Background: The COVID-19 pandemic represents one of the most stressful events of recent times. Among the population, healthcare professionals who treat COVID-19 patients are most likely to develop psychological distress and posttraumatic stress symptoms (PTSS). The present study thus aimed to investigate the psychological impact of the COVID-19 outbreak on Italian healthcare workers. Methods: The responses of 145 healthcare workers (72 medical doctors and 73 nurses) were included in the final dataset. Participants were asked to provide sociodemographic and clinical information, and to complete: 1) quality of life and health-related Visual Analogue Scales, 2) State-Trait Anxiety Inventory-Form Y1, 3) Beck Depression Inventory, and 4) PTSD Checklist for DSM-5. Results: A comparison between healthcare professionals working in COVID-19 wards and other units revealed that the former reported higher levels of both depressive symptoms and PTSS. Moreover, the results of regression analyses showed that in healthcare professionals working with COVID-19 patients, gender and marital status, and gender and age significantly predicted depressive symptoms and PTSS, respectively. Particularly, being female and not in a relationship were found to be associated with higher levels of depressive symptoms, whereas being female and older were found to be related to higher levels of PTSS. Conclusions: The current findings suggest that specific predisposing factors could identify healthcare workers who are at high risk of developing mental health symptoms when faced with COVID-19 patients.
In the United States chronic illnesses have become a way of life for multiple generations – they are the number one cause of death and disability (accounting for more than 70% of deaths), 60% of American adults have at least one chronic disease, and 40% have multiple chronic conditions. Although multiple factors contribute to the growth in chronic disease prevalence, a major factor has been overreliance on health care systems for promoting health and preventing disease. Large health care systems are ill equipped for this role since they are designed to detect, treat, and manage disease, not to promote health or address the underlying causes of disease. Improving health outcomes in the U.S. will require implementing broad-based prevention strategies combining biological, behavioral, and societal variables that move beyond clinical care. According to community medicine, clinical care alone cannot create, support, or maintain health. Rather, health can only ensue from combining clinical care with epidemiology and community organization, because health is a social outcome resulting from a combination of clinical science, collective responsibility, and informed social action. During the past 20 years, our team has developed an operational community medicine approach known as community health science. Our model provides a simple framework for integrating clinical care, population health, and community organization, using community-based participatory research (CBPR) practices for developing place-based initiatives. In the present paper, we present a brief overview of the model and describe its evolution, applications, and outcomes in two major urban environments. The paper demonstrates means for integrating the social determinants of health into collaborative place-based approaches, for aligning community assets and reducing health disparities. We conclude by discussing how asset-based community development can promote social connectivity and improve health, and discuss how our approach reflects the emerging national consensus on the importance of place-based population system change.
Rationale, aims and objectives: People living with dementia admitted to hospitals are more likely to experience poorer outcomes than people without dementia. Caregivers play an important role in managing medications across transitions of care. This qualitative study explores the experiences and perspectives of caregivers about the medication management guidance provided at hospital discharge. Methods: A qualitative approach using semi-structured, telephone interviews was conducted with 31 caregivers of people with dementia across Australia. Purposive sampling was used to ensure maximum variation of diverse experiences and perspectives. Results: Caregivers’ experiences of medication guidance for people with dementia at discharge were described in three themes including: a) inadequate information about medication management at discharge; b) limited caregiver engagement in medication management decisions; and c) difficulties ensuring medication supply post discharge. Most participants indicated they would like to be included in discussions at discharge. However, participation was influenced by caregivers being overwhelmed by discharge processes; proactively seeking information on medication-related harm; and belief in advocacy as part of their caregiver role. Caregivers reported they would like to receive a tailored medication list for people with dementia which included information on medications that may impact on the patient’s cognition, and for hospital staff to communicate with both the community pharmacist and primary care physician, to improve co-ordination post transition. Discussion: In our study of caregivers of people with dementia, we identified key recommendations that could be tested to facilitate regular participation of people living with dementia and their caregiver around medication guidance at discharge.
Rationale, aims, and objectives: The complexity of healthcare systems makes errors unavoidable. To strengthen the dialogue around how physicians experience and share medical errors, the objective of this study was to understand how experienced generalist physicians make meaning of and grow from their medical errors. Methods: This study used a narrative inquiry approach to conduct and analyze in-depth interviews from 26 physicians from the generalist specialties of emergency, internal, and family medicine. We gathered stories via individual interview, analyzed them for key components, and rewrote a ‘meta-story’ in a chronological sequence. We conceptualized the findings into a metaphor to draw similarities, learn from, and apply new principles from other fields of practice. Results: Through analysis we interpreted the story of an elite athlete (physician) who is required to make numerous decisions in a short period of time within the construct of a chaotic sports field (clinical environment) among spectators (the patient’s family) whilst abiding by existing rules and regulations. Through sharing stories of success and failure, the team coach (clinical mentor) helps optimize the players’ professional and psychological development. Similarly, through sharing and learning from stories, team members (colleagues) and junior team members (trainees) also contribute to the growth of the protagonist’s character and the development of the overall team (clinic/hospital) and sport (healthcare system). Conclusion: We draw parallels between the clinical setting and a generalist physician’s experiences of a medical error with the environment and practices within professional sports. Using this comparison, we discuss the potential for meaningful coaching in medical education.
Rationale, aims and objectives: Consistent data demonstrates negative psychological effects of caregiving on front-line health professionals. Evidence that psychological resilience factors can help minimise distress and the potential for low-cost interventions have created interest in resilience-based development programmes; yet evidence of perceived value amongst health professionals is lacking. This study explored health professionals’ experiences and perceptions of a novel, resilience-based intervention designed to pro-actively prepare staff for coping with error; to investigate their perceptions of what resilience meant to them, the relevance of the intervention, and impact of participation on ability to cope with error. Method: Semi-structured interviews 4-6 weeks post intervention with 23 randomly selected participants from seven cohorts (midwives, paediatricians, obstetrians/gynaecologists, paramedics) and trainees (physician associates, mammographers, sonographers). Thematic analysis of interview data. Findings: Participants reported various interpretations of, and a shift in perception regarding what the concept of psychological resilience meant to them and their practice. These included for example, resilience as a positive or negative concept and their awareness and response to a range of personal, organisational and system factors influencing personal resilience. They valued the prophylactic, clinically relevant, interactive and applied nature of the intervention; having developed and applied valuable skills beyond the context of involvement in error, noting that individuals needed to be willing to explore their own coping mechanisms and human fallibility to gain maximum benefit. There was also consensus that whilst proactively developing individual level psychological resilience is important, so too is addressing the organisational and system factors that affect staff resilience which are outside individual staff control. Conclusion: Enhancing resilience appears to be considered useful in supporting staff to prepare for coping with error and the wider emotional burden of clinical work, but such interventions require integration into wider system approaches to reduce the burden of clinical work for health professionals.
Artificial intelligence and big data are more and more used in medicine, either in prevention, diagnosis or treatment, and are clearly modifying the way medicine is thought and practiced. Some authors argue that the use of artificial intelligence techniques to analyze big data would even constitute a scientific revolution, in medicine as much as in other scientific disciplines. Moreover, artificial intelligence techniques, coupled with mobile health technologies, could furnish a personalized medicine, adapted to the individuality of each patient. In this paper we argue that this conception is largely a myth: what health professionals and patients need is not more data, but data that are critically appraised, especially to avoid bias. The validity of data and the validity of inferences drawn from the data by algorithms are indeed a major epistemic issue, though rarely addressed as such by health professionals or philosophers of medicine. Considering the history of epidemiology, specifically the formation of the concept of bias, we propose three research priorities concerning the use of artificial intelligence and big data in medicine.
The outbreak of the Covid-19 pandemic obliged us all to handle many dilemmas, some of which we took upon ourselves as philosophers, ethicists, doctors and nurses to discuss around four key ethical notions : responsibility, dignity, fairness and honouring death. The following collection of the symposium acts held online in May 2020 with the Paris Global Center of Columbia University and Columbia Global Centers, attempts to testify to the ongoing pandemic emergency and difficult challenges while evaluating whether the ethical principles in the official recommendations were able to meet the lived reality. Looking at accountability and consistency in regard to the context of exercise, it seemed equally important to examine, through an international exchange, whether the contextuality of Coronavirus across countries and cultures affected the ethical decision making processes. We hope that our discussion can serve as a resource for advanced care planning, helping medical providers and other specialists to consider the shared important aspects of medical ethics in times of great uncertainty.
Background: Lack of time has consistently been reported as a major barrier to effective research evidence-uptake into clinical practice. There has been no research to our knowledge that explores time as a barrier within the Transtheoretical model of Stages of Change (SoC), to better understand the processes of physiotherapists’ uptake of clinical practice guidelines (CPG). This paper explores the concept of lack of time as a barrier for CPG uptake for physiotherapists at different SoC. Methods: A 6-step process is presented to determine the best-fit SoC for 31 physiotherapy interviewees. This process used an amalgamation of interview findings and socio-demographic data, which was layered onto the SoC and previously identified time-barriers to CPG uptake (few staff; high workload; access to CPGs; evidence-based practice as priority in clinical practice; “time is money” attitude; and knowledge on the use of CPGs). Results: The analysis process highlighted the complexities of assigning individuals to a SoC. A model of time management for better CPG uptake is proposed which is a novel approach to assist evidence implementalists and clinicians alike to determine how to progress through the SoC and barriers to improve CPG uptake. Conclusions: To the authors’ knowledge, this is the first attempt at exploring the construct of (lack of) time for CPG-uptake in relation to the physiotherapists’ readiness to behaviour change. This study shows that ‘lack of time’ is a euphemism for quite different barriers, which map to different stages of readiness to embrace current best evidence into physiotherapy practice. By understanding what is meant by ‘lack of time’, it may indicate specific support required by physiotherapists at different stages of changing these behaviours.
Despite the great promises that artificial intelligence (AI) holds for health care, the uptake of such technologies into medical practice is slow. In this paper, we focus on the epistemological issues arising from the development and implementation of a class of AI for clinical practice, namely clinical decision support systems (CDSS). We will first provide an overview of the epistemic tasks of medical professionals, and then analyse which of these tasks can be supported by CDSS, while also explaining why some of them should remain the territory of human experts. Clinical decision-making involves a reasoning process in which clinicians combine different types of information into a coherent and adequate ‘picture of the patient’ that enables them to draw explainable and justifiable conclusions for which they bear epistemological responsibility. Therefore, we suggest that it is more appropriate to think of a CDSS as clinical reasoning support systems (CRSS). Developing CRSS that support clinicians’ reasoning process therefore requires that: 1) CRSSs are developed on the basis of relevant and well-processed data; and 2) the system facilitates an interaction with the clinician. Therefore, medical experts must collaborate closely with AI experts developing the CRSS. In addition, responsible use of an CRSS requires that the data generated by the CRSS is empirically justified through an empirical link with the individual patient. In practice, this means that the system indicates what factors contributed to arriving at an advice, allowing the user (clinician) to evaluate whether these factors are medically plausible and applicable to the patient. Finally, we defend that proper implementation of CRSS allows combining human and artificial intelligence into hybrid intelligence, were both perform clearly delineated and complementary empirical tasks. Whereas CDRSs can assist with statistical reasoning and finding patterns in complex data, it is the clinicians’ task to interpret, integrate and contextualise.
The commentary discusses the importance of developing Universal Health Coverage strategies through the lens of complex systems framework that evaluates policies not only in terms of the final desired outcome but also as an interplay of disparate views among diverse actors in the system. This view also confers a degree of agency and autonomy on the individual actors, whether they be patients or healthcare workers, and necessitates the inclusion of bottom-up participatory process in the development of UHC policies and interventions. These are consistent with the Primary Health Care principles articulated in the 1978 Alma Ata Declaration and will need to be integrated into the health system development framework to achieve UHC. Ultimately, this approach would encourage the creation of a more cooperative and adaptive policy environment in which each actor is encouraged to collaborate and are nudged toward a desirable outcome rather than through coercive means.
Rationale, aims and objectives: There is a large body of literature from all over the world that describes, analyzes, or evaluates home care models and interventions. The present article aims to identify the practical lessons that can be gained from a systematic examination of that literature. Method: We conducted a three-step sequential search process from which 113 documents were selected. That corpus was then narratively analyzed according to a realist review approach. Results: A first level of observation is that there are multiple blind spots in the existing literature on home care. The definition and delimitation of what constitutes home care services is generally under-discussed. In the same way, the composition of the basket of care provided and its fit with the need of recipients is under-addressed. Finally, the literature relies heavily on RCTs whose practical contribution to decisions or policy is disputable.At a second level, our analysis suggests that three mechanisms (system integration, case management and relational continuity) are core characteristics of home care models effectiveness. Conclusion: We conclude by providing advice for creating effective home care system change through rational and participatory design and evaluation alongside public dialogue about the purpose and future of home care.
Purpose This paper aims to elucidate the factors that play into physicians’ experience of receiving practice data and to subsequently develop a model that describes how individuals may interact with the data they receive. Methods In a prior study, we conducted a needs analysis of 105 physicians in the Hamilton-Niagara area in order to understand which data metrics were most valuable to physicians. Using these results, we designed an interview guide to study physicians’ perspectives on audit and feedback. By intentional sampling, we recruited 15 physicians amongst gender groups, types of practice (academic vs community), and duration of practice. The interviews were conducted by a single author and transcribed without identifiers. We then began with an open coding analysis for all of the transcripts, and thereafter conducted axial coding to group the data into larger themes. Results Several environmental and personal attributes were identified as either enabling or counterproductive attributes for participant improvement. The final proposed model identifies different zones of engagement on the basis of both the individual practitioner’s growth mindset and the quality of the existing data system. In the highest engagement zone, the mindset of the collective leadership is one of growth. Systemic supports are in place which potentiates learning that may come from an individual motivated to use their own data. Conclusion Our model shows how data feedback systems and individual growth-oriented mindsets interact to augment or hinder clinical practice improvement. This model provides important guidance to academic and administrative structures looking to develop appropriate performance feedback systems with clinicians.
One knowledge translation method, of putting evidence into practice, is the use of clinical practice guidelines (CPG). The purpose of this brief report is to describe an 8-step process of “how to” contextualise a training programme to increase CPG-uptake for a targeted audience in a clearly defined setting. This process may assist implementalists to fast-track the development of contextualised training to improve CPG-uptake.
This paper responds to one by Graham Martin and colleagues, who offered a critique of my previous publications on masks for the lay public in the Covid-19 pandemic. I address their charges that my co-authors and I had misapplied the precautionary principle; drawn conclusions that were not supported by empirical research; and failed to take account of potential harms. But before that, I remind Martin et al that the evidence on mask wearing goes beyond the contested trials and observational studies they place centre stage. I set out some key findings from basic science, epidemiology, mathematical modelling, case studies and natural experiments, and use this rich and diverse body of evidence as the backdrop for my rebuttal of their narrowly-framed objections. I challenge my critics’ apparent assumption that a particular kind of systematic review should be valorised over narrative and real-world evidence, since stories are crucial to both our scientific understanding and our moral imagination. I conclude by thanking my academic adversaries for the intellectual sparring match, but exhort them to remember our professional accountability to a society in crisis. It is time to lay straw men to rest and engage, scientifically and morally, with the dreadful tragedy that is unfolding across the world.
The onset of acute illness may be accompanied by a profound sense of disorientation for patients. Addressing this vulnerability is a key part of a physician’s purview, yet well-intended efforts to do so may be impeded by myriad competing tasks in clinical practice. Resolving this dilemma goes beyond appealing to altruism, as its limitless demands may lead to physician burnout, disillusionment, and a narrowed focus on the biomedical aspects of care in the interest of self-preservation. The authors propose an ethic of hospitality that may better guide physicians in attending to the comprehensive needs of patients that have entered “the kingdom of the sick”. Using philosophical methods, the authors explore what compels people to present to emergent medical attention and why altruism may not offer physicians a sustainable way to address the vulnerabilities that occur in such situations. They then present the concept of hospitality from a Derridean perspective and use it to interpret a narrative case of an on-call paediatrician caring for an infant with bronchiolitis to demonstrate how this approach may be practically implemented in the acute care hospital context. Hospitality allows physicians to acknowledge that clinical presentations that are routine in their world may be disorienting and frightening to patients experiencing them acutely. Further, it recognizes that the vulnerability that accompanies acute illness may be compounded by the unfamiliarity of the hospital environment in which patients have sought support. While it is unlikely that anything physicians do will make the hospital a place where patients and caregivers will desire to be, hospitality may focus their efforts upon making it less unwelcoming. Specifically, it offers an orientation that supports patients in navigating the disorienting and unfamiliar terrains of acute illness, the hospital setting in which help is sought, and engagement with the health care system writ large.
The aim of the present paper is to describe and discuss how recent theories about translation, bridging medical and humanistic understandings of knowledge translation, in the medical humanities (Kristeva et al 2018) can bring about a new understanding of health literacy in the context of patient education. We argue that knowledge translation must be understood as a simultaneous interrogation of the patient’s and the health care providers co-construction of new and shared meanings that can create realities with medical consequences. To illustrate our points, we will describe the case of Jim, a kidney transplant recipient who received standard patient education, but lost the graft (the new kidney). If we apply Kristeva’s view onto this context, graft function is not merely a biology but a complex bio-cultural fact. In this perspective, graft function is seen as a phenomenon that embraces translation between health as a biomedical phenomenon and healing as lived experience, and that opens for shared meaning -making processes between the patient and the health care provider. In Jim’s case this means that we need to rethink the approach to patient education in a way that encourage the patient’s idiosyncratic way of thinking and experiencing – and transform health information into a means for sustaining Jim’s particular life – not life ‘in general’. The patient education program did not take into consideration the singularities of Jim’s biographical temporality, with its changes in everyday life, priorities, attitudes and values. The arguments are generic and could be applied to other contexts.
Job satisfaction and retention of healthcare staff remains an ongoing issue in many health systems. Huddles have been endorsed as a mechanism to improve patient safety by improving teamwork, collaboration, and communication in teams. This study synthesizes the literature to investigate the impact of huddles on job satisfaction, teamwork, and work engagement in multidisciplinary healthcare teams. Five academic databases were searched to conduct a systematic review of peer-reviewed literature published from January 2000 – January 2020. Articles were included if they (1) featured a daily huddle, were conducted in a healthcare setting, and involved a multidisciplinary team and (2) measured variables including job satisfaction, work engagement, or teamwork. Results were reported in accordance with the Systematic Synthesis Without Meta-analysis (SWiM) and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We identified 445 articles of which 12 met the eligibility criteria and are included in this review. All 12 studies found a predominantly positive impact on teamwork and job satisfaction. None of the studies discussed or reported evidence of the impact of huddles on work engagement. This review highlights the value of a daily multidisciplinary healthcare team huddle in improving job satisfaction and teamwork for the healthcare staff involved. However, there is a dearth of high-quality, peer-reviewed evidence regarding the direct impact of huddles on job satisfaction, teamwork and in particular on work engagement. Further research – particularly controlled studies on adoption, implementation, and outcomes for healthcare team culture – is needed to further assess this intervention.
Sturmberg and Martin’s application of systems and complexity theory to understanding Universal Health Care (UHC) and Primary Health Care (PHC) is evaluated in the light of the influence of political economy on health systems. Further the role that neoliberal approaches to governance have had in creating increased inequities is seen as a key challenge for UHC. COVID-19 has emphasized long standing discrepancies in health and these disadvantages require government will and cooperation together with adequate social services to redress these discrepancies in UHC.