ABSTRACT
Background: Although
practice guidelines are important tools to improve quality of care,
implementation remains challenging. To improve adherence to an evidence-based
guideline for the management of mental health problems, we developed a tailored
implementation strategy targeting barriers perceived by occupational physicians
(OPs). Feasibility and impact on OPs’ barriers were evaluated. Methods OPs
received 8 training-sessions in small peer-learning groups, aimed at discussing
the content of the guideline and their perceived barriers to adhere to
guideline recommendations; finding solutions to overcome these barriers; and
implementing solutions in practice. The training had a plan-do-check-act (PDCA)
structure and was guided by a trainer. Protocol compliance and OPs’ experiences
were qualitatively and quantitatively assessed. Using a questionnaire, impact
on knowledge, attitude, and external barriers to guideline adherence was
investigated before and after the training. Results The training protocol was
successfully conducted; guideline recommendations and related barriers were
discussed with peers, (innovative) solutions were found and implemented in
practice. The participating 32 OPs were divided into 6 groups and all OPs
attended 8 sessions. Of the OPs, 90% agreed that the peer-learning groups and
the meetings spread over one year were highly effective training components.
Significant improvements (p < .05) were found in knowledge,
self-efficacy, motivation to use the guideline and its applicability to
individual patients. After the training, OPs did not perceive any barriers
related to knowledge and self-efficacy. Perceived adherence increased from
48.8% to 96.8% (p < .01). Conclusions The results imply that an implementation
strategy focusing on perceived barriers and tailor-made implementation
interventions is a feasible method to enhance guideline adherence. Moreover,
the strategy contributed to OPs’ knowledge, attitudes, and skills in using the
guideline. As a generic approach to overcome barriers perceived in specific
situations, this strategy provides a useful method to guideline implementation
for other health care professionals too.ABSTRACT
Background: The importance of the hidden curriculum is recognised as a practical training ground for the absorption of medical ethics by healthcare professionals. Pakistan’s healthcare sector is hampered by the exclusion of ethics from medical and nursing education curricula and the absence of monitoring of ethical violations in the clinical setting. Nurses have significant knowledge of the hidden curriculum taught during clinical practice, due to long working hours in the clinic and front-line interaction with patients and other practitioners.
Methods: The means of
inquiry for this study was qualitative, with 20 interviews and four focus group
discussions used to identify nurses’ clinical experiences of ethical
violations. Content analysis was used to discover sub-categories of ethical
violations, as perceived by nurses, within four pre-defined categories of nursing
codes of ethics: 1) professional guidelines and integrity, 2) patient informed
consent, 3) patient rights, and 4) co-worker coordination for competency,
learning and patient safety.
Results: Ten sub-categories
of ethical violations were found: nursing students being used as adjunct staff,
nurses having to face frequent violence in the hospital setting, patient
reluctance to receive treatment from nurses, the near-absence of consent taken
from patients for most non-surgical medical procedures, the absence of patient
consent taking for receiving treatment from student nurses, the practice of
patient discrimination on the basis of a patient’s socio-demographic status,
nurses withdrawing treatment out of fear for their safety, a non-learning
culture and, finally, blame-shifting and non-reportage of errors.
Conclusion: Immediate and
urgent attention is required to reduce ethical violations in the healthcare
sector in Pakistan through collaborative efforts by the government, the
healthcare sector, and ethics regulatory bodies. Also, changes in
socio-cultural values in hospital organisation, public awareness of how to
conveniently report ethical violations by practitioners and public perceptions
of nurse identity are needed.
Ahn K, Jhun HJ. New physical
examination tests for lumbar spondylolisthesis and instability: low midline
sill sign and interspinous gap change during lumbar flexion-extension motion. BMC Musculoskeletal Disorders 2015, 16:97
doi:10.1186/s12891-015-0551-0
ABSTRACT
Background: Lumbar
spondylolisthesis (LS) and lumbar instability (LI) are common disorders in
patients with low back or lumbar radicular pain. However, few physical
examination tests for LS and LI have been reported. In the study described
herein, new physical examination tests for LS and LI were devised and evaluated
for their validity. The test for LS was designated “low midline sill sign”, and
that for LI was designated “interspinous gap change” during lumbar
flexion-extension motion. Methods The validity of the low midline sill sign was
evaluated in 96 patients with low back or lumbar radicular pain. Validity of
the interspinous gap change during lumbar flexion-extension motion was
evaluated in 73 patients with low back or lumbar radicular pain. The
sensitivity, specificity, and positive and negative predictive values of the
two tests were also investigated. Results The sensitivity and specificity of
the low midline sill sign for LS were 81.3% and 89.1%, respectively. Positive
and negative predictive values of the test were 78.8% and 90.5%, respectively.
The sensitivity and specificity of the interspinous gap change test for LI were
82.2% and 60.7%, respectively. Positive and negative predictive values of the
test were 77.1% and 68.0%, respectively. Conclusions The low midline sill sign
and interspinous gap change tests are effective for the detection of LS and LI,
and can be performed easily in an outpatient setting. 
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