed 60 opium and heroin abusers who were willing to quit and were referred to the Mehr Center of Addiction Treatment and Rehabilitation Facility. The patients were allocated to two groups of 30 (intervention and control groups). While both groups received the routine care of the clinic, the intervention group also attended eight 45-minute family-centered PSE sessions. The Coopersmith Self esteem Inventory and Quit Addiction Self efficacy Questionnaire were filled out for all subjects before and after the intervention. Drug relapse was investigated four times with two-week intervals. The two groups were compared using chi-square and Student’s-t tests. Logistic regression analysis was applied to determine factors affecting drug relapse.

Results:

A total of 45 individuals (21 and 24 in the intervention and control groups, respectively) completed the study. At baseline, the two groups had no significant difference regarding their mean scores of self esteem and self efficacy (P = 0.692 and 0.329, respectively). After the intervention, however, the mean changes of self esteem scores were 20.10 ± 3.75 for the intervention group and 4.50 for the control group (P < 0.001). The mean changes of self efficacy scores in the mentioned groups were 34 34.17 ± 5.19 and 9.03± 2.04, respectively (P < 0.001). Drug relapse after two weeks was correlated with age (OR = 1.216; P = 0.026; 95% CI: 1.024-1.445) and implementation of the intervention (OR = 0.036; P = 0.003; 95% CI: 0.004-0.322).

Conclusions:

According to our findings, supplementing drug abuse treatment with cognitive behavior therapy, particularly PSE, can reduce relapse rate and enhance self efficacy and self esteem among patients.

E-learning for Critical Thinking: Using Nominal Focus Group Method to Inform Software Content and Design

Background:

Undergraduate nursing students are often confused by multiple understandings of critical thinking. In response to this situation, the Critiique for critical thinking (CCT) project was implemented to provide consistent structured guidance about critical thinking.

Objectives:

This paper introduces Critiique software, describes initial validation of the content of this critical thinking tool and explores wider applications of the Critiique software.

Materials and Methods:

Critiique is flexible, authorable software that guides students step-by-step through critical appraisal of research papers. The spelling of Critiique was deliberate, so as to acquire a unique web domain name and associated logo. The CCT project involved implementation of a modified nominal focus group process with academic staff working together to establish common understandings of critical thinking. Previous work established a consensus about critical thinking in nursing and provided a starting point for the focus groups. The study was conducted at an Australian university campus with the focus group guided by open ended questions.

Results:

Focus group data established categories of content that academic staff identified as important for teaching critical thinking. This emerging focus group data was then used to inform modification of Critiique software so that students had access to consistent and structured guidance in relation to critical thinking and critical appraisal.

Conclusions:

The project succeeded in using focus group data from academics to inform software development while at the same time retaining the benefits of broader philosophical dimensions of critical thinking.

Organizational culture associated with provider satisfaction

BACKGROUND

Organizational culture is key to the successful implementation of major improvement strategies. Transformation to a patient-centered medical home (PCHM) is such an improvement strategy, requiring a shift from provider-centric care to team-based care. Because this shift may impact provider satisfaction, it is important to understand the relationship between provider satisfaction and organizational culture, specifically in the context of practices that have transformed to a PCMH model.

METHODS

This was a cross-sectional study of surveys conducted in 2011 among providers and staff in 10 primary care clinics implementing their version of a PCMH: Care by Design. Measures included the Organizational Culture Assessment Instrument and the American Medical Group Association provider satisfaction survey.

RESULTS

Providers were most satisfied with quality of care (mean, 4.14; scale of 1-5) and interactions with patients (mean, 4.12) and were least satisfied with time spent working (mean, 3.47), paperwork (mean, 3.45), and compensation (mean, 3.35). Culture profiles differed across clinics, with family/clan and hierarchical cultures the most common. Significant correlations (P ≤ .05) between provider satisfaction and clinic culture archetypes included family/clan culture negatively correlated with administrative work; entrepreneurial culture positively correlated with the Time Spent Working dimension; market/rational culture positively correlated with how practices were facing economic and strategic challenges; and hierarchical culture negatively correlated with the Relationships with Staff and Resource dimensions.

CONCLUSIONS

Provider satisfaction is an important metric for assessing experiences with features of a PCMH model. Identification of clinic-specific culture archetypes and archetype associations with provider satisfaction can help inform practice redesign. Attention to effective methods for changing organizational culture is recommended.

Problem-solving deficits in Iranian people with borderline personality disorder

OBJECTIVE

Interventions for people suffering from borderline personality disorder (BPD), such as dialectical behavior therapy, often include a problem-solving component. However, there is an absence of published studies examining the problem-solving abilities of this client group in Iran. The study compared inpatients and outpatients with BPD and a control group on problem-solving capabilities in an Iranian sample. It was hypothesized that patients with BPD would have more deficiencies in this area.

METHODS

Fifteen patients with BPD were compared to 15 healthy participants. Means-ends problem-solving task (MEPS) was used to measure problem-solving skills in both groups.

RESULTS

BPD group reported less effective strategies in solving problems as opposed to the healthy group. Compared to the control group, participants with BPD provided empirical support for the use of problem-solving interventions with people suffering from BPD.

CONCLUSIONS

The findings supported the idea that a problem-solving intervention can be efficiently applied either as a stand-alone therapy or in conjunction with other available psychotherapies to treat people with BPD.

Overgenerality memory style for past and future events and emotions related in bipolar disorder. What are the links with problem solving and interpersonal relationships?

This study investigated patients with Bipolar Disorder's abilities to generate specific past and future events in response to positive and negative cues words as well as emotional intensity related to these ones. The relationships between the number of generated specific events cognitive functioning, interpersonal problems and the ability to problem solving were investigated. Nineteen BD and nineteen healthy controls completed a French version of the AMT to evaluate the past and future events recall, in function of their valence, and emotions related. Furthermore, they completed the Optional Thinking Test, the Inventory of Interpersonal Problems and the neuropsychological measures. Compared to healthy controls, BD recollected (1) fewer specific past negative events and (2) fewer future specific positive and negative events furthermore, (3) they felt more emotional intensity related to future events. These results were explained in the light of theoretical models. Finally, specific past memories deficits in BD were linked with issues in problem solving but not with levels of distress arising from interpersonal problems. In view of AM functions in everyday life, all types of deficits should be taken into consideration, and AM remediation envisaged.

Psychometric Evaluation of the Social Problem-Solving Inventory- Revised among Overweight or Obese Adults

Problem solving is a key component of weight loss programs. The Social Problem Solving Inventory-Revised (SPSI-R) has not been evaluated in weight loss studies. The purpose of this study was to evaluate the psychometrics of the SPSI-R. Cronbach's alpha (.95 for total score; .67 - .92 for subscales) confirmed internal consistency reliability. The SPSI-R score was significantly associated (ps<.05) with decreased eating barriers and binge eating, increased self-efficacy in following a cholesterol-lowering diet, consumption of fewer calories and fat grams, more frequent exercise, lower psychological distress, and higher mental quality of life; all suggesting concurrent validity with other instruments used in weight loss studies. However, confirmatory factor analysis of the hypothesized 5-factor structure did not fit the data well (χ2=350, p<.001).