Integrated Learning in Simulation: Theoretic Foundations Based on Carper’s Patterns of Knowing

Nursing education is a lifelong process. It is dynamic. Nurse educators strive to develop student-centered collaborative teaching strategies. Simulation serves as strategy to teach clinical reasoning skills and prepare students to provide safe, effective patient care. Increasing patient acuity and lack of clinical sites make simulation an essential and integral part of nursing education. This paper demonstrates the value of using Carper’s (1978) fundamental patterns of knowing in nursing as a theoretical foundation for the integration of simulation-based learning experiences in nursing education

THE EXPERIENCE AND PROCESS OF THE WORKING ALLIANCE IN COLLEGIATE ATHLETIC TRAINING

As healthcare evolves to consider the psychosocial effects of injury and disease on patient well-being, attention has turned to patient-provider relationships. Heightened attention to the significance of this relationship necessitates healthcare providers shift to a patientcentered model. One foundational model, the working alliance, emphasizes emotional bond, collaboration on goals, and agreement on tasks between patient and provider. Despite emphasis on a working alliance in healthcare research, conceptual understanding of the components of athletic trainer-patient relationships in collegiate athletic training remains unexplored. In this grounded theory study, six participants completed two rounds of semi-structured interviews guided by the research question: What is the collegiate athletic trainer’s experience and process of developing a working alliance in athletic training? The results from this grounded theory study emphasizes how athletic trainers create and enter patient and coach relationships and move through the care process, and their experiences with patient investment and ever present environmental, place, and person factors that broadly influence athletic trainers efforts to develop patient relationships and provides a guide to integrate a working alliance into athletic training practice. Bolstering care contracts with informed consent and adapting patient education supports patient understanding, involvement, and facilitates collaboration. Rapport, connection, and trust are essential to developing patient relationships and an emotional bond. Navigating care as partners and educators enhances athletic trainers ability to collaboratively establish goals and agreement on tasks, provide patient-centered care, and improve working alliances. Effectively managing patient resistance helps athletic trainers encourage adherence and buy-in. Drawing attention to establishing and navigating skills most beneficial to training clinical preceptors enables them to model and introduce these skills’ value and importance to athletic training students sooner during education. These results also offer a framework to guide education and skills training in Athletic Training Programs, connecting athletic training students with skills that enhance clinical learning and patient-centered care experiences before professional practice. Knowing when, how, and where working alliance skills surface in athletic training patient care enables counselor educators to enhance current proficiency and introduce focused skills training in the athletic training discipline, which may also enhance bond formation, gaining agreement on goals, and collaborating on tasks, thus supporting development of a working alliance

Evidence-Based Practice for Medical Students in a Family Medicine Clerkship: Collaborative, Active Learning for Clinical Decision Skills

Objectives: This active learning experience was designed to enhance the information literacy knowledge and skills of medical students for patient-centered, evidence-based decisions at the point of care. It includes formulating clinical questions using patient/problem, intervention, comparison, outcome (PICO), accessing the highest level of evidence-based medicine (EBM) information available in an effective manner, and evaluating the information in relation to a specific patient in an outpatient setting. Methods: Third-year medical students participate in a small-group collaborative, patient-centered learning experience during the family medicine clerkship, coordinated by the clerkship directors with participation by two medical librarians. At orientation, the clerkship directors provide the students with an overview of the evidence-based process and creating PICO questions. Librarians then direct a hands-on instruction session covering evidence-based resources and search strategies for finding point-of-care EBM information. Students select a clinical question from a patient encounter in their outpatient clinics. Each student submits a worksheet providing the PICO question, resources consulted, search strategy, selected bibliographic references, and clinical recommendations for their patient. Librarians provide a written assessment and suggestions for improvement relative to the students\u27 search strategies and resource selections. Students then present their patient clinical question, research, and recommendations to the clinical faculty and student group. Results: In the most recent 6 months of this course, 85% of the 55 students participating were rated as “competent” in the areas of resource selection and literature searching on their EBM assignment. Pre- and post-tests results indicate that a majority of the students had an increased familiarity with and appreciation of key evidence-based medicine resources such as Cochrane Reviews, ACP PIER, and FPIN after completing the EBM assignment. Student evaluations reflect increased interest and value in EBM through this experience. Conclusion: Providing an active learning, patient-centered experience with collaboration between clinical faculty and medical librarians has been successful in improving third-year medical student knowledge and skills in medical information literacy for clinical decision making. The project has also provided useful data for ongoing discussions with the college of medicine regarding increasing the longitudinal role of the library throughout the curriculum

Exploring learning in Patient-centered care

This paper consists of investigations into a strategic planning framework for information systems in support ofpatient-centered care (PCC) processes. The planning perspective that underpins the research includes learningtheories, organizational learning and knowledge management in general. A brief review of current PCC goalsand perspectives is used as a starting point for an investigation of PCC activities and support system. Theexamples of existing PCC activities are organized as a learning process and presented in a framework. Sevenmain points of framework includes: 1. Patient understanding and personal knowledge of his/her health situation.2. Facts/information gathering, about the condition that the patient is in. 3. Planning/Formulation of alternatives,based on facts, possible paths of action is planned. 4. Decision-making, including weighing alternatives andchoosing actions. 5. Taking action, performing what has been decided on. 6. Evaluation and record-keeping. 7.Patient interaction with health, either face-to-face experience or supported by technology

Closing the Culture Gap: Student Language Competencies for the Assessment of Patients in a Bilingual Health Care Setting

In a bilingual health care institution, how can specialized practitioners improve students’ administration of standardized assessments in neuropsychology to French-speaking patients in the absence of language competencies, in alignment with the cultures of both patient-centered care and efficiency? This OIP was developed for a Canadian bilingual health care institution, operating in alignment with political and legal language service and patient care obligations. However, increasing demand for services and professional language competency coupled with reduced funding has led to efficiency-focused departmental practices. Challenges in balancing a culture of efficacy and efficiency with the culture of patient-centered care and bilingualism have led to a culture gap. In this organization, specialized practitioners train students in a non-standardized manner to assess French-speaking patients, and graduate students without language competency tools or support must use clinical judgment to navigate the assessment process. This culture gap impacts the patient’s experience and overall assessment results, as well as the student and specialized practitioners value congruence with the organization. To implement change in this organization as an informal leader and teacher, I use both linear and cyclical change models that align with Symbolic Interactionism. To lead change, I use adaptive and distributed leadership styles, within an ethics of care framework. Both the implementation and leadership approaches focus on double-loop organizational learning, and participatory, stakeholder-driven change. The chosen solution targets the modification of three current organizational practices: student placement, student on-boarding, and patient assessment. The solution is incremental and iterative, promoting stakeholder empowerment and sustainable change, towards an organizational culture that is congruent with organizational and stakeholder values. All elements of the implementation plan, including ethical considerations, are subject to periodic study and revision. The communication strategy is tailored to each stakeholder group, and includes a questioning and appreciative approach, supporting informal leadership and development of a shared vision

Fall prevention with community dwelling seniors: A student interprofessional experiential learning activity

Purpose: This IPE curricular model was designed for PT and OT students to learn from one another about the role and effective collaboration between disciplines through the delivery of an evidenced based falls prevention program. The activity allowed students to utilize clinical skills learned in the classroom to deliver patient centered care to seniors. Background: Traditionally, students do not get an opportunity to see interprofessional care until they participate in full-time clinical experiences. The benefits of early experiential learning during the didactic portion of a program, along with interprofessional education, are becoming more prominent in the literature. Description of Program: PT and OT students participated in delivering an 8 week falls prevention clinic. The program included participation in an exercise program and educational group process, as recommended by the CDC for multifactorial falls prevention programs. Faculty facilitated the students’ delivery of the program and guided questions to provoke conversation related to interprofessionalism, collaborative practice, professional identity and patient centered care. Preliminary Results: Students reported that it was beneficial for them to see how each discipline approached patient care, through interactions and education, as well as ‘put together’ the skills they were learning in the classroom. The participants reported that they enjoyed working with students; helping them to learn, having someone to guide them with exercise and provide them with feedback. Relevance to IPE: This pilot activity proved to be valuable from all perspectives; faculty, student and participant. It was a non-simulated experiential learning activity that assisted students in developing respect and relationships between disciplines. Recommendations: While this pilot activity met the established objectives, more structure related to enhancing the interprofessional education components is recommended in future implementation of this program. Learning Objectives (relate most to Conference Learning Objective #5): Participants will identify the components of how to structure an IPE program to incorporate the learning of OT and PT students within a graduate curriculum. Participants will acknowledge the learned positive features of implementing a pilot, semester long IPE program and recommendations for future implementation. Participants will discuss the benefits of providing an interdisciplinary community based program and methods to incorporate this curricular model into their own setting

Optimizing patient partnership in primary care improvement: A qualitative study

BACKGROUND: The need to expand and better engage patients in primary care improvement persists. PURPOSE: Recognizing a continuum of forms of engagement, this study focused on identifying lessons for optimizing patient partnerships, wherein engagement is characterized by shared decision-making and practice improvement co-design. METHODOLOGY: 23 semi-structured interviews with providers and patients involved in improvement efforts in seven U.S. primary care practices in the Academic Innovations Collaborative (AIC). The AIC aimed to implement primary care improvement, emphasizing patient engagement in the process. Data were analyzed thematically. RESULTS: Sites varied in their achievement of patient partnerships, encountering material, technical, and sociocultural obstacles. Time was a challenge for all sites, as was engaging a diversity of patients. Technical training on improvement processes and shared learning ‘on the job’ were important. External, organizational and individual-level resources helped overcome sociocultural challenges: the AIC drove provider buy-in; a team-based improvement approach helped shift relationships from providers and recipients towards teammates; and individual qualities and behaviors that flattened hierarchies and strengthened interpersonal relationships further enhanced ‘teamness’. A key factor influencing progress towards transformative partnerships was a strong shared learning journey, characterized by: frequent interactions; proximity to improvement decision-making; learning together from the ‘lived experience’ of practice improvement. Teams came to value not only patients’ knowledge, but changes wrought by working collaboratively over time. CONCLUSION: Establishing practice improvement partnerships remains challenging, but partnering with patients on improvement journeys offers distinctive gains for high quality patient-centered care. PRACTICE IMPLICATIONS: Engaging diverse patient partners requires significant disruption to organizational norms and routines, and the trend toward team-based primary care offers a fertile context for patient partnerships. Material, technical and sociocultural resources should be evaluated not only for whether they overcome specific challenges, but also for how they enhance the shared learning journey.This research was supported by a grant from the Harvard Medical School Center for Primary Care and CRICO [362121]. Emma-Louise Aveling’s contribution was supported by funding from a Wellcome Trust Senior Investigator Award (WT097899M)

Designing a patient-centered personal health record to promote preventive care

<p>Abstract</p> <p>Background</p> <p>Evidence-based preventive services offer profound health benefits, yet Americans receive only half of indicated care. A variety of government and specialty society policy initiatives are promoting the adoption of information technologies to engage patients in their care, such as personal health records, but current systems may not utilize the technology's full potential.</p> <p>Methods</p> <p>Using a previously described model to make information technology more patient-centered, we developed an interactive preventive health record (IPHR) designed to more deeply engage patients in preventive care and health promotion. We recruited 14 primary care practices to promote the IPHR to all adult patients and sought practice and patient input in designing the IPHR to ensure its usability, salience, and generalizability. The input involved patient usability tests, practice workflow observations, learning collaboratives, and patient feedback. Use of the IPHR was measured using practice appointment and IPHR databases.</p> <p>Results</p> <p>The IPHR that emerged from this process generates tailored patient recommendations based on guidelines from the U.S. Preventive Services Task Force and other organizations. It extracts clinical data from the practices' electronic medical record and obtains health risk assessment information from patients. Clinical content is translated and explained in lay language. Recommendations review the benefits and uncertainties of services and possible actions for patients and clinicians. Embedded in recommendations are self management tools, risk calculators, decision aids, and community resources - selected to match patient's clinical circumstances. Within six months, practices had encouraged 14.4% of patients to use the IPHR (ranging from 1.5% to 28.3% across the 14 practices). Practices successfully incorporated the IPHR into workflow, using it to prepare patients for visits, augment health behavior counseling, explain test results, automatically issue patient reminders for overdue services, prompt clinicians about needed services, and formulate personalized prevention plans.</p> <p>Conclusions</p> <p>The IPHR demonstrates that a patient-centered personal health record that interfaces with the electronic medical record can give patients a high level of individualized guidance and be successfully adopted by busy primary care practices. Further study and refinement are necessary to make information systems even more patient-centered and to demonstrate their impact on care.</p> <p>Trial Registration</p> <p>Clinicaltrials.gov identifier: <a href="http://www.clinicaltrials.gov/ct2/show/NCT00589173">NCT00589173</a></p

The Maine Patient Centered Medical Home (PCMH) Pilot: Implementation Evaluation

The purpose of this Maine Patient Centered Medical Home (PCMH) Pilot is to improve quality of care, efficiency, and patient/family satisfaction provided by primary care practices. Its premise is that the resources provided to practices through the Pilot (including enhanced payments, training, consultation, and learning collaborative) will help them transform themselves and reach a higher level of functionality as medical homes, which in turn will lead to improvements in quality of care, efficiency, and patient/family satisfaction. The three-year Pilot was convened by MaineCare, the Maine Quality Forum, and Quality Counts. The participating payers are MaineCare (Maine Medicaid), Aetna, Anthem, and Harvard Pilgrim Health Care. Three aspects of the Pilot are being evaluated by the Muskie School of Public Service: 1) patient’s experiences; 2) the implementation process and interim results during Year 1; and 3) changes in the quality and efficiency of primary care. This report focuses on findings from the implementation evaluation. A national evaluation of a PCMH demonstration concluded that several factors, including practices’ workplace culture and resilience (or “adaptive reserve,” including communication, leadership, learning culture, teamwork and work environment) were major determinants in the degree to which practices could transform themselves into medical homes. The implementation evaluation describes the processes the Pilot practices engaged in during the first year and profiles adaptive reserve and several other factors that may contribute to their success in achieving the Pilot’s objectives. The objectives of the implementation evaluation are to Profile the characteristics of the Pilot practices Describe the practices’ objectives and strategies for implementing the Pilot Describe the implementation process during Year 1 Provide practical guidance to the practices, the Pilot conveners, and MaineCare Develop profiles of the Pilot practices for use in the quality and efficiency evaluation Make recommendations for use by evaluators of other PCMH pilot

Listening as medicine: A thematic analysis

Realizations of the importance of “the art of medicine” in trust-building and patient satisfaction have resulted in the incorporation of narrative medicine programs into training curricula. By learning how to respond to patient stories as well as communicate their own, healthcare providers can ensure that their patients feel heard and respected. This study seeks to define what constitutes empathetic listening through a qualitative analysis of personal narratives collected from patients, caregivers, and providers across an urban academic healthcare system. Stories (n=41) underwent thematic analysis to note common experiences related to listening during a health system encounter. Eighteen grounded codes were identified which were abstracted to the following five themes: (1) connection and trust, (2) emotion and vulnerability, (3) objectives and experiences, (4) interaction and opportunity, and (5) challenges of listening. The most common theme of “connection and trust” indicated that active listening and person-centered care were key drivers of patient satisfaction and medical adherence. Encouraging patients and providers to become more comfortable verbalizing vulnerability also provided emotional relief. Taking the time to listen to patient needs and values advanced shared-decision making and facilitated the establishment of care objectives. Storytellers also conveyed the challenges inherent to the listening process. By helping to define empathetic listening, these results may enable the development of healthcare training programs centered on improving clinician communication and patient experience. We hope this study encourages future research devoted to quantifying subjective features such as “connection and trust” and “emotion and vulnerability” utilizing psychometrically validated instruments. Experience Framework This article is associated with the Patient, Family & Community Engagement lens of The Beryl Institute Experience Framework (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens