Mona Stecker

Quality improvement in neurology: Epilepsy Update Quality Measurement Set.

Epilepsy is a common, debilitating, and costly disease. It is estimated that 2.2 million people in the United States are diagnosed with epilepsy, and 150,000 new cases of epilepsy are diagnosed in the United States annually.1 However, epilepsy prevalence might be underestimated due to numerous social issues that accompany a diagnosis of epilepsy.2 People with epilepsy have poorer overall health status, impaired intellectual and physical functioning, and a greater risk for accidents and injuries.1–3 It is estimated that the annual direct medical cost of epilepsy in the United States is

Disruptive staff interactions: a serious source of inter-provider conflict and stress in health care settings.

9.6 billion, and this estimate does not include indirect costs from losses in quality of life or productivity.1

Analysis of inter-provider conflicts among healthcare providers.

This study sought to explore the prevalence of workplace stress, gender differences, and the relationship of workplace incivility to the experience of stress. Effects of stress on performance have been explored for many years. Work stress has been at the root of many physical and psychological problems and has even been linked to medical errors and suboptimal patient outcomes. In this study, 617 respondents completed a Provider Conflict Questionnaire (PCQ) as well as a ten-item stress survey. Work was the main stressor according to 78.2% of respondents. The stress index was moderately high, ranging between 10 and 48 (mean = 25.5). Females demonstrated a higher stress index. Disruptive behavior showed a significant positive correlation with increased stress. This study concludes that employees of institutions with less disruptive behavior exhibited lower stress levels. This finding is important in improving employee satisfaction and reducing medical errors. It is difficult to retain experienced nurses, and stress is a significant contributor to job dissatisfaction. Moreover, workplace conflict and its correlation to increased stress levels must be managed as a strategy to reduce medical errors and increase job satisfaction.

Inter- and intraprofessional respect: A dying concept?

Background: Patient safety is a top priority of healthcare organizations. The Joint Commission (TJC) is now requiring that healthcare organizations promulgate polices to investigate and resolve disruptive behavior among employees. Methods: Our aims in this investigation utilizing the Provider Conflict Questionnaire (PCQ: Appendix A) included; determining what conflicts exist among a large sample of healthcare providers, how to assess the extent and frequency of disruptive behaviors, and what types of consequences result from these conflicts. The PCQ was distributed utilizing electronic postings, and predetermined e-mail lists to nurses and physicians across the US. Results: The convenience sample included 617 respondents to the questionnaire. All incomplete responses (failure to answer all 17 items on the questionnaire) were excluded from data analysis. Our major finding was that disruptive behavior was the greatest problem observed in 82% of organizations; 74% personally witnessed these behaviors, while 5% personally experienced these behaviors. Friedman analysis of variance (ANOVA) analyses demonstrated that the difference between these three estimates were significant (χ2 = 207.8 df = 2, P < 0.0001). Conclusion: Healthcare organizations in the US are bound by TJC regulations to develop leadership standards that address disruptive behavior. These organizations can no longer stand by and ignore behaviors that threaten not only the bottom line of the institution, but also most critically, patient safety. As more attention is being paid to recommendations and mandates from the TJC and the Institute of Medicine (IOM), we will need more data, like those provided from this study, to better document how to address, resolve, and prevent future “misbehaviors”.

The lost art of inter-provider communication.

Much has been written in the literature involving disruptive behavior among clinicians[3,5,6] and its effects on patient safety. There are also many papers that appear in the literature discussing workplace incivility and stress among healthcare professionals.[2,7] Unfortunately, the amount and timeliness of this literature suggests a sad fact. The problem of incivility and lack of respect in the workplace is getting worse, not better. Nurses are notorious for not respecting each other. The worn out cliche’ of “nurses eat their young” is, sadly, still relevant. Regrettably, it is not just new nurses who are treated poorly. More aggressive, more powerful nurses treat underlings, the timid, and less well-connected nurses with the same disdain as more seasoned nurses treat the less experienced. Physicians are no innocents. The hierarchy of attending, fellow, resident, intern, is fraught with the more powerful and experienced taking advantage of those who are less so. There is also animosity between primary care and specialty providers. And we cannot forget the acrimony between specialties who display the attitude of “Those (fill-in-the-blank) docs are clueless.” Inter-professional lack of respect, perhaps, is the worst. Physicians, largely, do not respect nurses. Nurses do not respect nursing assistants and nurses’ behavior toward nursing students is abysmal. Even nursing instructors and faculty have come under the microscope as bullying of students appear to be on the rise.[1,4] Why is the notion of basic respect then; not only among professionals, but also among the human race, in general, so poorly adhered too? Is disrespect prevalent due to time constraints, competing priorities, or an overarching trend of narcissism in society? While the aforementioned are indicators, they are not excuses for disrespect among healthcare workers. We, as individuals, do not have much influence with respect to work flow (especially others’ work flow), nor can we immediately change the rules and regulations within a healthcare organization that causes stress to emerge. We can, however, change our behavior as members, not only as members of a profession or institution, but also as members of society. We can treat colleagues and others with respect. We can improve our listening and communication skills. We can consider new ideas, embrace new strategies and make a concentrated effort to respect individuals for the contributions they make not only in the workplace (although the workplace would be an ideal place to start) but to humankind as a whole.

Well Being in Neurologic Illness

From the days of Neanderthal drawings on cave walls to the sophisticated tools of cell phones, cable phones, and satellite phones, communication among humans has evolved at a dizzying pace. Or has it? Communication among and between healthcare providers in the 21st century may have actually devolved. Computers and smart phones have taken the place of interpersonal communication. While communication among healthcare providers has become more efficient, one can argue that it has become less safe for the patient. Gone are the days of consultants speaking directly to one another about a mutual patient. Now, physicians and mid-level providers read one anothers notes either on paper or in a computerized medical record. Gone also are the days of nurses trading information on a patient between shifts. Shift report is either done through tape recordings or, again, via computerized notes. The rationale of decreased interpersonal communication between healthcare providers is “I am too busy.” Yes, we are constantly fighting the clock in our efforts to take care of patients in an environment that is wrought with “crossing Ts and dotting Is” to satisfy increasingly suffocating regulatory demands. Yet, while relying solely on digital communication, we are sacrificing the gain of subtle nuances of patient information that can be of supreme importance in their outcome. Family dynamics, psychosocial situations, or even a vague deviation from a normal exam may not be properly articulated to one another, and this can make a difference in the course of a patients hospitalization. Perhaps, the quality and quantity of interpersonal communication has suffered because of poorly defined roles and tasks,[4] “turf wars” among hospital departments/units, difficulty in socialization skills between professionals, or competing priorities among hospital staff. The problem of poor communication may be related to all of these factors. Irrespective of the underlying causes of communication breakdown between healthcare professionals, the adverse affect on patient outcome and development of tools to enhance and improve collaboration and communication is well documented in the literature.[1,2] Poor communication among healthcare providers also makes for a stressful workplace and encourages disruptive behavior among clinicians.[3] There is no healthcare professional that is too important or too busy to speak or interact with a colleague, especially when it concerns a patient care issue. Leave egos and personal feelings at the door. Provide unencumbered quality patient care. Let us get back to the fundamentals of patient care and do the best we can for our patients all day, every day.

Using intrinsic and extrinsic motivation in continuing professional education.

Patients with neurological illness often have both diminished Quality Of Life (QOL) and diminished feelings of Well Being (WB) because of both the underlying disease, and the adverse effects of medications, especially Antiepileptic Drugs (AED’s). The purpose of this pilot study is to evaluate whether a simple index of WB based upon the World Health Organization survey on WB (WHO-5) can provide useful information about patients with epilepsy. Data was obtained from WB surveys of 629 patients presenting to a neurology/epilepsy clinic. This data is used to explore the relationship between WB and neurologic illness. In particular the effects of epilepsy, AED use, age and the effect of serial visits to the provider were studied. Although the patients with epilepsy were younger than the other patients in the study, a factorial ANOVA suggested that there were statistically significant reductions in WB that could be attributed to both epilepsy and increased age. Further analysis focused on individual questions in the survey revealed the largest difference attributable to epilepsy centered around an investigator formulated question relating to being able to complete all activities of daily life. This is expected because epilepsy restricts important functions such as driving. AED use had no significant effect on WB. However, patients with epilepsy have improved WB scores with serial visits to the clinic while the other patients did not. This pilot study demonstrates that a very simple marker of well-being is powerful enough to elucidate complex effects of many variables in a population of patients presenting to an epilepsy clinic.

Exhibiting pride in the profession: Making the case for continued professional development.

The technologically advanced and super-charged pace of todays society poses a multitude of challenges in the medical and nursing professions. Safe and quality patient care depend on the skills and competence of the professional caring for them. In such a dynamic environment, life-long learning, professional development, and continuing professional education are not just a good idea, they are a necessity. The Dreyfus model of skill acquisition was developed around 1980 by the brothers, Dreyfus and Dreyfus.[3] Others have adapted this model to fit into disciplines other than those of the Dreyfus brothers. Benner, for example, adapted the skill acquisition model into what is known as From Novice to Expert nursing theory.[1] Both theories are founded on the principle that learners pass through five stages: Novice, competence, proficiency, expertise, and mastery. The phases are characterized by how rules interplay with real-world context. A novice will simply follow the rules that they are given and not consider context. Intermediate stages contain a mix of rule following, combined with more and more sophisticated consideration of context. The master is one who makes decisions and takes actions intuitively, even in new contexts. A master may, in fact, not be able to state the rules or the heuristics that they are using. In this light, the role of education is to move a learner from novice to master by exposure to increasingly more real-world and varied contexts. We could deconstruct the training pathway from novice to expert in the medical and nursing educational systems, but there is an equally important consideration. The skill acquisition model was developed with the assumption that students were learning skills in a relatively static domain; once a master, always a master. In fields such as medicine and nursing, where new knowledge, ideas, and methods are constantly being introduced, a master will not stay a master for long. A disruptive technology or process could even revert a master back to a novice. Ongoing education becomes necessary to maintain master status. However, here, we face an educational dilemma. How do we motivate a master, one who has already invested thousands of hours to become a master, to engage in continuous life-long learning? To begin to attack this question, we need to go back a decade before the Dreyfus brothers proposed their model. In 1971, Deci conducted a study where two groups of people solved simple puzzles. Subjects in Group A underwent three rounds of puzzles and never received a reward. Subjects in Group B also underwent the same three rounds of puzzles but received a reward only in round two. The ability to solve the puzzles was inconsequential in the study. What was measured was the duration of time participants spent solving puzzles between sessions, when the moderator told them to take a break. The research question was to determine the impact of extrinsic rewards on intrinsic motivation. The clear takeaway from this study was that the intrinsic motivation of Group B was essentially destroyed in the third round due to the reward bestowed in round two. This was the first glimmer of a comprehensive theory of motivation and behavior that has emerged over the past several decades to become self-determination theory.[2] At the heart of self-determination theory is the idea that people desire to feel that their actions are caused by the free-agency component of self.[5] The relationship between the desire to act and the action itself is described as a sort of iceberg model. The part that we can see and measure, what is called engagement, is above the surface.[7] It is multidimensional and is composed of a set of interdependent behavioral, emotional, and cognitive actions. Below the surface of the iceberg is motivation.[6] It is based on neural and other biological processes that are often not consciously recognized. Motivation endows engagement with its strength, intensity, and persistence. What Decis original experiment exposed was how extrinsic motivation (external rewards that drive internal motivation), if not executed very carefully can undermine long-term motivation. It is not that all extrinsic rewards are bad. Traditional sticks and carrots prevent un engagement and can work well for algorithmic tasks, such as making parts, seeing a high volume of patients or engaging in competency training. In these tasks, persistence and speed are directly related to productivity. Extrinsic rewards can boost motivation in these types of tasks in the short-term. However, unless the rewards are enhanced over time, they reach a saturation point in their effectiveness. As Decis work showed, we can too easily become dependent on extrinsic rewards for our motivation. Conversely, what about intrinsic motivation? It is tempting to conclude that intrinsic motivation is a fixed and complex characteristic of an individual and, therefore, not reachable or learnable. With such thinking, the best we can do is select bright and motivated people and hope their natural abilities will carry them through their careers. Countering this view is a large and growing body of psychological research suggesting that intrinsic motivation is not fixed.[4] Self-determination theory was in fact designed to explain how it is possible to influence an individuals intrinsic motivation. The key is that engagement and motivation are coupled together through their environment. Motivation strengthens engagement that leads to actions that make a change in the environment. That change may serve to enhance (a virtuous cycle) or dampen (a vicious cycle) self-determination. Someone outside of an individual can, therefore, establish an environment that will foster a virtuous positive feedback cycle that enhances the self-determination. These environments promote and reward three inter-related basic psychological needs. Autonomy is experiencing ones behavior as originating from and endorsed by the self. Competence is the feeling of effectively pursuing goals that impact the environment. Relatedness is the formation and maintenance of emotional bonds with others. An environment that fosters these elements will prime individuals to become passionately engaged. What is more, extrinsic rewards that endow one with more autonomy, more competence and more relatedness will further strengthen the virtuous cycle of intrinsic motivation. Hence, extrinsic rewards can, in fact, become an important positive influence on intrinsic motivation. We face a dilemma in the medical and nursing communities, but that dilemma also exposes an opportunity. Many of the systems that select, train and foster continuous improvement assume that motivation is fixed. As a result, rewards are extrinsic and aim simply to promote simple engagement, or even worse to avoid penalties. They dampen intrinsic motivation rather than fuel it. What we learn from self-determination theory is that there is a way to build continuing education systems that see intrinsic motivation as environmentally dependent and driven by autonomy, competence, and relatedness. To remain a life-long master, we must develop systems that encourage a passion to engage in life-long learning and professional development. Certifications, involvement in specialty societies and continuing to seek the master/expert pinnacle of ones area of practice are some ways that health care professionals can ensure that they are at the top of their game and are providing safe and quality care to their patients. Maintaining the status of a master or expert is not an easy task. Some would say that this is a task that can only be achieved through intrinsic motivation.

Neuroscience nursing interactive patient vignette: Number 2.

Nursing is a profession. Although the art and science has become more science than art due to advances in technology and regulatory requirements, the profession of nursing is among the most trusted in modern society. How do we continue to earn that trust and respect? One could argue that looking after our professional development through ongoing education and certification gives us the confidence to move forward and meet any challenge that we encounter in this complex healthcare environment. Investing in professional development is not only beneficial to nurses practicing in todays healthcare environment, but is also a way to practice safely while protecting patients. Caring for patients in a safe and compassionate manner is a herculean task. Nurses need every advantage at their disposal to keep up with practice and regulatory demands. Participating in and seeking out new challenges through continuing education and specialty certification provides a strong and expanding foundation of knowledge to afford nurses the tools to remain at the top of their game. Because one has gained, through sheer longevity, expert status in their chosen area of practice; does not mean that additional expertise can neither be attained nor utilized through ongoing professional development. From the patients perspective, having nurses who care about competence in their role by participating in continuing education and certification, is comforting. Ongoing professional development sends a message to patients that their caregiver is committed to provide the best care possible by constantly striving for more education in their chosen specialty. While studies have not been able to prove unequivocally that certification results in improved patient outcomes, it seems reasonable to hypothesize that nurses who regularly participate in continuing education will have a better skill set that they can employ in their everyday practice. Finally, because the nursing profession is one of great diversity, it is conceivable and even likely that nurses will move into different specialty areas of nursing through their career. It is unlikely, however, that nurses who change direction in specialties will want to remain novices in their new area of practice. This then puts a nurse on a trajectory of life-long learning and ongoing professional development. And that perhaps, is as it should be. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Patient vignette #1 answer analysis.

The purpose of these patient vignettes is to allow the reader to test their own approach to patients with various neurologic problems. Answering the questions on the website will allow the authors to discuss the various issues brought to light in the case based vignettes. Results of the survey will be discussed in the subsequent issue. The link for answering the questions is https://www. surveymonkey.com/s/snicases2.