Measures that can be used to teach critical thinking skills in nurse prescribers

Critical thinking is a pervasive skill that involves scrutinizing, differentiating, and appraising information and reflecting on the information gained in order to make judgements and inform clinical decisions. Studies inform us of the need for agreement on the approaches used to teach and measure critical thinking. Nurse prescribers undertake an advanced role that encompass the need to be able to make clinically based decisions about the appropriateness of a specific medication. This requires critical thinking attributes. A variety of teaching and learning approaches are offered which can be used by nurse educators to develop critical thinking skills in nurse prescribers

Deliberate clinical inertia: Using meta-cognition to improve decision-making

Deliberate clinical inertia is the art of doing nothing as a positive response. To be able to apply this concept, individual clinicians need to specifically focus on their clinical decision-making. The skill of solving problems and making optimal clinical decisions requires more attention in medical training and should play a more prominent part of the medical curriculum. This paper provides suggestions on how this may be achieved. Strategies to mitigate common biases are outlined, with an emphasis on reversing a 'more is better' culture towards more temperate, critical thinking. To incorporate such an approach in medical curricula and in clinical practice, institutional endorsement and support is required

New perspectives - approaches to medical education at four new UK Medical Schools

To create more UK doctors, the government has funded an increase in medical student numbers of 57% (from 3749 to 5894)1 between 1998 and 2005. This has been done by increasing student places at existing medical schools; creating shortened programmes open to science graduates; “twinning” arrangements, which host an existing curriculum at a new site; and four entirely new schools (table 1). Through reflection on our experiences and the literature evidence, we examine to what extent these new schools have a common vision and approach to undergraduate medical education, and we discuss the rationale for and likely outcomes of these new ventures

Knowledge engineering complex decision support system in managing rheumatoid arthritis.

Background: The management of rheumatoid arthritis (RA) involves partially recursive attempts to make optimal treatment decisions that balance the risks of the treatment to the patient against the benefits of the treatment, while monitoring the patient closely for clinical response, as inferred from prior and residual disease activity, and unwanted drug effects, including abnormal laboratory findings. To the extent that this process is logical, based on best available evidence and determined by considered opinion, it should be amenable to capture within a Clinical Decision Support Systems (CDSSs). The formalisation of logical transformations and their execution by computer tools at point of patient encounter holds the promise of more efficient and consistent use of treatment rules and more reliable clinical decision making. Research Setting: The early Rheumatoid Arthritis (eRA) clinic of the Royal Adelaide Hospital (RAH) with approximately 20 RA patient visits per week, and involving 160 patients with a median duration of treatment of more than 4.5 years. Methods: The study applied a Knowledge Engineering approach to interpret the complexities of RA management, in order to implement a knowledge-based CDSS. The study utilised Knowledge Acquisition processes to elicit and explicitly define the RA management rules underpinning the development of the CDSS; the processes were (1) conducting a comprehensive literature review of RA management, (2) observing clinic consultations and (3) consulting with local clinical experts/leaders. Bayes’ Theorem and Bayes Net were used to generate models for assessing contingent probabilities of unwanted events. A questionnaire based on 16 real patient cases was developed to test the concordance agreement between CDSS generated guidance in response to real-life clinical scenarios and decisions of rheumatologists in response to the scenarios. Results: (1) Complex RA management rules were established which included (a) Rules for Changes in Dose/Agent and (b) Drug Toxicity Monitoring Rules. (2) A computer interpretable dynamic model for implementing the complex clinical guidance was found to be applicable. (3) A framework for a methotrexate (MTX) toxicity prediction model was developed, thereby allowing missing risk ratios (probabilities) to be identified. (4) Clinical decision-making processes and workflows were described. Finally, (5) a preliminary version of the CDSS which computed Rules for Changes in Dose/Agent and Drug Toxicity Monitoring Rules was implemented and tested. One hundred and twenty-eight decisions collected from the 8 participating rheumatologists established the ability of the CDSS to match decisions of clinicians accustomed to application of Rules for Changes in Dose/Agent; rheumatologists unfamiliar with the rules displayed lower concordance (0.7857 vs. 0.3929, P = 0.0027). Neither group of rheumatologists matched the performance of the CDSS in making decisions based on highly complex Drug Toxicity Monitoring Rules (0.3611 vs. 0.4167, P = 0.7215). Conclusion: The study has made important contributions to the development of a CDSS suitable for routine use in the eRA clinic setting. Knowledge Acquisition processes were used to elicit domain knowledge, and to refine, validate and articulate eRA management rules, that came to form the knowledge base of the CDSS. The development of computer interpretable guideline models underpinned the CDSS development. The alignment of CDSS guidance in response to clinical scenarios with questionnaire responses of rheumatologists familiar with and accepting of the management rules (and divergence with responses by rheumatologists not familiar with the rules) indicates that the CDSS can be used to guide toward evidence-based considered opinion. The poor correlation between CDSS generated guidance regarding out of range blood results and response of rheumatologists to questions regarding toxicity scenarios, underlines the value of computer aided guidance when decisions involve greater complexity. It also suggests the need for attention to rule development and considered opinion in this area. Discussion: Effective utilisation of extant knowledge is fundamental to knowledgebased systems in healthcare. CDSSs development for chronic disease management is a complex undertaking which is tractable using Knowledge Engineering and Knowledge Acquisition approaches coupled with modelling into computer interpretable algorithms. Complexities of drug toxicity monitoring were addressed using Bayes’ Theorem and Bayes Net for making probability based decisions under conditions of uncertainty. While for logistic reasons the system could not be developed to full implementation, preliminary analyses support the utility of the approach, both for intensifying treatment on a response contingent basis and also for complex drug toxicity monitoring. CDSSs are inherently suited to iterative refinements based on new knowledge including that arising from analyses of the data they capture during their use. This study has achieved important steps toward implementation and refinement.Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 201

Do people with intellectual disabilities have the skills to undertake cognitive behavioural therapy? An investigation into computerised training to improve accessibility

While people with intellectual disabilities (IDs) are at increased risk of developing mental health problems, they are disadvantaged when accessing mental health services. The aims of this thesis are threefold: 1) to evaluate the efficacy of psychological therapies for people with IDs who experience mental health problems, 2) to improve the suitability of adults with IDs for cognitive behavioural therapy (CBT), and 3) to explore the acceptability of computer programmes in therapy as a reasonable adjustment to improve therapy accessibility. A systematic review and meta-analysis of the current literature were conducted and identified CBT and individual therapies as the most efficacious treatment for anger and depression. Although adults with IDs and concurrent mental health problems appear to benefit from psychological therapies, clinical trials need to make use of improved reporting standards and larger samples. Next, in two subsequent single-blind mixed experimental designs the efficacy of computerised training programmes in improving CBT skills in people with mild to moderate IDs is evaluated. Training programmes focused on linking situations to feelings and discriminating between thoughts, feelings and behaviours. When compared to an attention-control condition, training improved cognitive mediation skills, as assessed by the ability to link situations and mediating beliefs to feelings, and improved the ability to differentiate between thoughts, feelings and behaviours. In a concluding qualitative study, the perspectives of service users with IDs and clinicians on using computers in therapy were explored. Both service users and clinicians were positive about the potential functions and benefits of using computers in therapy, but also drew attention to potential challenges and barriers. Together, these studies show that computers can be used to improve the suitability of people with IDs for CBT and meanwhile encourage further exploration into the possibilities that these technologies can open up for improving the accessibility of psychological therapies

Evidence-based planning and costing palliative care services for children : novel multi-method epidemiological and economic exemplar

Background: Children’s palliative care is a relatively new clinical specialty. Its nature is multi-dimensional and its delivery necessarily multi-professional. Numerous diverse public and not-for-profit organisations typically provide services and support. Because services are not centrally coordinated, they are provided in a manner that is inconsistent and incoherent. Since the first children’s hospice opened in 1982, the epidemiology of life-limiting conditions has changed with more children living longer, and many requiring transfer to adult services. Very little is known about the number of children living within any given geographical locality, costs of care, or experiences of children with ongoing palliative care needs and their families. We integrated evidence, and undertook and used novel methodological epidemiological work to develop the first evidence-based and costed commissioning exemplar. Methods: Multi-method epidemiological and economic exemplar from a health and not-for-profit organisation perspective, to estimate numbers of children under 19 years with life-limiting conditions, cost current services, determine child/parent care preferences, and cost choice of end-of-life care at home. Results: The exemplar locality (North Wales) had important gaps in service provision and the clinical network. The estimated annual total cost of current children’s palliative care was about £5.5 million; average annual care cost per child was £22,771 using 2007 prevalence estimates and £2,437- £11,045 using new 2012/13 population-based prevalence estimates. Using population-based prevalence, we estimate 2271 children with a life-limiting condition in the general exemplar population and around 501 children per year with ongoing palliative care needs in contact with hospital services. Around 24 children with a wide range of life-limiting conditions require end-of-life care per year. Choice of end-of-life care at home was requested, which is not currently universally available. We estimated a minimum (based on 1 week of end-of-life care) additional cost of £336,000 per year to provide end-of-life support at home. Were end-of-life care to span 4 weeks, the total annual additional costs increases to £536,500 (2010/11 prices). Conclusions: Findings make a significant contribution to population-based needs assessment and commissioning methodology in children’s palliative care. Further work is needed to determine with greater precision which children in the total population require access to services and when. Half of children who died 2002-7 did not have conditions that met the globally used children's palliative care condition categories, which need revision in light of findings

Integration of decision support systems to improve decision support performance

Decision support system (DSS) is a well-established research and development area. Traditional isolated, stand-alone DSS has been recently facing new challenges. In order to improve the performance of DSS to meet the challenges, research has been actively carried out to develop integrated decision support systems (IDSS). This paper reviews the current research efforts with regard to the development of IDSS. The focus of the paper is on the integration aspect for IDSS through multiple perspectives, and the technologies that support this integration. More than 100 papers and software systems are discussed. Current research efforts and the development status of IDSS are explained, compared and classified. In addition, future trends and challenges in integration are outlined. The paper concludes that by addressing integration, better support will be provided to decision makers, with the expectation of both better decisions and improved decision making processes