cjrt jctrcomprehensive overview of various patient safety concerns related to respiratory therapy....

Fall | Automne 2012Volume | Numéro 48.3

cjrt jctr canadian journal of respiratory therapy | journal canadien de la thérapie respiratoire

The journal for respiratory health professionals in CanadaLe journal des professionnels de la santé respiratoire au Canada

MESSAGE FROM THE EDITOR IN CHIEF | MESSAGE DU RÉDACTEUR EN CHEF 4... Jason Nickerson

ORIGINAL ARTICLES | ARTICLES ORIGINAUX 7... Innovative Community of Practice Development within the Alberta Respiratory Community Rena Sorensen, Roberta Dubois, Patricia Paton

13... Patient Safety in Respiratory Therapy: Importance of Human Factors Assessment and Involvement of the Respiratory Therapist in Medical Device Risk Identification, Analysis, and Learning Laura Harvie

19... Position Statement – Degree as Entry to Practice

21... Énoncé de position - Grade universitaire pour l’accès à la profession

COLUMNS / CHRONIQUES

23... Leadership - Chroniques de la direction Accessing Professional Development Tools: Free and Easy Professional Development Options in your Browser / Accès aux outils de perfectionnement professionnel:Options de perfectionnement professionnel gratuites et faciles dans votre navigateur en utilisant le lecteur Google ou netvibes Gilbert V. Wilkes

25... Student - Chroniques étudiante Welcome Students / Bienvenue aux étudiants! Edouard Saadé

28... Educator’s - Chroniques des enseignants Clinical Simulation: Designing Scenarios and Implementing Debriefing Strategies to Maximize Team Development and Student Training / Simulation clinique : concevoir des scénarios et mettre en oeuvre des stratégies de débriefing afin de maximiser l’établissement d’une équipe et la formation des étudiants Kevin G. Middleton

33... ABSTRACTS OF CURRENT LITERATURE

Canadian Journal of respiratory therapyJournal Canadien de la thérapie respiratoire

fall | autoMne 2012VoluMe | nuMéro 48.3

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OFFICIAL JOURNAL OF THE CSRT | FALL 2012, 48.3

Publications Mail Agreement | No. 40012961

Registration No. | 09846 ISSN 0831-2478

Return undeliverable Canadian addresses to: Suite 400 - 331 Cooper St., Ottawa ON K2P 0G5

[email protected]

© 2012 Canadian Journal of Respiratory Therapy / Journal canadien de la thérapie respiratoire - all rights reserved

MARkETING AND ADvERTISING SALES

For advertising rates and information contact Rita Hansen, Suite 400-331 Cooper St., Ottawa ON, K2P OG5; 800-267-3422, ex 223; Fax 613-521-4314; [email protected]; or visit our website at www.csrt.com under “Publications”

SUBSCRIpTIONS

CJRT is published four times a year (Spring, Summer, Fall and Winter)

Annual subscriptions are included in annual membership to the CSRT. Subscription rate for 2012 for other individuals and institutions within Canada is $50. International orders are $60 Cdn. All Canadian orders are subject to 13% HST. Requests for subscriptions and changes of address: Membership, CSRT, Suite 400 - 331 Cooper St., Ottawa, ON K2P 0G5.

Once published, an article becomes the permanent property of The Canadian Journal of Respiratory Therapy and may not be published elsewhere, in whole or in part, without written permission from the Canadian Society of Respiratory Therapists. All editorial matter in CJRT represents the opinions of the authors and not necessarily those of The Canadian Journal of Respiratory Therapy, the editors, Editorial Board, the publisher of the journal, or the CSRT. The Canadian Journal of Respiratory Therapy assumes no responsibility or liability for damages arising from any error or omission of from the use of any information or advice contained in the CJRT including editorials, articles, reports, book and video reviews letters and advertisements.

EDITOR IN CHIEF

Jason Nickerson, RRT, FCSRT, PhD(c) Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, ON

MANAGING EDITOR

Rita Hansen, Ottawa ON

EDITORIAL BOARD MEMBERS

Wrae Hill, MSc, RRT, FCSRT Director of Patient and System Safety Interior Health, Kelowna, BC

Peter J. Papadakos, MD, FCCM Director, Critical Care Medicine Professor, Departments Anesthesiology, Surgery and Neurosurgery, University of Rochester, Rochester, NY

Norman H. Tiffin, BSc, MSA Vice President, Salus Global, London, ON

Andrea White Markham, RRT, CRE Professor, Respiratory Therapy, The Michener Institute, Toronto ON

Kathy F. Spurr BSc, RRT, MHI, FCSRT Assistant Professor, School of Health SciencesDalhousie University, Halifax, NS

Andrew West, MAppSc, RRT Assistant Professor and Head Department of Respiratory Therapy School of Medical Rehabilitation University of Manitoba, Winnipeg, MB

CSRT EXECUTIvE DIRECTOR

Christiane Ménard, Ottawa ON

CSRT BOARD OF DIRECTORS 2012-2013

President, Angela Coxe, Ontario

Past-President, Jim McCormick, Ontario

Treasurer, Jeff Dmytrowich, Saskatchewan

BOARD MEMBERS

Louis-Phillip Belle-Isle, Québec

Chantale Blanchard, Prince Edward Island

Barbara MacDonald, Nova Scotia

Susan Martin, Ontario

David Sheets, British Columbia

Cynthia Welton, Ontario

Edouard Saadé, New Brunswick



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MARkETING ET pUBLICITÉ / ANNONCES CLASSÉES

Rita Hansen, Suite 400- rue 331 Cooper., Ottawa ON, K2P 0G5; 800-267-3422, poste 223; Courriel 613-521-4314; [email protected]; ou visitez notre site Web: www.csrt.com sous « Publications »

ABONNEMENTS

La JCRT paraît 4 fois l’an (en printemps, été, automne et hiver).

L’abonnement annuel est compris dans la cotisation des membres de la SCTR. Le tarif annuel d’abonnement pour les non-membres et les établissements au Canada est de 50 $. Les commandes internationales sont 60 $ Canadien. La TVH de 13% est ajoutée aux commandes canadiennes. Veuillez faire parvenir les demandes d’abonnement et les changements d’adresse à l’adresse suivante: Centre des services aux membres, SCTR, Suite 400 - rue 331 Cooper, Ottawa ON K2P 0G5.

Dès qu’un article est publié, il devient propriété permanente de The Canadian Journal of Respiratory Therapy, et ne peut être publié ail-leurs, en totalité ou en partie, sans la permission de la Société canadienne des thérapeutes respiratoires. Tous les articles à caractère éditorial dans le JCRT représentent les opinions de leurs auteurs et n’engagent ni le Canadian Journal of Respiratory Therapy, ni les rédacteurs ou l’éditeur de la revue, ni la SCTR. Le journal canadien de la thérapie respiratoire décline toute responsabilité civile ou autre quant à toute erreur ou omission, ou à l’usage de tout conseil ou information fi gurant dans le JCRT et les éditoriaux, articles, rapports, recensions de livres et de vidéos, lettres et publicités y paraissant.

Concernant l’adhésion à la SCTR : Suite 400 - rue 331 Cooper, Ottawa ON K2P 0G5 800-267-3422 poste 223

RÉDACTEUR-EN-CHEF

Jason Nickerson, RRT, FCSRT, PhD(c) Centre for Global Health, Institut de recherche sur la santé des popula-tions, Université d’Ottawa, Ont.

DIRECTRICE DE LA REDACTION

Rita Hansen, Ottawa, Ont.

COMITÉ DE RÉDACTION

Wrae Hill, MSc, RRT, FSCTR Directeur – Amélioration de la qualité et de la sécurité des patients, Interior Health, Kelowna, C.-B.

Peter J. Papadakos, MD, FCCM Directeur, Médecine des soins intensifs Professeur, Départements d’anesthésiologie, de chirurgie et de neurochirurgie, Université de Rochester, Rochester, NY

Norman H. Tiffin, BSc, MSA Vice-président, Salus Global, London, Ont.

Andrea White Markham, RRT, CRE Membre du corps professoral, Thérapie respiratoire, Coordinatrice de l’ERA, The Michener Institute, Toronto, Ont.

Kathy F. Spurr, BSc, RRT, MHI, FSCTR Professeure adjointe, School of Health SciencesUniversité Dalhousie, Halifax, N.-É.

Andrew West, MAppSc, RRT Professeur adjoint et Chef Département de thérapie respiratoire École de réadaptation médicale Université du Manitoba, Winnipeg, Man.

DIRECTRICE GÉNÉRALE DE LA SCTR

Christiane Ménard, Ottawa, Ont.

CONSEIL D’ADMINISTRATION 2012 - 2013

Président, Angela Coxe, Ontario

Ancien président, Jim McCormick, Ontario

Trésorier, Jeff Dmytrowich, Saskatchewan

MEMBRE DU CONSEIL

Louis-Phillip Belle-Isle, Québec

Chantale Blanchard, Île-du-Prince-Édouard

Barbara MacDonald, Nouvelle-Écosse

Susan Martin, Ontario

David Sheets, Columbie-Britannique

Cynthia Welton, Ontario

Edouard Saadé, Nouveau-Brunswick

Courrier de publications | No. 40012961

No d’enregistrement | 09846 ISSN 0831-2478

Retourner toute correspondence ne pouvant être livrée au : Suite 400 - rue 331 Cooper, Ottawa ON K2P 0G5

[email protected]

© 2012 Canadian Journal of Respiratory Therapy / Journal canadien de la thérapie respiratoire - tous droits reservés

JOURNAL OFFICIEL DE LA SCTR | AUTOMNE 2012, NUMÉRO 48.3



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In this issue of the Canadian Journal of Respiratory Therapy (CJRT), we are delighted to be featuring two articles that draw renewed attention to quality improvement and assurance in

respiratory therapy. These articles address the need for respiratory therapists

to embrace and respond to the complexity of the clinical environment, addressing not only concerns at the individual level of clinical care, but also systemic concerns that play a salient role in patient safety. Both of the articles included in this issue stress the need to identify comprehensive approaches to quality care and patient safety through improvements in the processes of care.

One of these articles, by Laura Harvie, provides a comprehensive overview of various patient safety concerns related to respiratory therapy. Drawing on several relevant case studies as well as the patient safety literature, the author makes a pertinent argument that respiratory therapists ought to play a leading role in enhancing patient safety. This ought to take the form of a comprehensive approach to quality and patient safety, through prospective and retrospective reporting and the sharing of concerns among colleagues.

Building on this concept, Sorenson, Dubois, & Paton, present their experiences from Alberta in building a Community of Practice (CoP), to address complex problems within respiratory therapy clinical practice. The authors describe key aspects of engineering better strategies for communicating relevant practice issues, and creating an environment conducive to enhancing clinical practice through the sharing of ideas, knowledge, and experiences.

Both of these articles address the need for respiratory therapists to be critically engaged in the practice and coordination of respiratory therapy. As frontline clinicians who practice evidence-based medicine, ensuring that the best evidence available reaches our patients is critical. Furthermore, ensuring that risks to patient safety (both potential and actual risks) are addressed through structured processes is a critical aspect of how we contribute to enhanced patient care.

These are not new concepts for our profession. Respiratory therapists have played a strong role in one of Canada’s most vigorous attempts to enhance patient safety, the Safer Healthcare Now! campaign, where the reduction of ventilator-associated pneumonia is a critical component. [1] This is an area where respiratory therapists have actively engaged with quality assurance at both the bedside and systems levels, changing not only the way that we engage with patients, but the policies and procedures that guide these interactions. By identifying a major risk to patient safety, and working with our

MESSAGE FROM THE EDITOR-IN-CHIEF

Quality Improvement in Respiratory Therapy: A Critical Component of Clinical practice

jason Nickerson, rrt, FcSrt, PhD(c) Centre for Global Health, Institute of population Health, University of Ottawa, Ottawa, Ontario, Canada

colleagues from other health professions, respiratory therapists have worked to enhance patient safety and improve the quality of care we provide to our patients. [2]

Addressing these challenges head-on requires a clinician who is trained to respond to the complexities of the current and evolving clinical environment. Respiratory therapists are increasingly required to stay attuned to the best evidence available in order to guide our practice and ensure that our patients benefit from advances in clinical science. This requires a practitioner who is not only technically proficient in the delivery of patient care, but also one with the requisite critical thinking skills to solve complex problems and evaluate the rigor of evidence to support the decisions we make every day in clinical practice. For this reason, we are pleased to be printing the Canadian Society of Respiratory Therapists (CSRT) position statement on a Degree as Entry-to-Practice.

As the healthcare system continues to evolve to meet patient demands, so too ought our profession. Respiratory therapists are integral members of the healthcare team, and it is imperative that the profession continues to evolve to meet the needs of our patients. Degree-educated RTs are one means of responding to this challenge, opening the door for diverse learning opportunities before entering into clinical practice, and bringing a robust knowledge of respiratory therapy to the clinical environment. Furthermore, a degree as a requirement for entry-to-practice aligns us with other healthcare professions, creating a more level playing field for interprofessional collaboration.

As always, the CJRT looks forward to continuing to support the development of the practice and delivery of respiratory therapy, and the professional development of respiratory therapists. With a new academic year upon us, we also want to wish the best of success to our students and educators, and would like to encourage everyone to continue to support the development of the Journal. We are always looking for interesting and innovative case reports and articles detailing innovations within the practice and delivery of respiratory therapy.

REFERENCES[1] Safer Healthcare Now! [Internet]. Ventilator-Associated Pneumonia

[updated 2012; cited 2012 October 23]. Available from: http://www.saferhealthcarenow.ca/EN/Interventions/VAP/Pages/default.aspx.

[2] Kaye, J., Ashline, V., Erickson, D., Zeiler, K., Gavigan, D., Gannon, L., et al. Critical care bug team: a multidisciplinary team approach to reducing ventilator-associated pneumonia. Am J Infect Control. 2000; 28(2): 197-201.



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Dans le présent numéro du Journal canadien de thérapie respiratoire (JCTR), nous sommes heureux de présenter deux articles qui attirent encore une fois l’attention sur

l’amélioration et l’assurance de la qualité en thérapie respiratoire. Ces articles traitent de la nécessité pour les thérapeutes

respiratoires d’accepter la complexité de l’environnement clinique et d’y réagir, et abordent non seulement les préoccupations en matière de personnes, mais aussi les préoccupations systémiques qui jouent un rôle de premier ordre dans la sécurité des patients. Les deux articles soulignent la nécessité d’établir des approches globales pour la sécurité et la qualité des soins offerts aux patients au moyen de l’amélioration des soins.

Un de ces articles, rédigé par Laura Harvie, donne un aperçu général des diverses préoccupations en matière de sécurité des patients liées à la thérapie respiratoire. S’inspirant de diverses études de cas pertinentes et de documents sur la sécurité des patients, l’auteure soutient judicieusement que les thérapeutes respiratoires doivent jouer un rôle de premier plan dans l’amélioration de la sécurité des patients. Ce rôle doit prendre la forme d’une approche globale de la qualité et de la sécurité des patients grâce à un compte rendu prospectif et rétrospectif et à l’échange des préoccupations entre collègues.

À partir de ce concept, Sorenson, Dubois et Paton présentent leurs expériences en Alberta dans l’établissement d’une communauté de pratique pour aborder des problèmes complexes au sein de la pratique clinique de la thérapie respiratoire. Les auteurs décrivent les principaux aspects de l’élaboration de meilleures stratégies pour communiquer des questions de pratique pertinentes et créer un milieu propice à l’amélioration de la pratique clinique grâce à l’échange d’idées, de connaissances et d’expériences.

Ces deux articles portent sur la nécessité pour les thérapeutes respiratoires de s’engager de façon éclairée dans la pratique et la coordination de la thérapie respiratoire. En qualité de cliniciens de première ligne qui pratiquent une médecine fondée sur des données probantes, il est essentiel de veiller à ce que les meilleures données probantes disponibles atteignent nos patients. En outre, l’assurance que les risques à la sécurité des patients (tant potentiels que réels) sont atténués à l’aide de processus structurés représente un aspect essentiel de la façon dont nous contribuons à l’amélioration des soins aux patients.

Il ne s’agit pas de concepts nouveaux pour notre profession. Les thérapeutes respiratoires ont joué un rôle important dans l’une des tentatives les plus vigoureuses du Canada d’améliorer la sécurité des patients, soit la campagne Soins de santé plus sécuritaires maintenant!, dans laquelle la diminution de la pneumonie associée aux ventilateurs est un élément essentiel.[1] Il s’agit d’un domaine où les thérapeutes respiratoires se sont engagés activement en matière d’assurance de la qualité, tant au chevet des patients qu’à l’échelon des systèmes, en changeant non seulement la façon de s’engager

MESSAGE DU RÉDACTEUR EN CHEF

L’amélioration de la qualité en thérapie respiratoire : un élément essentiel de la pratique clinique

jason Nickerson, rrt, FcSrt, PhD(c) Centre pour la santé mondiale (Centre for Global Health), Institut de recherche sur la santé des populations,

Université d’Ottawa, Ottawa, Ontario, Canada

auprès des patients, mais aussi les politiques et les procédures qui orientent ces interactions. En décelant un risque important pour la sécurité des patients et en travaillent avec nos collègues des autres professions de la santé, nous avons contribué à améliorer la sécurité des patients et la qualité des soins que nous leur prodiguons. [2]

Pour aborder ces défis de front, il faut un clinicien formé pour réagir aux complexités de l’environnement clinique actuel et en évolution. Les thérapeutes respiratoires doivent de plus en plus demeurer au fait des meilleurs données disponibles afin d’orienter leur pratique et de veiller à ce que leurs patients profitent des progrès de la science clinique. Pour ce faire, un praticien ne doit pas être uniquement un technicien chevronné au plan de la prestation des soins aux patients, mais aussi posséder les compétences nécessaires en matière de pensée critique pour résoudre des problèmes complexes et évaluer la rigueur des données afin d’appuyer les décisions que nous prenons tous les jours en pratique clinique. C’est pourquoi nous sommes heureux de publier la déclaration de principe sur un grade universitaire pour l’accès à la profession de la Société canadienne des thérapeutes respiratoires (SCTR).

À mesure que le système de santé continue d’évoluer pour satisfaire aux exigences des patients, notre profession emboiter le pas. Les thérapeutes respiratoires font partie intégrante de l’équipe des soins de santé et il est essentiel que la profession continue d’évoluer pour répondre aux besoins de nos patients. Les TR diplômés sont une façon de relever ce défi, ouvrant la voie à des occasions d’apprentissage diversifiées avant l’entrée en pratique clinique et faisant bénéficier l’environnement clinique d’une connaissance poussée en thérapie respiratoire. En outre l’exigence d’un diplôme pour accéder à la profession nous place au rang des autres professions de la santé, uniformisant davantage les règles du jeu pour une collaboration interprofessionnelle.

Comme toujours, la SCTR espère obtenir un appui continu pour le développement de la pratique et de la prestation de la thérapie respiratoire ainsi que pour le perfectionnement des thérapeutes respiratoires. En ce début d’année universitaire, nous voulons aussi souhaiter tout le succès possible à nos étudiants et enseignants et encourager chacun à continuer d’appuyer le développement du journal. Nous sommes toujours à la recherche d’études de cas et d’articles novateurs détaillant les innovations dans la pratique et la prestation de la thérapie respiratoire.

REFERENCES[1] Safer Healthcare Now! [Internet]. Ventilator-Associated Pneumonia

[updated 2012; cited 2012 October 23]. Affiché à : http://www.saferhealthcarenow.ca/EN/Interventions/VAP/Pages/default.aspx.

[2] Kaye, J., Ashline, V., Erickson, D., Zeiler, K., Gavigan, D., Gannon, L., et al. Critical care bug team: a multidisciplinary team approach to reducing ventilator-associated pneumonia. Am J Infect Control. 2000; 28(2): 197-201.



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ORIGINAL ARTICLE

Innovative Community of practice Development within the Alberta Respiratory Community

rena Sorensen, rrt, MSc, roberta Dubois, rrt, MA, Patricia L. Paton, BA, MA a. Community Liaison, The Lung Association, AB & NWT, Edmonton, Alberta, Canada

b. Senior practice Lead, Respiratory Services and Equipment, Health professions Strategy & practice, Alberta Health Services, Edmonton, Alberta, Canada

c. knowledge Management Consultant, Quality & Healthcare Improvement, Alberta Health Services, Edmonton, Alberta, Canada

RÉSUMÉLa pratique de collaboration permet aux personnes

d’élargir le contexte de leur travail et d’élaborer des solutions novatrices à des problèmes complexes. Cet article a pour but d’échanger des observations tirées de nos expériences en établissant des liens menant à la collaboration. Nous avons constaté que l’établissement d’un capital social et l’utilisation des communautés de praticiens (CdP) sont des façons fructueuses d’engager les gens à créer des pratiques novatrices qui ont des répercussions plus marquées. Dans notre projet, nous avons analysé les modèles mentaux qui entravent la pratique de collaboration et découvert un processus novateur en cinq étapes sur la façon d’établir des CdP. Ces cinq éléments ont été validés dans la documentation, mais nous espérons créer de la valeur pour d’autres en regroupant les techniques de façon précise : a) effectuer une analyse des écarts, b) créer un sentiment d’urgence, c) élaborer un plan de gestion des risques, d) combler les lacunes et d) saisir la valeur.

INTRODUCTIONThe level of complexity in today’s health system

can present challenges that seem overwhelming and insurmountable to health professionals. Traditional models of working are inadequate for the current level of complexity [1,2,3]. Collaborative practice enables individuals to broaden the context of their work and develop innovative solutions to these complex problems [4]. The purpose of this article is to share observations from a project on building bridges to collaboration.

The more engaged people are with their practice, the more likely they are to contribute to organizational success within a complex adaptive system [1,5,6,7,8,9]. Through project activities it was noted that building social capital and utilizing Communities of Practice (CoPs) are successful ways to engage people in creating innovative practices that have stronger impacts. CoPs create an environment where the members are engaged in sharing and creating knowledge in order to enable practice improvements [10]. CoPs are “groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis” [11]. Individuals participate on a voluntary basis in areas or on topics that are of specific interest to them and their area(s) of practice. The dialogue uses “Practice Talk,” where stories of practice experiences communicate the perspectives and values of a group of professionals [12].

ABSTRACTCollaborative practice enables individuals to broaden

the context of their work and develop innovative solutions to complex problems. The purpose of this article is to share observations from project experiences building bridges to collaboration. During the project it was discovered that building social capital and utilizing “Communities of Practice” (CoPs) are successful ways to engage people in creating innovative practices that have a stronger impact. The project explored mental models that obstruct collaborative practice, and from this, outlined an innovative five-step process on how to engineer CoPs: (1) perform a gap analysis, (2) create a sense of urgency, (3) develop a risk management plan, (4) bridge the gaps, and (5) capture value. The five elements have been validated in the literature, but hopefully it will create value for others by bringing the techniques together in a specific way.

Figure 1. Anatomy of Practice talk

Service Provision Cops share success

stories, what is going well and providing

job satisfaction?

Work Barriers Cops share problems that create frustration on the job and share

solutions

career Development Cops motivate learning, share

references, career plans

From: parboosingh J. practice talk – How to enhance conversations about practice. In Tools for CoP Facilitators. Unpublished manuscript. p. 7. Reprinted with permission.



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Wenger notes that CoPs require freedom and flexibility on the part of an organization to allow participants to become involved to the degree best suited to their level of interest; where “a community of practice is a unique combination of three fundamental elements: (a) a domain of knowledge, which defines a set of issues; (b) a community of people who care about this domain; and (c) the shared practice that they are developing to be effective in their domain” [13]. Individual participation is based on knowledge and experience in the domain, and provides an opportunity to improve skills or personal connections. Participation in CoPs varies by degrees from core to active to peripheral membership, with peripheral members making up the largest portion of participants [10].

Social capital is created when people create new knowledge through meaningful conversations in a setting where they share a common practice area. There is an understanding of that practice area and the terminology that goes along with it [14]. Any time a group of like-minded individuals comes together to make an improvement and they find success, social capital is created. This can be a formal working group or task force, or it can exist outside of the regular work structure. The voluntary nature of CoPs develops social capital that can result in the generation of new knowledge or innovations that improve practices in health service delivery [14,15].

In order to capitalize on the positive outcomes that can be generated when a collaborative group comes together, a dialogue that develops a “flow of meaning,” which is the point at which a shared understanding is reached, must begin [16]. In order to develop a flow of meaning, people should first explore the mental models of the group in a setting where there is trust [17]. A mental model is the filter through which people perceive their current situation. Health care professionals have been shown to be particularly bad at developing awareness of their mental models, with a tendency to stay close to a fear-based norm (e.g., blaming, power and control, personal agendas, etc.) [16].

This project observed three types of mental models that are so obstructive to the collaborative process that they can bring engagement to a standstill:1. Status quo. Those who have developed a comfortable

level of expertise and efficiency and thus have something to offer a collaborative group. However, they are quite happy with their situation and do not wish to change it, so they will not become openly engaged in the collaborative process, even though they attend group activities. Sometimes, this group will openly obstruct the collaborative process, and it becomes clear that they do not want the collaboration to succeed.

2. Secrets to hide. Those who have not been able to develop a perceived acceptable level of expertise and efficiency will become elusive because they feel they have secrets to hide. If they cannot speak openly about their situation, then they cannot become engaged in the collaborative process.

3. Lack of trust. Those who are quiet observers and have seen so much dishonest, manipulative, or obstructive actions by others in the collaborative group that they have lost all faith that this group will be capable of accomplishing anything at all.

This project worked with several CoPs and was able to show some success with overcoming these mental models. There should be value for others by bringing the techniques together in a specific way.

ENGINEERING A COpBecause CoPs have the capacity to improve practice [14],

there is increasing interest from health system management in Alberta to use them to improve specific practice outcomes. The problem is that CoPs are not easy to engineer if you already have the desired outcome in mind before the group is formed. This project identified an innovative five-step process on how to engineer CoPs. Many of the steps have already been validated in the literature; however, it will create value for others by bringing the techniques together in a specific way. These five steps include:1. Performing a Gap Analysis2. Creating a Sense of Urgency3. Developing a Risk Management Plan4. Bridging the Gaps5. Capturing Value.

1. perform a Gap Analysis In an organically formed CoP, the element of shared

practice belongs to members of the community. The fact that organizationally mandated CoPs are formed to deal with issues identified by organizational leadership presents a challenge. CoP members are identified by these leaders and may not feel issues are of the same significance as does the organization. Shared purpose, self-identified membership, and member enthusiasm are factors that lead to success in CoPs [18]. These factors are not necessarily present in organizationally mandated groups where members are identified by leaders. A gap analysis can lead to an understanding of the differences between priority issues identified by the organization and those identified by individual practitioners.

Understanding organizational values and an awareness of research evidence alone are not enough to bring about practice change. Practice changes are more likely to occur if providers have clarity related to their professional roles, knowledge of the social influences involved in practice changes, and the belief that they are capable of making the changes [19]. CoP members who understand the value of the group in facilitating practice improvements are more likely to contribute in meaningful ways.

Organizationally mandated CoPs can easily overlook the important first step of identifying the “what’s in it for me” factor for members. Mitigating the risk associated with this is important and requires time and dedicated facilitation.



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Intentional conversations facilitate trust and provide the means to uncover stories that have the ability to bring focus on factors that influence practice changes [1,9]. Narratives that have the capacity to lead to practice changes are relevant, controversial, and give hope [10]. Through conversations with CoP members, insight is gained into what members view as important practice issues and where they would be most likely to devote time and energy.

CoPs in which group objectives are aligned with organizational goals have a greater likelihood of success than those in which these elements are disparate [20]. It is challenging to bridge the gap between what management and frontline staff consider important. Based on research evidence, a manager may decide that a practice area needs improvement and mandate the formation of a CoP to develop and implement a solution. If the issue is of not of equal importance to members in the context of their daily work, it is unlikely that CoP members will create a solution that will result in lasting practice improvements. For example, a group of managers may have noticed practice variations among geographically isolated or dispersed employees and may have collected research data showing that a standardized approach to practice will result in better outcomes. They decide the best way to solve the problem is the formation of a CoP. Members of the CoP are frontline practitioners who have never met each other, but who share identical practice domains in isolated areas. Through member conversations, it is discovered that the most important thing to members is to develop connections with other practitioners who share the same domain. By encouraging practice talk, an experienced facilitator can encourage the group to overcome barriers to sharing practices. Skilled facilitation will uncover pockets of practice excellence among the members and facilitate the creation of enough trust to enable the group to explore good and better practices. Once this is accomplished, the group can discover the value of standardized practice, resulting in alignment with organizational priorities.

Without performing a gap analysis and providing skilled facilitation, employees experience confusion when participating in initiatives that have expected outcomes reaching beyond their individual work areas. Facilitating generative conversations, identifying the issues that matter to members, and intentionally aligning these issues with organizational priorities can lead employees to see themselves as being connected to the organization.

2. Create a Sense of UrgencyAs with any collaborative initiative, it is difficult for

participants to find the time to interact in community activities [18]. One must be competitive to be able to expect people to become engaged in something that exists outside of their regular work, or even to open an email in an inbox that is so full they cannot cope with their messages. This project proposes that by creating opportunities to mitigate a threat, one can create a sense of urgency that is competitive enough to combat all of the other things that take up a

participant’s time. This project found a fear-based initiative is successful at generating social capital in a healthcare setting where threats of mergers, downsizing, and practice changes are common. A former Respiratory Services Director commented, “The department seemed to function at a higher level of collaboration when they were working together to combat a perceived threat or injustice” (K. Tin, personal communication, August 16, 2012).

The project suggests that when people come together to fight a common threat, the result is enough social capital to sustain a CoP. Social capital makes the impossible seem possible, and “one should not underestimate the value of a sense companionship in the face of demanding tasks” [21]. While taking a negative focus may seem dangerous, it was interesting to note characteristics of groups who banded together to fight for something. They felt a strong sense of legitimacy and had very effective communication pathways. They felt they had a legitimate cry for justice, which overcame personal or organizational barriers. In situations where people have been unable to collaborate on a practice issue at work, they are quite capable of moving together against a common threat. If a communication was circulated on improving a practice issue, there would be much less uptake from the staff than from an update on the status of the threat. Sometimes, formal communications would not even have to be developed because the network would inform each other very efficiently.

Once “hot topics” or common fears or threats have been identified, it must be determined if any can be aligned with organizational goals. One can then build a sense of urgency around hot topics that are of interest to the sponsoring organization. The most engaging topics are those that engage participants in mitigating a negative element or threat. By collecting narratives or stories through practice talk, one can select a story that has the power to engage all comers.

3. Develop a Risk Management planWhile an engaging story can be very powerful, it can be

controversial to enter a discussion that is upsetting to those higher up in a hierarchy. Any time a group of people band together to create or share knowledge, there is the potential that some power will be shifted from top management down to frontline staff. For example, if a common problem expressed in a CoP is the difficulty accessing expertise on a certain topic, they could build a framework that makes the required expertise accessible. This may remove power from a manager who traditionally was in control of or who had access to this expertise. While distinguishing what the right thing to do in this situation is not difficult, it can be difficult to make the decision to upset the manager. One thing that can combat this phenomenon is collaborative coercion.

Collaborative coercion occurs when a group is diverse and the sessions are well-attended. If one person in the group is pushing for something that is only for selfish gain, the rest of the group will point out that this is not for the greater good of the community and the request will be declined; hence, collaborative coercion. One of the first things the team used as



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a risk management technique was to ensure that all CoPs have a diverse and inclusive membership. Self-regulation occurs when people feel comfortable enough with collaboration to speak up about things they do not agree with. For example, if a physician speaks against something that a group of allied health professionals would like to develop and there is no other physician in the room, it may not be challenged. However, ensuring that any multidisciplinary team has more than one representative for each profession, geographical area, or contextual situation (like independent health services and publically funded health services) can create a situation conducive to collaborative coercion.

Another risk management technique is to perform a formal or informal network analysis. When viewing the situation as a network, one can look at how connected a group or person is, and how stable those connections are. If network analysis software is available, one can measure degree, density, closeness and betweenness centrality, and reciprocity of relationships. A high score on degree centrality indicates many connections to other people or groups (i.e., nodes) [22]. If members of a group are directly connected to each other, the density score will be higher. Indirect connections are also important because it takes time and effort to maintain a connection. If key members of the CoP are doing a good job of connecting people to the right person when it is needed, then the closeness centrality score will be higher [23]. There is also value to being linked with expertise indirectly, which is quantified by the betweenness centrality score [23]. For example, independent health service providers do not have a direct link to publically funded health system managers; however, by connecting through representatives on a CoP, knowledge exchange can still occur between these two groups. Arguably the most important factor in network knowledge exchange is bidirectional links, or dyads (when two people or organizations recognize each other as being connected) [24]. If one CoP member states that they have a connection to another institution, but that institution does not recognize that connection, then the reciprocity score will not be as positive. The team was not able to include a network analysis visual at the time of publication; however, assessing the robustness of the network did occur through informal learning and needs assessments.

Once a better understanding of network connections has been reached, a risk management plan can be developed by asking some important questions: How robust are the connections? How diverse is the group? How much do they trust each other? If a diverse group of people who feel passionate about something that threatens them collectively are interacting regularly enough that they have established trust, then it may be time to develop a CoP or project that allows them to counteract the threat. If the network is not robust enough, then network weaving activities can develop or strengthen necessary connections. Network weaving can be as simple as introducing people who have a common concern.

By far, the most effective network weaving is done by bringing “people together for projects, initially small, so they can learn to collaborate” [25]. There is no magic recipe for how to accurately gauge risk management, but establishing that the network is strong enough to tackle a threat is a good indicator for future success.

4. Bridge the GapsThere have been too many gap-bridging activities carried

out by the team over the last year to mention them all in this paper, but the following stand out as particularly effective:

• Identify the hubs• Influence network diversification• Utilize communication management• Group facilitation• Crisis aversion.

Identify the hubs: An important team strength we possessed was that each member came to the table with a rich and diverse set of relationships with key players in the respiratory community. By leveraging the collective knowledge and connections, the team was able to increase its sphere of influence. For example, the team did not have the capacity to map the network or identify hubs (i.e., those with high degree centrality) when first forming. By pooling team knowledge on the state of the network, including an informal gap analysis, hubs that could be influenced were identified. The most common bridging activity was for one team member who had a strong relationship with a hub to exert influence and initiate change.

Influence network diversification: The most common change initiated by team members was to diversify the network. If developing an innovation to eliminate a threat to the community is likely to be something this group is called upon to undertake, then “one should not underestimate the value of a sense of companionship in the face of demanding tasks” [21]. For example, one project group was an association of independent health service providers who were not connected with every provider in the province. By increasing their membership to 100% of the industry, a collective voice is being developed and recognized. An example of such recognition is the invitations that can now be issued or requested for collaborative activities that they would not have had access to on an individual basis.

Utilize communication management: It is amazing how personal differences can interfere with communication. This project documented two people on discussion boards saying almost identical things; however, they continued to debate with each other on the topic without realizing that they were both in agreement. They are speaking out using only assumptions they have about the other person, with no regard for message content. An easy communication management tactic that bridged gaps to collaboration was to moderate discussion boards and meetings. Having a facilitator summarize arguments or intervene in a debate was very



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effective for moving things forward. Another communication management tactic that bridged gaps was to have an objective partner manage communications or newsletters that went out to a broad group of stakeholders. If those communications had been generated by someone from an organization within the network, those who were not in agreement with that organization would not have read it or may not have believed what they had read. Utilizing communication management tactics has generated the most positive feedback from the participants thus far in the project.

Group facilitation: Two very important determinants of success for CoPs are having access to funding for face-to-face meetings and a committed facilitator [15,18]. The outcomes of this project have been able to validate the literature on the importance of meeting support and facilitation. One exciting outcome was that the project’s largest and most diverse group of stakeholders who had travelled long distances to meet and collaborate all stated they would be willing to continue meeting with each other in the absence of funding [26].

Crisis aversion: Having a facilitator who has a good understanding of collaborative processes helped avert crisis in some groups. In one instance, a governance issue was so controversial that it threatened the group’s capacity to function. There was considerable debate over the issue of consensus decision making. Since the group had so many personal differences and disagreements to navigate, it was not possible to assume that there would be many instances of 100% consensus on decisions, yet they would not approve a consensus-minus-one decision making structure in their governance documents. Members were unable to look past their own opinions on who should be allowed to vote to see that without a voting structure at all, nothing would be accomplished. The facilitator, who was experienced in collaborative processes, proposed that they hold a second vote should consensus not be reached. This vote would have gone out to the entire network, not just the leadership council, and created a situation where the group could progress. It is felt that a crisis was averted by having a facilitator with collaboration expertise [4] intervene at a critical point in the formation of governance for this group.

5. Capture valueIt is very difficult to quantify the value of the activities

in a CoP. The knowledge, both tacit and explicit, that is gained through CoP activities is absorbed into everyday practice without much thought about how that information was accessed. It requires time to reflect on where the value resides for a group. Almost all project groups so far have stated that the opportunity to participate in a group of like-minded individuals was of high value. The value of information is dynamic in nature. When there is a scarcity of information, then having access to it is extremely valuable. However, once that knowledge is shared, it immediately loses value [27]. By creating a framework for capturing the value of CoP

activities as members come across key opportunities to share knowledge, one can provide a legacy document to reflect the value of CoP activities.

Some bridging activities have resulted in the creation of a “boundary object.” If you can see something with your eyes, or it is tangible and it can be individually interpreted, then it is considered a boundary object [28]. CoPs are great at sharing, or even creating new knowledge and disseminating learnings extensively with their members [29]; however, they are not always good at moving that knowledge outside the membership. Localization of knowledge within CoPs creates a boundary, and a boundary object can be crucial to knowledge transfer across a larger network. The bridging effect of boundary objects occurs because “they act as common information spaces that enable interaction and coordination without consensus or shared goals” [30]. An example of a boundary object is a clinical practice guideline or a briefing paper.

CONCLUSIONHealth care providers are encouraged to work in care teams

and in collaborative, interdisciplinary environments. Not all systems or practitioners support such working environments or have structures in place to encourage collaborative learning and development within care teams. One member of a team directing others is not a collaborative practice; nor does it support professional learning and development.

CoPs are one method that can be used to create, facilitate, and sustain collaboration for learning and practice improvement. Recruiting and engaging busy health care professionals requires dedicated resources and skilled facilitation. Facilitators must not only build and sustain initial interest and social capital, they must also be aware of key CoP functional elements and the function of the CoP as keepers of knowledge generated by the community.

CoPs are not a solution to every challenge, nor is it suggested that they meet every need. Sometimes, strengthening the network that supports the information needs of the team should be the first step. In order to strengthen a network, one must first understand the assumptions and mental models that stand in the way of collaborative practice and then build network-weaving opportunities to encourage a collaborative culture.

CONFLICT OF INTEREST STATEMENTThis research has been supported by a Knowledge

Translation Grant from the Research Transfer Network of Alberta, Alberta Innovates Health Solutions. All authors contributed to all areas of manuscript development and writing.

ACkNOWLEDGEMENTSThe authors thank Karen Graham for her thorough

review of this document.



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19. Godin G, Belanger-Gravel A, Eccles M, Grimshaw J. Healthcare professionals’ intentions and behaviours: A systematic review of studies based on social cognitive theories. Implementation Science. 2008;3:36.

20. Kimball L, Ladd A. Facilitator toolkit for building and sustaining virtual communities of practice. Hershey, PA: Idea Group Publishing; 2004.

21. Wenger E, Trayner B, de Laat M. Promoting and assessing value creation in communities and networks: a conceptual framework. Rapport 18. Heerlen: Open Universiteit, Ruud de Moor Centrum. 2011: p. 20.

22. Provan KG, Nakama L, Veazie M, Teufel-Shone N, Huddleston C. Building community capacity around chronic disease services through a collaborative interorganizational network. Health Education Behavior. 2003;30:646-62.

23. Provan K, Fish A, Sydow J. Interorganizational networks at the network level: A review of the empirical literature on whole networks. Management Journal. 2007;33:479-516.

24. Hanneman R, Riddle M. Introduction to social network methods. Riverside, CA: University of California, Riverside. 2005. Available from http://faculty.ucr.edu/~hanneman/. Accessed August 15, 2012.

25. Krebs V, Holley J. Communities are built on connections. 2011: para. 25. http://www.womenmakingconnections.com/about/women-in-the-news/260-communities-are-built-on-connections?date=2011-01-01. Accessed August 15, 2012.

26. Summary of March 2012 Respiratory Action Meetings. Red Deer, Alberta: The Lung Association, AB & NWT. 2012.

27. Castro MC. Explaining and capturing CoP value. Paper presented to the Third European Knowledge Management Summer School, Sebastian, Spain. 2003. http://www.providersedge.com/docs/km_articles/Explaining_and_Capturing_CoP_Value.pdf. Accessed August 1, 2012.

28. Swan J, Bresnen M, Newell S, Robertson M. The object of knowledge: the role of objects in biomedical innovation. Human Relations. 2007;60:1809.

29. Wenger E. Communities of Practice: A Brief Introduction. 2006. www.ewenger.com/theory/communities_of_practice_intro_WRD.doc. Accessed August 1, 2012.

30. Bartel CA, Garud R. Narrative knowledge in action: Adaptive abduction as a mechanism for knowledge creation and exchange in organizations. In: The Blackwell Handbook of Organizational Learning and Knowledge Management. Oxford: Blackwell; 2003. p. 333.

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organization. New York: Doubleday; 2006: p. 259.

2. Iedema R, Meyerkort S, White L. Emergent modes of work and communities of practice. Health Serv Mgmt Res. 2005;18(1):13–24.

3. Rowe A, Hogarth A. Use of complex adaptive systems metaphor to achieve professional and organisational change. JAdv Nurs. 2005;51(4)396–405.

4. Canadian Interprofessional Health Collaborative. A National Interprofessional Competency Framework. 2010. http://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210r.pdf. Accessed August 1, 2012.

5. Begun JW, Zimmerman B, Dooley K. Health care organizations as complex adaptive systems. In: Mick SM, Wyttenbach M, editors. Advances in health care organization theory. San Francisco, CA: Jossey-Bass; 2003. p. 253-88.

6. Oshry B. Seeing systems. San Francisco, CA: Berrett Koehler; 2007.

7. Westley F, Zimmerman B, Patton M. Getting to maybe: how the world is changed. Toronto, ON, Canada: Vintage Canada 2007.

8. Wheatley M. Turning to one another: simple conversation to restore hope to the future. Journal of Quality and Participation. 2002;25(2):8-20.

9. Wheatley M. Finding our way. San Francisco, CA: Berrett-Koehler; 2007. p. 172.

10. Wenger E, McDermott R, Snyder W. Cultivating communities of practice: a guide to managing knowledge. Boston: Harvard Business Press; 2002.

11. Wenger et al. 2002: p. 4.

12. Parboosingh J. Practice talk – how to enhance conversations about practice. In Tools for CoP Facilitators. Unpublished manuscript. p. 6-13.

13. Wenger et al. 2002: p. 27.

14. Lesser E, Storck J. Communities of practice and organizational performance. IBM Systems Journal. 2001;40:831-41.

15. Verburg R, Andriessen J. The assessment of communities of practice. Knowledge and Process Management. 2006;13(1):13-25.

16. Pawar M. Committees and boards in healthcare organizations: barriers to organizational learning? Reflections. 2006;6:4-5.

17. Senge P, Kleiner A, Roberts C, Ross RB, Smith BJ. The fifth discipline fieldbook: strategies and tools for building a learning organization. New York: Doubleday;1994.

18. Ranmuthugala G, Cunningham F, Plumb J, Long J, Georgiou A, Westbrook J, Braithwaite J. A realist evaluation of the role of communities of practice in changing healthcare practice. Implementation Science. 2011;6:49.



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ORIGINAL ARTICLE

patient Safety in Respiratory Therapy: Importance of Human Factors

Assessment and Involvement of the Respiratory Therapist in Medical Device Risk Identification, Analysis, and Learning

Laura Harvie, Respiratory Therapy Student, Dalhousie University, Halifax, NS

ABSTRACTRespiratory therapists play an important role in ensuring

quality and safe patient care. The primary objective of patient safety is to minimize events which cause harm to our patients as a result of care. Adverse events remain a pressing issue within the healthcare system, and as such, healthcare organizations seek methods to minimize their occurrence by development of a comprehensive approach to quality and patient safety. These comprehensive programs are designed to assure both prospective risk avoidance and retrospective learning and process improvement. These programs are increasingly being improved upon by the integration of methods commonly used in other industries, such as human factors and human factors engineering. It is important that respiratory therapists familiarize themselves with the measures within their organization to assure safe patient care delivery and take an active role in risk identification and avoidance.

INTRODUCTIONPatient safety is a fundamental concern for all healthcare

providers, yet despite all efforts, adverse events are far too common within the healthcare system. Adverse events are most commonly described as unintended injuries or complications that are caused by healthcare management, as opposed to the patient’s underlying disease process [1-4]. Nearly one in ten hospitalized patients will experience an adverse event; approximately seven percent of these events result in the death of the patient [1]. Adverse events are not solely a concern of acute care providers, they also occur within the scope of ambulatory and continuing care [5]. It is important to note that on average, more than forty percent of adverse events are considered preventable [1]. The need for quality patient care demands that healthcare organizations develop strategies to minimize adverse events in a manner that is both comprehensive and effective.

Quality is difficult to define because there are at least seven dimensions. These include: acceptability, appropriateness, accessibility, efficiency, effectiveness, equity, and safety [6]. “In practice, quality is easier to define by its opposite...” (Wrae Hill, September 30, 2012)

A comprehensive approach to quality, patient safety, and overall risk management includes prospective (preventative) elements and retrospective elements such as: reporting, investigation, and organizational learning from adverse events.

Quality and patient safety management utilizes quality control (QC) measures in an effort to control unwanted variation of a process, such as limiting the variation on a standard blood gas values. In this context, doing QC is very important to assure accuracy so that clinicians can have confidence in the data. Quality assurance (QA) is defined as “a program for the systematic monitoring and evaluation of the various aspects of a project, service, or facility to ensure

RÉSUMÉLes événements indésirables dans la prestation des soins

de santé représentent un risque important pour les patients qui nous sont confiés. Les organisations de soins de santé cherchent à réduire l’éventualité de tels incidents à l’aide de procédures d’assurance de la qualité. Ces programmes sont conçus pour assurer et améliorer la prestation sécuritaire des soins aux patients en fournissant un moyen de prévenir, signaler et évaluer les événements indésirables. Une assurance de la qualité efficace repose sur les efforts de tous les membres des équipes de soins de santé et il est donc essentiel que les thérapeutes respiratoires se familiarisent avec les mesures de leur organisme qui visent à garantir la prestation sécuritaire de soins aux patients. Le présent document a pour objectif de souligner certaines mesures d’assurance de la qualité qui existent dans les hôpitaux pour appuyer le personnel en soins directs. On y aborde également les stratégies que les thérapeutes respiratoires peuvent utiliser comme moyen de réduire les événements indésirables.

Mots clés : assurance de la qualité, événements indésirables, risques, gestion des risques, thérapie respiratoire.

Keywords: quality and patient safety, quality assurance, human factors engineering, human factors usability analysis, adverse events, hazards, risk management, respiratory therapy



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that standards of quality are being met” [7]. QA is a generic term which describes efforts to restrain variation in a process; through development of a policy, a procedure, and then auditing that process. A simple example of QA would be to observe how closely respiratory therapy students actually perform an Allen’s test prior to a radial artery cannulation, thereby providing clinician supervisors assurance that the correct process is uniformly followed.

While QC and QA are important components of a prospective Quality Program, these two older methods are increasingly used as fundamental building blocks. More sophisticated process improvement methods such as Lean methodology, which focuses on elimination of steps and processes which do not add value for the patient [8] and Human Factors or Human Factors Engineering are now becoming more common. As such, a comprehensive approach to quality and patient safety will include prospective quality assurance of procedures designed both to assure and enhance quality of care, as well as an overall risk management system designed to enable reporting, investigation, and organizational learning from adverse events. Increasingly, both prospective and retrospective elements are supported by human factors and system safety approaches and a just and trusting culture of patient safety [9].

Human Factors is defined as “designing for human use, a body of information about human abilities, limitations, and other human characteristics that are relevant to design” [10], whereas Human Factors Engineering is defined as, “The application of human factors information to the design of tools, machines, tasks, jobs and environments for safe, comfortable and effective use” [10].

In order to provide optimum patient care, it is essential that respiratory therapists familiarize themselves with the processes in place to ensure safe care delivery and what to do if incidents arise; however, we must make efforts to become more resilient. “We are not custodians of already safe systems, the systems we work in are inherently flawed, complex, and we must manage many opposing goals including safety” [11]. It is of equal importance for respiratory therapists to keep a discussion of risk alive even when everything seems safe; anticipating and identifying hazards within their environment and pre-checking all equipment they utilize is key.

LITERATURE REvIEW METHODSA review of literature relevant to quality assurance in healthcare was conducted through the databases PubMed, CINAHL, and Embase. MeSH terms included “quality assurance,” “health care,” “risk,” “risk management,” and “safety management.” Limits placed on the search query included “humans,” “English,” links to full text, and literature published within the last 10 years. Hazard reports and alerts were reviewed through the Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) and Emergency Care Research Institute (ECRI) event reporting systems.

EXpERT CONSULTATION METHODSSubsequent discussion with experts in patient and system

safety in other provinces was conducted, as well as additional review of Accreditation Canada - Quality Dimensions and Human Factors approaches to Patient Safety.

DISCUSSION Quality improvement and patient safety measures can

provide healthcare workers with means to reduce the number of adverse events experienced by patients in our care. The Clinical Engineering Department within the hospital has a significant role to play in ensuring the safety of patients in our care. Clinical engineering staff follow stringent procedures relating to the preventative maintenance and other QC measures of hospital equipment. Increasingly, healthcare teams, including clinical engineering departments are becoming familiar with Human Factors and usability analysis for both (prospective) pre-purchase evaluation and for (retrospective) systems safety investigations of adverse events [12, 13].

Within clinical engineering, from a QC/QA perspective, new devices are assigned a control number. This control number is entered into a work order system which tracks all maintenance, tests, and repairs of the device. Scheduled maintenance occurs for medical devices such as mechanical ventilators according to manufacturer specifications. These scheduled maintenance events include items such as cleaning, sensor calibrations, battery and filter changes, and performance verification tests which utilize automated software. All work order events are tracked through the work order system by the Biomedical Department Manager. The department also contains clinical engineers who monitor Emergency Care Research Institute (ECRI) alerts and forward them to biomedical staff to address. These alerts are logged into the work order system and recorded within the history record for each device (Brian Thibeau, March 14, 2012). The actions taken by the Clinical Engineering Department are the first line of defense to ensure safe operation of medical equipment within the hospital.

pRE-USE CHECkS Safe operation of medical equipment also depends on the efforts of frontline care providers, such as respiratory therapists. It is essential that equipment be consistently inspected prior to use. There have been several documented cases of patient injury or death resulting from failure to inspect devices prior to use. One such case report involves a patient who received an electrochemical burn from a disposable pulse oximeter sensor. In this particular incident, the insulation over the LED portion of the sensor had been torn, allowing uninsulated electrical connections to come in contact with the patient’s skin. This resulted in a burn at the site caused by “low-voltage, direct-current tissue electrolysis” [14]. Visual inspection of these sensors prior to each application is often overlooked; however, it is necessary to prevent patient injury.



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Misconnection of luer lock connections also pose a significant risk to patient safety that respiratory therapists need to be aware of. Several of the items used by respiratory therapists employ this type of connector. Luer fittings are comprised of male and female components, which when threaded together form a secure connection known as a luer lock. These connections are found on a large number of medical devices, ranging from intravascular to respiratory care equipment [15]. Due to the widespread use of these connectors, equipment that should never be connected is compatible. In one such report investigated by the ECRI, a patient death occurred as a result of a connection made between his central intravenous line and his tracheostomy tube cuff inflation port. Initiation of the patient’s intravenous infusion pump resulted in tracheostomy tube occlusion as the cuff filled with fluid [16]. Another report describes a patient death from a massive air embolism sustained when a non-invasive blood pressure (NIBP) monitoring line was inadvertently connected to a needless luer port on the patient’s intravenous catheter. The patient had an intravenous catheter in place due to a pending computed tomography scan, as well as the automatic NIBP cuff. The cuff had been disconnected in order for the patient to go to the bathroom, and upon his return, the tubing was mistakenly reconnected to the luer on the intravenous catheter [17,18]. Examples of other adverse events involving the misconnection of luer connectors include: an enteral feeding set connected to a central venous catheter, an enteral feeding set to a hemodialysis line, and oxygen tubing to a needless intravenous port [19]. Simple QA measures such as educating staff regarding this risk, labelling lines, and tracing all lines from the source prior to connection are methods healthcare workers can use to assist in managing the risks associated with these types of connectors [15,16,19].

INFECTIONSRespiratory therapists also have an essential role to

play in QA by means of preventing adverse events related to hospital-acquired infections. Infections transmitted within hospitals remain a significant factor in patient morbidity and mortality [20]. Environmental transmission of these infections can occur through a variety of equipment utilized by respiratory therapists. In fact, norovirus has been isolated from both non-invasive ventilators and pulse oximeters, even after clinical cleaning [21]. Acinetobacter, which is responsible for diseases such as pneumonia and serious blood infections [22], has been found on respiratory equipment such as ventilator surfaces, suction equipment, and stethoscopes [20]. This bacteria can cause death in hospitalized patients, with ventilated patients being at significant risk [22]. Respiratory therapists can minimize the risk of such infections by paying rigorous attention to infection control procedures, such as hand washing and equipment disinfection. Items such as pulse oximeters and stethoscopes can easily transmit infections between patients and are often overlooked by healthcare providers. Ensuring consistent disinfection after each use is

an important step for respiratory therapists to take in an effort to reduce the occurrence of hospital acquired infections.

STAFF INJURyIt is not only patients that are at risk of adverse events

occurring in the healthcare environment. Staff injury can also occur without proper education regarding the hazards associated with equipment and materials in use. For example, alcohol-based hand sanitizers pose a fire risk which can be amplified in environments in which oxygen is in use [23]. A neonatal intensive care nurse experienced burns to her hand when a fire occurred due to failure to allow her hands to completely dry after using a sanitizer. The nurse’s hand was still wet when she walked across the floor and reached to change a setting on an air/oxygen blender. The combination of a static shock, the alcohol-based sanitizer, and oxygen-enriched environment resulted in the fire [23].

MEDICAL DEvICE FAILUREMedical equipment is often designed to prevent

adverse events; however, device damage can render these measures ineffective. For example, medical gas flowmeters and outlets have unique gas-specific connectors in order to prevent delivery of incorrect medical gas to a patient. There have been several documented cases of patient injury and death resulting from damaged flowmeters being forced into inappropriate outlets. For example, two patients undergoing cardiac catheterization died as a result of asphyxiation when an oxygen flowmeter was inadvertently connected to a nitrous oxide wall outlet. The flowmeter had damage to its PIN index safety system, allowing the misconnection to occur [24,25]. Visual inspection of equipment prior to use is a simple QA measure which will assist respiratory therapists to prevent such adverse events from occurring.

An example of medical device failure in the clinical setting involves facilities using the PB 840 mechanical ventilator (Puritan Bennett, 6135 Gunbarrel Avenue, Boulder, CO 80301 USA). User facilities reported failures of the ventilator at their sites [26]. Investigation resulted in determining that cellular phone operation within close range of the ventilator resulted in the device going into Vent-Inop mode, in which the device ceases ventilation and the safety valve opens to ambient air [27]. The ECRI issued a hazard report and the manufacturer took swift corrective action for the potentially life-threatening hazard by improving the shielding of the breath delivery unit and upgrading software to filter the self-check function responsible for the defect [26].

A single report of an incident involving the VIP Infant Ventilator (Viasys Healthcare Inc., Suite 200, 227 Washington Street, Conshohocken, PA 19428 USA) caused the manufacturer to pledge to modify the device in order to prevent similar incidents. A neonate received a bilateral pneumothorax and possible neurological damage when a clinician inadvertently connected the inspiratory limb of the breathing circuit to the exhaust port on the ventilator while



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operating in a time-cycled pressure-limited mode. Although the error was quickly corrected, this resulted in pressure greater than 800 cmH2O being delivered to the neonate’s lungs. After report of this adverse event, the manufacturer informed ECRI that modifications would be made to the exhaust port to make misconnection impossible, and thus prevent such errors in the future [28].

MEDICAL DEvICE USABILITy It is imperative to note that patient safety issues (such

as those described above) resulting from medical device or equipment failure are exceedingly rare, and usually corrected quickly. Far more common, are poorly designed medical devices with inherent error traps which invite human error. “Adverse events can and do occur even with very experienced clinicians if the devices they utilize are not easy to use” [29].

“Training is the last bastion of poor design” [30]

An issue of growing importance is human factors, and seeking first to understand “what made sense at the time” when investigating adverse events [13]. For instance, a system safety analysis in British Columbia (2010) using human factors usability analysis demonstrated that infusion pump programming errors initially attributed to nurses were found to be design faults , and that the infusion pump had seven severe usability violations. This triggered a wholesale change toward more intuitive and user friendly infusion pump technology for an entire health authority in Canada [13]. As reported in this Journal in 2006, [31] the legislated, designed in protections against medical gas misconnections such as diameter index safety systems (DISS) and pin index systems (PIN) end at the wall outlet. The similar Thorpe tube design of both medical air and oxygen flowmeters with a common threading for oxygen tubing easily facilitated misconnections for years. A reported death in 2005 triggered a large-scale change in a large regional health authority toward the use of medical [air] valves as opposed to Thorpe tube [air] flowmeters (see figure 1). This approach also used a human factors forced function and did not rely solely on education, policies, and procedure, which (by themselves) are very weak measures to improve safety [13].

The Canadian Patient Safety Institute’s Root Cause Analysis Framework (2006) describe the human factors hierarchy of effectiveness, where forcing functions are most effective and education and training is less effective [32] (see figure 2).

REpORTING AND USING ADvERSE EvENTS TRENDS TO IMpROvE SySTEM SAFETy

In order to facilitate investigation and effect change, it is essential to report any incidents that compromise safe healthcare delivery. Even near-miss events warrant reporting [33]. These are described as mishaps that have the potential to cause harm but are prevented from doing so due to chance or interception [4]. Although there may be variances between facilities, virtually all healthcare organizations provide

Figure 1. thorpe tube Flowmeters (oxygen and air) vs thorpe tube Flowmeter (oxygen) and Medical Air Valve [13,31]

Figure 2. Human Factors Hierarchy of effectiveness [13]

systems with which to report incidents. These may be either paper-based or electronic forms which contain pertinent information such as the time and location of occurrence, as well as a description of the incident or near-miss [3]. Healthcare workers should familiarize themselves with the adverse event reporting system (AES) available to them.

Reporting systems within healthcare facilities are an integral component to patient safety efforts as they provide



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organizations with a means to learn from experience [4,33]. Incidents experienced within an organization should be analysed for trends in their AES and can then be shared by means of an external reporting system, such as the Global Patient Safety Alerts (CPSI Canada), ECRI or Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) databases. External reporting enables other facilities to become aware of an issue or hazard, which serves to prevent and identify similar adverse events at a system-wide level. “Although each event is unique, there are likely to be similarities and patterns in sources of risk which may otherwise go unnoticed if incidents are not reported and analyzed” [4].

Consultation with a Risk Management and Patient Safety Consultant with the Capital District Health Authority (CDHA) in Halifax, Nova Scotia, revealed that events originally recorded into the district’s Patient Safety Reporting System had resulted in three international recalls and/or advisories of medical devices. In one of these cases, the CDHA was the only facility to report the issue internationally, resulting in a recall, redesign, and an improved quality inspection process of the product (Beth Kiley, July 18, 2012). This reinforces the concept that a small piece of information, when properly reported, can effect big changes which improve the safety of our patients.

Despite the importance of event reporting, many adverse events are not reported through hospital or organization reporting systems. In fact, a study revealed that only 3.6% of adverse events found in retrospective hospital record review were found in one or more of four available reporting systems [3]. Literature suggests that there are several barriers to event reporting by healthcare workers, such as time constraints, peer disapproval, and lack of perceived benefit [3,33]. It is important that healthcare professionals realize the impact of adverse event reporting in order to encourage the utilization of such systems when incidents or near-misses arise.

Respiratory therapists can play an integral role in patient safety by educating themselves to hazards which may impede safe patient care delivery, correcting these where possible, and promoting measures to prevent incidents such as consistent inspection and disinfection of respiratory equipment, and cautious bedside care. Through talking with patient safety experts locally and in other jurisdictions, staff can remain informed of hazards and assist in adverse event prevention. Respiratory therapists should familiarize themselves with local procedures in place to maintain safe patient care delivery, including the QC measures of biomedical engineers and the importance of risk management by means of event reporting. A comprehensive approach to quality and patient safety which includes both prospective components such as QC/QA procedures as well as retrospective components serves to ensure safe patient care by outlining processes to prevent deficiencies, identify problems, and initiate corrective action.

ACkNOWLEDGEMENTSThe author would like to gratefully acknowledge

the contribution and expertise provided by Wrae Hill, Director of Patient and System Safety for Interior Health, in Kelowna, British Columbia. As well, sincere thanks for clinical engineering information provided by Brian Thibeau, Biomedical Professional at the Halifax Infirmary Site, QEII Health Sciences Center, in Halifax, Nova Scotia and to Beth Kiley, Risk Management and Patient Safety Consultant with the Capital District Health Authority (CDHA) in Halifax, Nova Scotia, for information provided on local adverse event reporting.

REFERENCES1. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma, DJ,

Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17:216-223.

2. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678-1686.

3. Christiaans-Dingelhoff I, Smits M, Zwaan L, Lubberding S, vand der Wal G, Wagner C. To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports? BMC Health Services Research [serial on the internet]. 2011 [cited 2012 Jul 4];11(49). Available from: http://www.biomedcentral.com/1472-6963/11/49.

4. World Health Organization. WHO draft guidelines for adverse event reporting and learning systems [monograph on internet]. Geneva (Switzerland): WHO Press; 2005 [cited 2012 Jul 23]. Available from: http://who.int/patientsafety/events/05/Reporting_Guidelines.pdf

5. Forster AJ, Asmis TR, Clark HD, Saied GA, Code CC, Caughey SC, et al. Ottawa hospital patient safety study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. CMAJ. 2004;170(8):1235-1240.

6. BC Patient Safety & Quality Council. BC Health Quality Matrix Handbook [internet]. Vancouver (Canada): 2010 [cited 2012 Sept 30]. Available from: http://www.bcpsqc.ca/pdf/BC%20Health%20Quality%20Matrix%20-%20Handbook.pdf

7. Merriam-Webster Dictionary [Internet]. Springfield: Merriam-Webster Inc.; 2012 [cited 2012 Mar 14]. Available from: http://www.merriam-webster.com/medical/quality%20assurance

8. Seidl KL, Newhouse RP. The intersection of evidence-based practice with 5 quality improvement methodologies. JONA. 2012;42(6):299-304.

9. Dekker, S. Patient Safety – A Human Factors Approach. Boca Raton: CRC Press; 2011

10. Chapanis A. Ergonomics in product development: a personal view Ergonomics 1995;38(8):1625-1638.

11. Dekker,S. Leading Opinion Films: Sidney Dekker on Resilience [internet video]. 2008. Available from: http://www.youtube.com/watch?v=mVt9nIf9VJw

12. Namshirin P, Ibey A, Lamsdale A. Applying a multidisciplinary approach to the selection, evaluation, and acquisition of smart infusion pumps. J Med Biol Eng. 2011;31(2):93-98.

13. Hill W. Human factors in laboratory science-Patient safety and device usability. Presented to: BC Society of Medical Laboratory Sciences; 2012 Sept 29. Kamloops, Canada.



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14. Emergency Care Research Institute. Hazard report: exposed connections in pulse oximeter sensors can cause electrochemical burns. Health Devices. 2001;30(12):456-7.

15. Emergency Care Research Institute. Preventing misconnections of lines and cables. Health Devices. 2006;35(3)81-91.

16. Emergency Care Research Institute [homepage on internet]. Plymouth Meeting: ECRI Institute; c2008-2010 [updated 2002 Mar 8; cited 2012 Jul 17]. Health Devices Alerts: Accession No. 39388. IV connection to tracheostomy cuff inflation port reflects larger problem. Available from: www.ecri.org

17. Eakle M, Albrecht Gallauresi B, Morrison A. Luer-lock misconnects can be deadly. Nursing. 2005 Sep; 35(9):73

18. Emergency Care Research Institute. Hazard report: fatal air embolism caused by the misconnection of medical device hoses to needless luer ports on IV administration sets. Health Devices. 2004 Jun;33(6):223-5.

19. The Joint Commission. Tubing misconnections-a persistent and potentially deadly occurrence. Jt Comm J Qual Patient Saf. 2006 Jul;32(7):411-3.

20. Weber DJ, Rutala WA, Miller MB, Huslage K, Sickbert-Bennett E. Role of hospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, clostridium difficile, and acinetobacter species. Am J Infect Control. 2010;38(5):s25-33.

21. Morter S, Bennet G, Fish J, Richards J, Allen DJ, Nawaz S, et al. Norovirus in the hospital setting: virus introduction and spread within the hospital environment. J Hosp Infect. 2011 Feb;77(2):106-12.

22. Centers for Disease Control and Prevention [homepage on internet]. Atlanta: Centers for Disease Control and Prevention; [updated 2010 Nov 24; cited 2012 Jul 25]. Acinetobacter in healthcare settings. Available from: http://www.cdc.gov/HAI/organisms/acinetobacter.html

23. Emergency Care Research Institute. Hazard report: fire risk from alcohol-based hand sanitizers worsens in oxygen-enriched environments. Health Devices. 2006 Oct;35(10):390.

24. Emergency Care Research Institute [homepage on internet]. Plymouth Meeting: ECRI Institute; c2008-2010 [updated 2002 Jan 25; cited 2012 Jul 17]. Health Devices Alerts: Accession No. S0003. Misconnected flowmeter leads to two deaths. Available from: www.ecri.org

25. Emergency Care Research Institute [homepage on internet]. Plymouth Meeting: ECRI Institute; c2008-2010 [updated 2005 Jan 7; cited 2012 Jul 17]. Health Devices Alerts: Accession No. A6033. Oxygen flowmeters: report of death caused by misconnected flowmeter. Available from: www.ecri.org

26. Emergency Care Research Institute. Hazard report: Close-range EMI sends Nellcor Puritan Bennett 840 ventilators into “Vent Inop” mode. Health Devices. 2003 Mar;32(3):128-30.

27. Shaw CI, Kacmarek RM, Hampton RL, Riggi V, El Masry A, Cooper JB, et al. Cellular phone interference with the operation of mechanical ventilators. Crit Care Med. 2004 Apr;32(4):928-31.

28. Emergency Care Research Institute. Hazard report: VIP infant ventilator seriously injures newborn. Health Devices. 2005 Aug;34(8):286-7.

29. Zhang J, Johnson TR, Patel VL, Paige DL, Kubose T. Using usability heuristics to evaluate patient safety of medical devices. J Biomed Inform. 2003;36:23-30.

30. BC Patient Safety & Quality Council. Human Factors in Healthcare (Lamsdale/ Hill) [internet]. Vancouver (Canada): 2010. Available from: http://www.bcpsqc.ca/education/virtual-learning/An%20Introduction%20to%20Human%20Factors.pdf

31. Hill W, Yong C, Duchscherer C. Air/Oxygen Misconnections. CJRT. 2006;42(4):15-17.

32. Canadian Patient Safety Institute [internet]. CSPI;c2012. Canadian Root Cause Analysis (RCA) Framework (2006). Available from: http://www.patientsafetyinstitute.ca/english/toolsresources/rca/pages/default.aspx

33. Leape LL. Reporting of adverse events. N Engl J Med. 2002 Nov;347(20)1633-8.

SuBMiSSioNS AccePteDThe CJRT accepts submission of original articles, papers, commentaries, case studies,

literature reviews, letters to the editor and directed reading papers. All manuscripts are peer-reviewed.

The CJRT is published four times a year and represents the interests of respiratory therapists nationally and internationally.

For additional information or to submit an article, please contact: rita Hansen

CSRT Communications Manager400-331 Cooper St.,Ottawa ON k2p [email protected]

800-267-3422 ext. 223



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CSRT pOSITION STATEMENT

Degree as Entry-to-practice

The Canadian Society of Respiratory Therapists (CSRT) advocates for a degree as entry-to-practice for respiratory therapists (RTs) and actively supports provincial health

and education stakeholders in achieving this goal.As the national professional association for respiratory

therapists and the credentialing body for non-regulated provinces, the CSRT believes that graduates should have the knowledge, skills and professional judgement in all practice settings within the field of respiratory therapy. The CSRT supports learning outcomes that are reflective of current practice, through the promotion of safe and best practice as outlined in the National Competency Profile. The CSRT advocates for a multi-skilled respiratory therapist that can adapt easily to the evolving complexities of the health care environment.

Skills, Knowledge and Judgement to Work in a Complex Health Care Environment

The health care environments have become more complex and diverse due to advances in research, the evolution of medical therapies and technology, and the increasing complexity and acuity of clinical respiratory care. As such, entry-to-practice respiratory therapists require advanced knowledge that is not provided in diploma-level education. Examples of knowledge acquisition that is enhanced through a degree program include:• Broader knowledge of the Canadian health care system

and current health care issues• Enhanced knowledge and professional judgement

relative to medical ethics and privacy legislation• Enhanced communication skills to work effectively with

more informed patients and families• Enhanced knowledge, skills and professional judgement

to work more effectively within the interprofessional team• Enhanced critical thinking and independent decision-

making skills• Better comprehension of health promotion and

prevention; acting as role models and mentors for colleagues, patients, and other health care professionals

• Sufficient knowledge about research to contribute to evidence-based decisions; the ability to critically evaluate evidence and apply to daily practice

• Enhanced understanding of research project development, implementation and evaluation

• Enhanced leadership and management skills, including systems analysis and organizational behaviour, budgeting, risk management, and strategic thinking

• Effective interprofessional collaboration, teamwork, and conflict resolution skills

• Improved understanding of patient safety initiatives and quality improvement principles

• Enhanced understanding and commitment to lifelong learning and continuing professional development.

The CSRT advocates for high standards of practice for the profession and harmonization of standards across all Canadian provinces and territories. A degree graduate will have the foundational knowledge required to meet the needs of the national health care sector.

Employers Require Qualified Health Care ProfessionalsEmployers require an entry-level respiratory therapist

who has the critical knowledge and clinical judgement, problem-solving, adaptability, and leadership qualities to provide safe and effective patient care in a multifaceted health care environment.

Creating a Level Playing Field in the Health Care SectorA degree as entry-to-practice will enable respiratory

therapists to align with other health care professionals in terms of academic standards and involvement in critical thinking and decision-making through interprofessional collaboration.

A degree education will provide respiratory therapists with equal opportunities for advancement in health care teams and management positions, for employment in other provinces and countries, in pursuit of post-graduate education, and to be leaders in respiratory-related research.

Improvements in Patient CareA recent report from the Canadian Institute of Health

Information (CIHI) entitled Respiratory Disease in Canada1

states that “Canada is facing a wave of chronic respiratory

diseases. Since many of these diseases affect adults over the age of 65, the number of people with respiratory diseases will increase as the population ages. The corresponding increase in demand for services will pose a significant challenge for the health care system.”

With the increasing incidence of chronic respiratory

diseases and the complexity of preventing, treating and effectively managing this population in Canada, there is an increasing demand for respiratory therapists who have the appropriate level of education to meet these challenges. The CSRT recognizes that respiratory therapists must have a broader scope of knowledge, critical thinking and independent decision-making skills to provide optimal care in the future.



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Current Role and Responsibilities of the Respiratory TherapistRespiratory therapists are health care professionals who

assess, monitor and treat individuals with respiratory and cardio-respiratory disorders. Respiratory therapists are vital members of the health care team. They work in hospitals’ intensive care units, neonatal units, operating rooms, general wards, coronary care units and emergency departments. Respiratory therapists also work in the community in areas such as family health teams, home care, and sleep labs. Respiratory therapists treat patients of all ages, from infants and children to adults, including geriatric patients.

Respiratory therapists must have the skills, knowledge and judgment to:• Maintain an open airway for trauma, intensive care, and

surgery patients• Assist in cardiopulmonary resuscitation and support of

critically ill patients• Provide life support for patients who cannot breathe on

their own• Attend high risk births and assist babies who have

breathing problems• Stabilize high risk patients being moved by air or ground

ambulance• Provide assistance in the delivery of general anaesthesia

procedures• Administer inhaled drugs and medical gases such as

asthma medication and oxygen

• Conduct tests to measure lung function• Teach people how to manage their chronic lung disease

or to quit smoking• Provide in-home respiratory care to adults and children

In addition to their vast health care knowledge and highly developed technical and clinical skills, respiratory therapists also require critical thinking and decision-making skills, good judgment, excellent interpersonal skills, and the ability to maintain composure in critical medical situations.

ABOUT THE CSRTThe CSRT is the national professional association

representing approximately 3,200 respiratory therapists across Canada. The CSRT is also the credentialing agency for respiratory therapists who practice in non-regulated jurisdictions and administers the accreditation process for respiratory therapy education programs.

AppROvAL By CSRT BOARD OF DIRECTORSThis position statement was approved by the Board of

Directors of the Canadian Society of Respiratory Therapists on September 15, 2012.

REFERENCE

1. CIHI et al. September 2001, Respiratory Disease in Canada.

SouMiSSioNS AccePtéeSLe JCTR accepte les versions originales d’articles, de communications, de commentaires,

d’études de cas, d’analyses documentaires, de lettres à la rédaction et de lectures dirigées. Tous les manuscrits proposés sont examinés par les pairs.

Le JCTR est publié quatre fois par année et présente des sujets de nature nationale et internationale qui intéressent les thérapeutes respiratoire.

pour de plus amples renseignements ou pour présenter un article, veuillez vous adresser à :

rita HansenDirectrice des communications

400-331, rue Cooper Ottawa (Ontario) k2p 0G5

[email protected] 267-2422, poste 223



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ÉNONCE DE pOSITION

Grade universitaire pour l’accès à la profession

La Société canadienne des thérapeutes respiratoires (SCTR) revendique l’obtention d’un grade universitaire comme condition d’accès à la profession pour les

thérapeutes respiratoires (TR). La Société compte soutenir activement les intervenants provinciaux du secteur de la santé et de l’éducation dans l’atteinte de cet objectif.

À titre d’association professionnelle nationale pour les thérapeutes respiratoires et d’organisme de sanction pour les provinces non réglementées, la SCTR croit que les nouveaux diplômés doivent posséder les connaissances, les compétences et le jugement professionnel avancés requis dans tous les champs de pratique de la thérapie respiratoire. La SCTR soutient les résultats d’apprentissage qui reflètent la pratique de soins respiratoires sécuritaires et exemplaires tel qu’énoncée dans le Profil national des compétences. La SCTR revendique pour une formation de thérapeutes respiratoires polyvalents qui seront en mesure de s’adapter facilement à l’évolution et les complexités qui existent dans le domaine de la santé.

Compétences, connaissances et jugement dans le domaine complexe de la santé

Le domaine de la santé devient de plus en plus complexe et diversifié en raison des progrès de

la recherche, de l’évolution des thérapies et des technologies médicales et de la complexité et de l’acuité croissantes des soins respiratoires cliniques. C’est pourquoi les thérapeutes respiratoires qui accèdent à la profession doivent posséder des connaissances complexes qui ne sont pas données dans un programme d’éducation menant à un diplôme. Voici quelques exemples de connaissances bonifiées par un programme de formation menant à un grade universitaire :

• Une meilleure connaissance du système de santé du Canada et des enjeux actuel dans le domaine de la santé;

• Une amélioration des connaissances et du jugement professionnel en matière d’éthique médicale et des lois sur la protection de la vie privée;

• Une amélioration des compétences de communication permettant de travailler efficacement avec des patients et des familles mieux informés;

• Une amélioration des connaissances, des compétences et du jugement professionnel permettant de travailler plus efficacement au sein d’équipes interprofessionnelles;

• Une amélioration des compétences de pensée critique et de prise de décision Indépendante;

• Une meilleure compréhension de la promotion de la santé et de la prévention afin de jouer un rôle de modèle et de mentor auprès des collègues, des patients et des autres professionnels de la santé;

• Une connaissance suffisante de la recherche afin de contribuer à la prise de décision fondée sur les connaissances et les faits, et la capacité d’évaluer de façon critique les preuves et ainsi pouvoir en faire la mise en pratique;

• Une meilleure compréhension de l’élaboration, de la mise en oeuvre et de l’évaluation des projets de recherche;

• Une amélioration des compétences de leadership et de gestion, notamment : analyse des systèmes et comportement organisationnel, élaboration des budgets, gestion du risque et réflexion stratégique, etc.;

• Des compétences de collaboration interprofessionnelle efficace, de travail d’équipe et de résolution des conflits;

• Une compréhension accrue des initiatives touchant la sécurité des patients et des principes de l’amélioration de la qualité;

• Une compréhension et un engagement accrus face à l’apprentissage permanent et au perfectionnement professionnel continu;

La SCTR revendique pour des normes de pratique élevée pour la profession et de l’harmonisation des normes dans toutes les provinces et territoires au Canada. Le titulaire d’un grade universitaire disposera de la base de connaissances nécessaires pour répondre aux exigences du domaine de la santé à l’échelle nationale.

Les employeurs à la recherche de professionnels de la santé qualifiés

Les employeurs recherchent des thérapeutes respiratoires débutant dans la profession qui possèdent les connaissances critiques, le jugement clinique et les qualités de résolution de problèmes, d’adaptabilité et de leadership nécessaires pour offrir aux patients des soins de manière efficace et sécuritaire dans un environnement de soins de santé présentant de multiples facettes.

Établir des conditions équitables dans le secteur de la santé Exiger un grade universitaire comme condition d’accès

à la profession permettra aux thérapeutes respiratoires de s’intégrer aux autres professionnels de la santé en termes de niveau de scolarisation et de participation à la pensée critique et à la prise de décision dans le cadre de la collaboration interprofessionnelle.

Un grade universitaire offrira aux thérapeutes respiratoires des chances égales d’avancement dans les équipes de soins de santé; les postes de gestion; l’emploi dans les autres provinces et à l’étranger, la poursuite d’études supérieures la possibilité d’être des chefs de file dans la recherche respiratoire.



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Optimisation des soins respiratoires Un rapport publié récemment par l’Institut canadien

d’information sur la santé (ICIS) et intitulé Les maladies respiratoires au Canada1 indique que :

« Le Canada fait face à une vague de maladies respiratoires chroniques. Étant donné que bon nombre de ces maladies touchent les adultes de 65 ans et plus, le nombre de personnes souffrant de telles maladies augmentera au fur et à mesure que vieillira la population. La hausse de la demande pour des services de santé qui en découlera constituera un défi de taille pour le système de soins de santé. »

Avec l’incidence croissante de maladies respiratoires chroniques et la complexité de la prévention, du traitement et de la gestion efficace de cette population au Canada, il y a une demande croissante de thérapeutes respiratoires possédant le niveau de scolarisation approprié pour relever ces défis. La SCTR reconnaît que les thérapeutes respiratoires doivent élargir leurs connaissances, leur pensée critique et leurs compétences de prise de décision afin d’offrir dorénavant des soins optimaux.

Rôle et responsabilités des thérapeutes respiratoires Les thérapeutes respiratoires sont des professionnels

de la santé qui évaluent, surveillent et traitent les personnes atteintes de troubles respiratoires et cardio-respiratoires. Les thérapeutes respiratoires sont des membres essentiels de l’équipe de soins de santé. Ils travaillent dans les unités de soins intensifs des hôpitaux, les unités de néonatalité, les salles d’opérations, les salles, les unités de soins coronariens et les services d’urgence. Les thérapeutes respiratoires travaillent aussi dans la collectivité, au sein des équipes de médecine familiale, de soins à domicile et dans les laboratoires du sommeil. Les thérapeutes respiratoires traitent des patients de tous âges, depuis les nourrissons et les enfants jusqu’aux adultes, y compris les patients gériatriques.

Les thérapeutes respiratoires doivent posséder les

compétences, les connaissances et le jugement pour : • maintenir l’ouverture des voies respiratoires des patients

des unités de traumatologie, des soins intensifs et de chirurgie;

• aider à la réanimation et au soutien cardio-pulmonaires des patients en phase critique;

• assurer le maintien des fonctions vitales des patients incapable de respirer seuls;

• être présents lors des naissances à haut risque et aider les nouveau-nés qui présentent des troubles respiratoires;

• stabiliser les patients à haut risque avant leur transport par ambulance ou ambulance aérienne;

• fournir une assistance dans les procédures d’anesthésie générale;

• administrer les médicaments dispensés par inhalation et les gaz médicaux, comme les

• médicaments pour l’asthme et l’oxygène; • effectuer les tests de mesure de la fonction pulmonaire; • enseigner aux gens à gérer leurs maladies pulmonaire

chroniques ou à cesser de fumer; • fournir des soins respiratoires à domicile aux adultes et

aux enfants.

En plus de leurs vastes connaissances en matière de santé et de compétences techniques et cliniques avancées, les thérapeutes respiratoires doivent également faire preuve de pensée critique et posséder des compétences de prise de décision, un bon jugement, d’excellentes compétences interpersonnelles, et la capacité de conserver leur calme dans des situations médicales critiques.

LA SOCIÉTÉ CANADIENNE DES THÉRApEUTES RESpIRATOIRES

La Société canadienne des thérapeutes respiratoires est l’association professionnelle nationale qui représente environ 3 200 thérapeutes respiratoires au Canada. La SCTR est l’organisme qui attribue le titre professionnel aux thérapeutes respiratoires dans les provinces non réglementées et administre le processus d’agrément des programmes éducatifs des thérapeutes respiratoires.

AppROBATION DU CONSEIL D’ADMINISTRATION DE LA SCTR

Le présent énoncé de position est approuvé par le Conseil d’administration de la Société canadienne des thérapeutes respiratoires en date du 15 septembre 2012.

RÉFÉRENCE

1 CIHI et coll., septembre 2001 : Les maladies respiratoires au Canada.



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LEADERSHIp COLUMN

Accessing professional Development Tools: Free and Easy professional Development Options in your Browser

gilbert V. Wilkes iV, PhD, Assistant professor, Royal Roads University, School of Communication and Culture, victoria British Columbia, Canada

Respiratory therapists are always looking for ways to improve and enhance their continuing education. There are many options available to keep you abreast of topics

like new treatments, various equipment choices, and the latest job opportunities. One great option is using services or “apps” called aggregators to organize blogs or other sources into tabs, folders, or dashboards, so that you can scan headlines to find the information you need to raise your performance as a respiratory therapist, or follow news, sports, or whatever else you would like to do.

An aggregator app or service is a place to organize a lot of RSS feeds. RSS stands for Real Simple Syndication, and every blog has an RSS feed attached to it so that you can load it into an aggregator like Google Reader. So rather than have lots of bookmarks in your browser, you can use an aggregator to scan all the headlines you want to scan about respiratory therapy, or container gardening, or popular geology, in one place. And it all updates for you automatically. You can learn to use RSS by simply googling “RSS Tutorial” and selecting a tutorial that is right for you. Once you start finding sources, those sources will lead you to other sources. Some sources will be productive, others not so much. So, like a good gardener you add new vegetables or flowers as the seasons change, and you weed a lot. This is called curation.

I used a service called delicious.com, which is a social bookmarking site where people share links to find what that

the Delicious community believes are the top blogs or syndi-cated sources in respiratory therapy. Here are those sources in a dashboard format using a free service called netvibes: <http://www.netvibes.com/casist#respiratory.therapy>.

So, what did I learn just from a brief scan of the head-lines that I put together? Well, I’m no respiratory therapist, but I now know that Canada is urging people to test for radon gas in their basements, I know that children exposed to “phthalates” - hey, what’s a phthalate? - have an “elevated risk of asthma related airway inflammation,” and I know that there’s a job opening somewhere for a Director for Clinical Education for Respiratory Therapy.

To find the sources in the netvibes dashboard page I put together, I searched for “respiratory therapy.” When I searched for respiratory therapy I found out that a lot people interested in respiratory therapy are also interested in health-care issues in general, in home care, and in asthma and related conditions, so I gathered some of these sources, too.

If you have any questions, please write me at [email protected]. I can provide you with the .OPML file for the page I prepared so that you can upload the sources that I found into your own reader. If you don’t know what .OPML means, then let Google be your friend and google “what is opml?”

Columns submitted to the CJRT are not subject to peer-review.



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CHRONIQUE SUR LE LEADERSHIp

Accès aux outils de perfectionnement professionnel Options de perfectionnement professionnel gratuites et faciles dans votre navigateur

en utilisant le lecteur Google ou netvibes

gilbert V. Wilkes iV, Ph. D., professeur agrégé, Université Royal Roads, École de communication et de culture, victoria, C.-B.

Les thérapeutes respiratoires sont toujours à la recherche de façons d’améliorer et de parfaire leur formation continue. De nombreuses options sont offertes pour vous

tenir au courant de sujets tels que de nouveaux traitements, divers choix de matériel et dernières possibilités d’emploi. Une option remarquable est l’utilisation de services ou d’applications appelées agrégateurs pour organiser des blogues ou d’autres sources en languettes, dossiers ou tableaux de bord afin que vous puissiez parcourir les titres pour trouver les renseignements dont vous avez besoin pour augmenter votre rendement en tant que thérapeute respiratoire ou suivre les nouvelles, les sports ou toute autre activité qui vous plait.

J’ai utilisé un service appelé delicious.com, qui est un site de signets sociaux où les gens échangent des liens, afin de trouver ce que les participants estiment être les meilleurs blogues ou sources groupées en matière de thérapie respiratoire. Voici ces sources en format tableau de bord utilisant un service gratuit appelé netvibes : <http://www. netvibes.com/casist#respiratory.therapy>.

Alors, qu’ai-je appris uniquement en parcourant rapidement les titres que j’ai rassemblés? Eh bien, je ne suis pas thérapeute respiratoire, mais je sais maintenant que le Canada demande avec instance aux gens de vérifier les émanations du radium dans leur sous-sol, je sais que les enfants exposés aux « phthalates » - qu’est-ce que le phthalate? - ont un « risque élevé d’inflammation des voies respiratoires liée à l’asthme » et je sais qu’il y a une possibilité d’emploi de directeur de formation clinique en thérapie respiratoire.

Pour trouver les sources dans la page du tableau de bord de netvibes que j’ai rassemblées, j’ai cherché la thérapie respiratoire et j’ai découvert que plusieurs personnes

intéressées à la thérapie respiratoire sont intéressées aux questions de soins de santé en général, aux soins à domicile, à l’asthme et aux états connexes. J’ai donc recueilli certaines de ces sources également.

Une application ou un service d’agrégateur est un endroit pour organiser plusieurs fils RSS pour une méthode simple de syndication et chaque blogue possède un fil RSS qui lui est attaché afin que vous puissiez le télécharger dans un agrégateur tel qu’un lecteur Google. Donc, plutôt que d’avoir plusieurs signets dans votre navigateur, vous pouvez vous servir d’un agrégateur pour balayer tous les titres que vous voulez consulter sur la thérapie respiratoire ou la culture en conteneurs, ou la géologie populaire, en un seul endroit. Le tout se met à jour automatiquement pour vous.

Vous pouvez apprendre à utiliser le RSS en allant dans Google et en tapant « Google tutoriel » et en choisissant le tutoriel qui vous convient. Lorsque vous commencerez à trouver des sources, celles-ci vous mèneront à d’autres sources. Certaines seront productives, d’autres moins. Donc, à l’instar d’un bon jardinier, vous ajoutez de nouveaux légumes ou de nouvelles fleurs au fil des saisons et vous éliminez les mauvaises herbes. C’est ce qu’on appelle l’édition de contenu.

Si vous avez des questions, veuillez me les faire parvenir par courriel à l’adresse suivante : <[email protected]>. Je peux vous fournir le fichier .OPL pour la page que j’ai préparée afin que vous puissiez télécharger les sources que j’ai trouvées dans votre propre lecteur. Si vous ignorez ce que signifie .opl, allez dans Google et tapez « que signifie opml »!



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As summer comes to an end, respiratory therapy students are preparing for their upcoming journey. Getting a lot of sleep, exercise, and getting into good eating habits

in the weeks prior to September’s awaited (but nerve-racking) debut are common objectives for returning RT students and new recruits alike.

For me, the first year of the program was one of discovery. Reading about the profession and jumping into it headfirst are two very different things! Here are a few pieces of advice I collected from second- and third-year students.

• Askalotofquestions,participateinclass,andstudyinsmall groups. The program is strenuous but amazing. Stay surrounded by positivity and have fun with it!

• Donotstressoverthelittlethings.Focusonunderstanding fundamental concepts, not memorizing.

• Upperairwayanatomy:donotmixupuvulaandvulva.

• Respiratoryphysiology:memorizethealveolarairequa-tion the first time it is introduced. Flipping back through your notes all the time to find it becomes annoying.

• Pharmacology: yes, parasympatholytic, anticholinergic,and antimuscarinic mean the same thing. Instructors love to confuse you, so stay on top of it!

• Pharmacology:makeneatflashcardsofdrugcategories,trade and generic names, dosages, indications, contrain-dications, and adverse effects. These are not only great for studying, but you can carry them in your coat pocket during clinical. Do them neatly so you don’t have to redo them prior to clinical.

• Pulmonaryfunction:memorizeyourspirograph,volumes, and capacities. It will make studying much easier and will help in other courses too!

• Respiratory physiology: as much as you think you understand compliance and elastance, you do not, and you probably won’t until you start playing with ventilators (if at that). Compliance is rarely static, so your logic of it shouldn’t be either.

• Tracheostomy lab: if you pull out the outer cannulaof your dummy’s stoma by accident, do not cover the hole to hide your mistake – the instructor will be even less impressed.

• Have fun, learn with enthusiasm, practice your skills often, and get the most of your education. You’ll be a better therapist for it!

STUDENTS COLUMN

Welcome Students!

edouard Saade, Director Student Relations, CSRT Board of Directors, Saint John, New Brunswick

For second-year students like me, the prospect of starting the last didactic year is overwhelming. Great optimism meets anxiety and fear. We reflect on last year and realize just how much knowledge and skill we have gained. We are thrilled to embark on this final year of in-class learning in a field we are truly passionate about. It is exciting to think of how far we have come in such a short time. At this same time, however, many students exhibit some anxiety. The fear of not remembering the theory that was covered during the previous 10 months and the fear of the upcoming clinical practice component are major sources of anxiety. “How am I supposed to remember all of this? What is Laplace’s Law again? How do you calculate physiological deadspace? Pores of Kohn or Canals of Lambert? Chloride shift, Oxyhemoglo-bin dissociation curve, electrolyte values and compliance...” And then comes the reality that in 8 months or so, not only will we be expected to recall this information (with the additional 11 courses worth of material) but we will have to apply them to scenarios, major examinations, and, most scary of all, to actual patients. This is the bittersweet part of second year: we’re not close or competent enough to be confident about the nearing clinical component, nor are we far enough to let our guards down. It’s the constant worry of remember-ing yesterday, learning today, preparing for tomorrow, and realizing just how close we are to the practicum.

As for third-year students, their didactic days are behind them, but their studying days are far from over. With the intense cramming sessions before a particular rotation, the mid- and post-rotation exams, the clinical oral exams, and the preparation for their final program examination to contend with, 8-hour shift days are supplemented by hours and hours spent in the library. When they graduate from a strenuous 3 years of intense didactics and demanding clinical practice, they are faced with another challenge: that of writing the National Registry Exam set by the Canadian Board of Respiratory Care. If the stress of finding work and relocating (if applicable) was not great enough, they need to prepare for the biggest examination yet, the one that will award them their Registered Respiratory Therapist title. On behalf of RT students, I wish you the best of luck!

When the arduous fight to becoming a respiratory therapist is won, there lies a new and professional battle: contributing to the promotion, growth, and success of the profession. How can students become involved and make a difference prior to the completion of their programs? Firstly, they can engage their classmates and friends in promoting



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Avec la fin de l’été, les étudiants en thérapie respiratoire se préparent à leurs prochaines activités. Les anciens et nouveaux étudiants semblent poursuivre des objectifs

communs, soit dormir beaucoup, faire de l’exercice et adopter de saines habitudes alimentaires au cours des semaines de septembre qui précèdent la rentrée tant attendue, mais angoissante.

La première année du programme en était une de décou-vertes. Il existe une grande différence entre lire sur la profession et s’y lancer tête première. Voici quelques conseils que j’ai recueillis d’étudiants de deuxième et troisième années dans différents programmes.• Posez de nombreuses questions, participez en classe et

étudiez en petits groupes. Le programme est ardu, mais sensationnel. Demeurez positif et amusez-vous!

• Ne soyez pas stressé pour des riens. Concentrez vosétudes sur la compréhension des concepts fondamentaux et non sur leur mémorisation.

• Anatomie de l’appareil respiratoire supérieur : ne pasconfondre uvule et vulve.

• Physiologie respiratoire : mémorisez l’équation de l’air alvéolaire la première fois qu’on vous l’apprend. Il devient ennuyeux de toujours consulter vos notes pour la trouver.

• Pharmacologie : oui, parasympatholytique, anticholin-ergique et antimuscarinique ont la même signification. Les chargés de cours adorent vous dérouter pour rester maîtres de la situation!

• Pharmacologie : préparez des fiches de repérage des catégories de médicaments, des dénominations commerciales et génériques, des doses, des indications, des contre-indications et des effets indésirables. Ces fiches ne sont pas seulement utiles pour étudier, mais vous pouvez les ranger dans votre poche en clinique. Préparez-les avec soin une fois pour toutes et vous n’aurez pas à les recommencer avant d’aller en clinique.

• Fonctionpulmonaire:mémorisezvotrespirographe,vosvolumes et vos capacités, ce qui facilitera beaucoup vos études et qui vous aidera également dans d’autres cours!

• Physiologie respiratoire : même si vous croyez comprendre la compliance et l’élastance, tel n’est pas le cas et vous ne les comprendrez pas avant de commencer à manipuler des ventilateurs. La compliance n’est pas statique; donc votre logique à cet égard ne doit pas l’être non plus.

• Laboratoiredetrachéostomie:sivoussortezaccidentel-lement la canule extérieure de la stomie de votre manne-quin, ne recouvrez pas le trou pour cacher votre erreur. Le chargé de cours sera même moins impressionné.

• Amusez-vous, apprenez avec enthousiasme, pratiquezvos compétences souvent et tirez tout ce que vous pouvez de votre apprentissage. Vous serez ainsi un meilleur thérapeute!

Pour les étudiants de deuxième année, comme moi-même, la perspective d’entreprendre la dernière an-

CHRONIQUE DES ÉTUDIANTS

Bienvenue aux étudiants!

edouard Saadé, Directeur des relations avec les étudiants, SCTR, Collège communautaire du Nouveau-Brunswick, Saint John, Nouveau-Brunswick, Cana

Respiratory Therapists Week, which was celebrated from October 21-27, 2012. How did your program celebrate RT week? Contact me at [email protected], send me pictures of your events and continue promoting your profession with pride and enthusiasm!

Secondly, students can promote their profession and ensure its growth by solidifying relations amongst themselves, and with their national association! A Facebook page, Canadian Respiratory Therapy Students, will be launched this fall. This social medium will enable students from any Canadian respiratory therapy program to come together, discuss hot topics related to our profession, have input on things going on with their national association, discuss school-related challenges, share hilarious anecdotes, discuss travel options for clinical rotations, take part in stimulating scenarios, and much more!

Finally, I strongly encourage students to become members of the CSRT. For a one-time-only fee of $100.00, students become members of their national association for all 3 years of their program’s duration, with a bonus of one year following graduation! The benefits of being a CSRT member are worthwhile and abundant. Contact me directly or visit the website’s Membership section at http://www.csrt.com/en/membership/membership_benefits.asp for further details!

Wishing everyone a great school year and looking forward to hearing from fellow students!

Edouard Saadé




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née didactique est extraordinaire. Notre optimisme est égal à l’angoisse et à la peur. En commençant cette deuxième année, nous pensons à l’an dernier et réalisons combien de connaissances et de compétences nous avons acquises. Nous sommes ravis d’entreprendre cette dernière année d’apprentissage en classe et de continuer à acquérir des connaissances sur un domaine qui nous passionne vraiment. Il est stimulant de penser au chemin que nous avons parcouru en si peu de temps. En même temps, toutefois, de nombreux élèves ressentent une certaine angoisse. La peur de ne pas se rappeler de la théorie qui a été couverte au cours des dix derniers mois et de l’élément pratique clinique imminent sont des sources d’angoisse importantes. « Comment suis-je censé me rappeler de tout ça? Qu’est-ce que la loi de Laplace? Comment calcule-t-on l’espace mort physiologique? Les pores de Kohn ou les canaux de Lambert? Échange des ions chlore, courbe de dissociation de l’oxyhémoglobine, valeurs et conformité des électrolytes…Vient alors la dure réalité que, dans environ huit mois, non seulement devrons-nous nous souvenir de cette information (en plus du contenu de onze autres cours), mais encore aurons-nous à les mettre en application dans des scénarios, des examens importants et, ce qui est plus angoissant encore, en face de vrais patients. C’est là l’amère douceur de la deuxième année. Nous ne sommes pas assez près de l’élément clinique qui suit, ni assez compétents ou confiants pour en être enchantés, ni assez éloignés pour ne pas être sur nos gardes. Nous vivons dans l’inquiétude constante de nous rappeler d’hier, d’apprendre aujourd’hui, de nous préparer à demain et de nous rendre compte à quel point nous approchons du stage.

En ce qui a trait aux étudiants de troisième année, leurs jours didactiques sont chose du passé, mais leurs jours d’étude sont loin d’être terminés. Avec les sessions de bourrage intenses avant une rotation particulière, les examens de mi-rotation et post-rotation, les examens cliniques oraux et la préparation à l’examen du programme final, il semble qu’on ajoute à un quart de huit heures des heures et des heures à la bibliothèque. Lorsqu’ils obtiennent leur diplôme à la fin de trois années ardues d’étude intense et de pratique clinique exigeante, ils font face à un autre défi, celui de passer l’examen d’agrément national établi par le Conseil canadien des soins respiratoires. Comme si le stress lié s à la recherche d’un emploi ou à une réinstallation (le cas échéant) ne suffisait pas, ils doivent se préparer à l’examen le plus important jusqu’à maintenant, soit celui qui leur conférera le titre de thérapeute respiratoire agréé. Au nom des étudiants en TR, je vous souhaite bonne chance!

Lorsque la bataille ardue pour devenir un thérapeute respiratoire est gagnée, il reste une bataille nouvelle et professionnelle, soit celle de contribuer à la promotion, à la croissance et à la réussite de la profession. Comment les étudiants peuvent-ils participer et changer les choses avant de terminer leurs programmes? Premièrement, en invitant leurs condisciples et leurs amis à promouvoir la Semaine des thérapeutes respiratoires que nous avons célébrée du 21 au 27 octobre 2012. J’encourage les étudiants à me faire part de ce qu’ils ont fait et à m’envoyer des photos de leur événements afin qu’ils puissent être affichés sur notre site Web! On peut communiquer avec moi à l’adresse qui figure sur le site Web suivant : http://www.csrt.com/fr/about/board_directors.asp et j’ai hâte d’entendre parler de mes condisciples!

Deuxièmement les étudiants peuvent promouvoir leur profession et veiller à sa croissance en raffermissant les relations entre eux et avec leur association nationale! Une page Facebook, sera lancée cet automne! Ce média social permettra à tous les étudiants d’un programme de thérapie respiratoire canadien de se rassembler, de discuter de sujets brûlants liés à notre profession, de commenter ce qui se passe dans leur association nationale, de discuter des défis relatifs aux études, d’échanger des anecdotes amusantes, de discuter de possibilités de voyages pour des rotations cliniques, de participer à des scénarios stimulants, etc. !

Enfin, j’encourage fortement les étudiants à devenir membres de la SCTR. Pour une cotisation unique de 100 $, les élèves deviennent membres de leur association nationale pour toute la durée de leur programme de trois ans, avec une prime d’un an après l’obtention de leur diplôme! Les avantages de l’adhésion à la SCTR sont appréciables et nombreux! Communiquez avec moi directement ou consultez le site Web suivant : http://www.csrt.com/fr/membership/membership_benefits.asp pour obtenir des renseignements supplémentaires!

Je vous souhaite une très belle année scolaire et j’espère recevoir des nouvelles de mes coéquipiers!



27

Clinical simulation is an instructional medium that is increasingly being used in the education of healthcare students and professionals. As educators, we seek to provide our learners with the opportunity to apply skills and competencies in the context of the clinical environment. This enhances practitioners’ ability to perform clinical skills and to respond appropriately to critical events in the clinical setting. The ability of the learners to function in the clinical environment is an important objective in simulation [1].

In simulated clinical immersion, a case scenario is created and then managed in an actual clinical environment or in an environment which replicates as closely as possible a realistic clinical setting. During a simulation, the concept of environment includes not only the physical space, but also the equipment, peers, other members of the healthcare team, and any other individuals likely to assist in reproducing the desired setting [2]. For instance, if you were providing asthma education to a child in an outpatient clinic, it would be logical to have a parent or guardian present with the child.

Simulation laboratories are built to look (from the learner’s perspective) like a typical clinical setting. Many labs have a variety of rooms that can be configured in different ways for different purposes. A room might represent a ward room one day, and a bay in the emergency department the next. It is therefore the way we set-up the room and the equipment we make available that “sets the stage.”

Almost all schools involved in training the healthcare professions have space that is designed for and dedicated to clinical simulation. Many hospitals are beginning to invest in space for clinical simulation to support the orientation and ongoing training of their staff and physicians. In actual clinical settings, in-situ simulation is also a favorable venue for simulation-based learning [3,4]. In-situ simulation is simulation that is conducted in the actual clinical setting with the actual people who work in that setting. Instead of replicating an emergency department, you conduct simulation in an actual emergency department. In-situ simulation has significant advantages to learners, including such things as the realistic layout of the room/space, the equipment available, and the presence of the actual care team for that environment. Although in-situ simulation can be hard to coordinate based on patient and bed availability, the gains are well worth the effort.

EDUCATORS’ COLUMN

Clinical Simulation: Designing Scenarios and Implementing Debriefing Strategies to Maximize Team Development and Student Training

Kevin g. Middleton, BSc, rrt,

Clinical Outreach Specialist, Simulation and Outreach program, McMaster Children’s Hospital, Hamilton ON; and Clinical Coordinator – Respiratory Therapy, The Michener Institute for Applied Health Sciences, Toronto, Ontario, Canada

planning and Conducting Simulation for Maximal Gain

Simulation is most effective when it is carefully planned and conducted. Planning and conducting simulation involves a three-step process, including: (1) developing the learning objectives, (2) creating a case to simulate, and (3) running the simulation.

Developing Learning ObjectivesIn developing learning objectives for simulation, it is

best to select three or four main objectives to be addressed. As you determine the learning objectives for a case, consider the terminal objectives as well as enabling objectives. Learning objectives in simulation-based activities often include clinical skills and knowledge, communication skills, and behavioural competencies [5].

Creating a Case Scenario Often, the best cases come from real-life cases [4]. Case

scenarios do not need to be complex in order to provide rich learning opportunities. There can be many things to consider when designing a case scenario, but in general, these can be reduced to ten core considerations [6], including:

1. The level of the learners

2. The learning objectives and/or competencies that you have selected

3. The clinical setting in which the case will occur

4. The players, including peers, other members of the healthcare team, and other individuals who will play a role (i.e., a spouse, significant other, parents of a child)

5. The case – the patient, their clinical condition, their presentation

6. Key “take home” message(s)

7. The case narrative

8. Teaching strategies

9. The method of evaluation/assessment that will be used (is there a checklist or other tool that would be appropriate?)

10. Identifying debriefing strategies or debriefing points.



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Running the SimulationTo us as educators, our simulations are usually referred

to as “scenarios,” but we should always present them to the learner as “cases to be managed.” As the case runs, we are observing for gaps in performance [7]. In other words, we are observing for mismatch between desired performance and actual performance.

As the scenario unfolds, it is important to monitor the stress level of the participants. The intensity of the scenario should maintain an optimal level of stress. Stressing participants appropriately is good, as it enhances learning and it is often more true to clinical practice [8]. Imposing an appropriate level of stress on participants is favourable; however, care must be taken to avoid distress, which ultimately will detract from our goal.

Once the simulation is complete, it is helpful to record any last notes, quickly gather our thoughts, and head into the debriefing session.

Debriefing“Debriefing is a conversation between two or more

people to review a real or simulated event in which particip ants analyze their actions and reflect on the role of their thought processes, psychomotor skills, and emotional states to improve or sustain performance in the future [6].” The three phases of objective-oriented debriefing involve: (1) exploring reactions and discussing facts, (2) the understanding phase, and (3) summarizing.

Exploring Reactions and Discussing FactsThe first phase in the debriefing process involves

exploring the participants’ reactions to the simulation. This involves briefly identifying the participants’ feelings or emotional state. The act of verbalizing frustration, disappointment, stress, and similar feelings can greatly help in defusing such feelings, and can be helpful in clearing the air and setting the stage for meaningful discussion [5,7]. Following the feelings stage, it is useful to lay out basic facts about the case that has just been simulated. Reviewing these basic facts facilitates having all participants “on the same page” as discussion goes forward.

Understanding PhaseDuring this phase, we as the debriefer seek to explore

the learner’s perspective on the events of the scenario. Results are the product of actions. Actions are the product of mental “frames,” or cognitive windows that we have. During clinical immersion, as an observer, we can witness the actions that took place and the results of those actions, but we cannot see the frames that lead to those actions (or more often, inactions) [7,9]. Never assume that you know what a learner’s frames are. Frames are constructed from a variety of factors includ-ing our assumptions, our feelings, goals that we have, rules as we understand them, our knowledge base, situational aware-ness, and the influence of context. Ultimately, if we can iden-

tify a learner’s frame through exploration, we can then help to move learners to new perspectives, new understandings, and new skills.

Frames are best explored through an approach of advocacy and inquiry [9]. Advocacy is the use of a statement that reflects your perspective. Advocacy involves making a statement of observation, followed by a statement of concern or appreciation, such as the following:

• Inoticedthat...• Iobserved...• Isaw...

• Iamconcernedbecause...• Ithoughtthatwasgoodbecause...

Immediately following our statements of advocacy, we should make our inquiry. Inquiry is the use of short, open-ended questions to reveal the learners’ perspective. Inquiry involves posing questions aimed at exploring the participants’ thought processes. Examples of inquiry include:

• I’mwonderingwhatwasonyourmindatthetime?• Whatwereyourthoughts?• Whatwasgoingthroughyourmind?• Howdoyouseeit?

Once the learners’ frames have been identified, it is now our goal to try to adjust existing frames or create new ones. This is accomplished through discussion, teaching, and generalization.

Summarizing PhaseDuring the summary phase of debriefing, your goal is to

clearly distill lessons learned for future use by the learner [7]. This involves discussing:

• Whatworkedwell?• Whatshouldbechangednexttime?• Major“take-aways.”

The Goals of a DebrieferDuring debriefing, our aim is to see through the learner’s

mind’s eye. We hope to establish a context for learning and change. As well, we hope to provide information, motivation, and applications for change. As an ultimate outcome, we certainly hope to link what has been learned in the simulation to the “real world.”

Studies have shown that following simulated clinical experiences, learners frequently fail to independently recognize/identify the richest learning outcomes from the experience. Thus, reflection on learning events is a key piece of experiential learning [2,3,10]. Most experts recommend planning for debriefing time to last 2 to 3 times longer than the length of the scenario [4]. By addressing shortcomings and formulating solutions, our overall ability to talk about difficult topics is also strengthened through debriefing.

Simulation continues to show us its value in enhancing practitioners’ ability to perform clinical skills and respond



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CHRONIQUE DES ENSEIGNANTS

Simulation clinique : concevoir des scénarios et mettre en oeuvre des stratégies de débriefing afin de maximiser l’établissement d’une équipe et la formation des étudiants

Kevin g. Middleton, B. Sc., t.r.a.

Clinical Outreach Specialist, programme de simulation et de sensibilisation, McMaster Children’s Hospital, Hamilton, Ont.

Coordonnateur clinique – Thérapie respiratoire, Michener Institute for Applied Health Sciences, Toronto, Ont.

La simulation est une méthode didactique qui est de plus en plus utilisée dans la formation des professionnels de la santé, étudiants et membres du personnel. La simulation continue de nous démontrer sa valeur dans l’amélioration de la capacité des praticiens d’utiliser leurs compétences cliniques et de réagir adéquatement aux événements critiques en milieu clinique.

Dans une immersion clinique simulée, une histoire de cas est créée puis gérée dans un environnement clinique réel ou dans un environnement qui reproduit le plus possible un milieu clinique réaliste.

L’immersion dans un contexte clinique est un aspect critique. En tant que formateurs, nous cherchons à fournir à nos apprenants l’occasion de mettre en application leurs connaissances et leurs compétences dans le contexte de l’environnement clinique où ils en auront besoin. La capacité des apprenants de fonctionner dans l’environnement clinique est un important objectif dans une simulation [1].

Pendant une simulation, le concept d’environnement comprend non seulement l’espace physique, mais aussi le matériel, les pairs, d’autres membres de l’équipe des soins de santé et d’autres personnes susceptibles d’aider à reproduire le milieu souhaité [2]. À titre d’exemple, si vous étiez en train de renseigner un enfant sur l’asthme dans une clinique externe, il se-rait logique qu’un parent ou un tuteur soit présent avec l’enfant.

Les laboratoires de simulation sont construits pour ressem-bler à un milieu clinique type (du point de vue de l’apprenant).

De nombreux laboratoires ont diverses pièces qui peuvent être configurées de différentes façons à des fins différentes. Une pièce peut représenter une chambre un jour et une cellule dans une salle d’urgence le lendemain. Par conséquent, la façon dont on dispose la pièce et le matériel qu’on y rend disponible réunissent des conditions propices.

La plupart des écoles qui participent à la formation des pro-fessions de la santé disposent d’un espace qui est conçu pour la simulation clinique et qui lui est réservé. De nombreux hôpitaux commencent à investir dans de l’espace destiné à la simulation clinique afin d’appuyer l’orientation et la formation continue de leur personnel et de leurs médecins. Dans les milieux cliniques réels, la simulation in situ est également une méthode favorable à l’apprentissage axé sur la simulation [3,4].

La simulation in situ est menée dans le milieu clinique réel avec les personnes qui y travaillent. Plutôt que de reproduire un service d’urgence, on effectue une simulation dans le service d’urgence réel. La simulation in situ offre des avantages importants pour les apprenants, dont l’aménagement réel de la pièce et de l’espace, le matériel disponible et la présence de l’équipe de soins réelle pour cet environnement. Bien que la simulation in situ puisse être difficile à coordonner en fonction de l’acuité des patients et de la disponibilité des lits, les gains valent bien l’effort déployé.

appropriately to critical events in the clinical setting. By properly designing case scenarios and implementing optimal debriefing strategies, we are able to maximize the gains for our learners. Simulation is a powerful and effective instructional medium for team development and student training.

REFERENCES

1. Birkhoff SD, Donner C. Enhancing pediatric clinical compe-tency with high-fidelity simulation. J Contin Educ Nurs. 2010; 41(9):418-423.

2. Rudolph JW, Simon R, Raemer DB. Which reality matters? Ques-tions on the path to high engagement in healthcare simulation. Simulation in Healthcare. 2007;2:161-163.

3. Miller KK, Riley W, Davis S, Hansen H.E. In Situ Simulation: A method of experiential learning to promote safety and team behav-ior. J Perinat Neonat Nurs. 2008;22(2):105-113.

4. Kyle RR, Murray WB, editors. Clinical simulation: operations, engineering and management. Academic Press: Boston; 2008.

5. Arafeh J, Hansen, SS, Nichols, A. Debriefing in simulation-based learning: facilitating a reflective discussion. J Perinat Neonat Nurs. 2010;24(4):302-309.

6. The Center for Medical Simulation. Institute for Medical Simula-tion Comprehensive Instructor Workshop Participant Resources, Cambridge, MA, 2012.

7. Rudolph JW, Simon R, Raemer DB, Eppich W J. Debriefing as for-mative assessment: closing performance gaps in medical education. Acad Emerg Med. 2008;15:1010–1016.

8. Russell, J. A circumplex model of affect. J Pers Soc Psychol. 1980;39:1161-1178.

9. Rudolph JW, Simon R, Dufresne RL, Raemer DB. There’s no such thing as a non-judgmental debriefing: a theory and method for de-briefing with good judgment. Simulation in Healthcare. 2006;1:49-55.

10. Kolb DA. Experiential learning: experience as the source of learning and development. Prentice-Hall Inc: Englewood Cliffs, NJ, 1984.




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planification et réalisation d’une simulation pour un gain maximal

La simulation est plus efficace lorsqu’elle est planifiée et menée avec soin, ce qui comporte un processus en trois étapes, dont : 1) l’élaboration des objectifs d’apprentissage, 2) la création d’un cas à simuler et 3) la réalisation de la simulation.

Élaboration des objectifs d’apprentissageEn élaborant les objectifs d’apprentissage d’une simulation,

il est préférable de choisir trois ou quatre objectifs principaux à aborder. Lorsque vous déterminez les objectifs d’apprentissage pour un cas, analysez les objectifs terminaux ainsi que les objec-tifs de base.

Les objectifs d’apprentissage dans les activités axées sur la simulation comprennent souvent : 1) les compétences et les con-naissances cliniques, 2) les aptitudes à communiquer, 3) les com-pétences comportementales [5].

Création d’un scénario de cas Souvent, les meilleurs cas sont tirés de cas de la vie réelle

[4]. Ces scénarios n’ont pas à être complexes afin de fournir des occasions d’apprentissage très intéressantes.

En concevant un scénario de cas, on peut prendre plusieurs aspects en considération, mais en général, on peut se limiter à dix considérations importantes [6], dont :

1) le niveau des apprenants

2) les objectifs d’apprentissage ou les compétences que vous avez choisies

3) le milieu clinique dans lequel le cas se déroulera

4) les joueurs, dont les pairs, d’autres membres de l’équipe de soins de santé et d’autres personnes qui joueront un rôle (c.-à-d. un conjoint, un proche, les parents d’un enfant)

5) le cas – le patient, son état clinique, son aspect

6) le(s) message(s) à retenir

7) l’exposé du cas

8) les stratégies d’enseignement

9) la méthode d’évaluation qui sera utilisée. Existe-t-il une liste de vérification ou un autre outil qui serait approprié?

10) la détermination des stratégies de débriefing ou les points de débriefing

Réalisation de la simulationPour nous, en tant que formateurs, nos simulations sont

habituellement appelées des « scénarios », mais nous devrions toujours les présenter à l’apprenant comme des « cas à gérer ».

Pendant le déroulement du cas, nous observons des lacunes en matière de rendement [7]. Autrement dit, nous observons la disparité entre le rendement souhaité et le rendement réel.

À mesure que le scénario se déroule, il est important de surveiller le niveau de stress des participants et de doser l’intensité du scénario afin de maintenir un niveau optimal de stress. Il est bon de stresser les participants étant donné que cela améliore l’apprentissage et qu’il est plus conforme à la pratique clinique [8]. L’imposition d’un niveau de stress approprié aux participants est favorable. Cependant, on doit éviter la détresse qui détourne en dernier ressort de l’objectif.

Lorsque la simulation est terminée, il est utile d’inscrire les dernières notes, de se concentrer rapidement et de passer à la séance de débriefing.

Débriefing« Le débriefing est une conversation entre au moins deux

personnes afin d’examiner un événement réel ou simulé par laquelle les participants analysent leurs actions et réfléchissent au rôle de leurs processus mentaux, de leurs habiletés psychomo-trices et de leur état émotif afin d’améliorer ou de maintenir le rendement dans l’avenir [6]. »

Les trois étapes d’un débriefing axé sur les objectifsLes trois étapes d’un débriefing axé sur les objectifs

comportent : 1) l’analyse des réactions et la discussion des faits, 2) la compréhension et 3) la récapitulation.

Analyse des réactions et discussion des faitsLa première étape du processus de débriefing comporte

l’analyse des réactions des participants à la simulation. Cette analyse consiste à établir brièvement les sentiments ou

l’état émotif des participants. Le fait de verbaliser sa frustration, son stress et des sentiments semblables, peut aider considérable-ment à désamorcer de telles sensations, à détendre l’atmosphère et à ouvrir la voie à une discussion significative [5,7].

Après cette étape, il est utile d’établir les faits de base du cas qui vient d’être simulé. Grâce à l’examen de ces faits, il est plus facile pour tous les participants d’être sur la même longueur d’onde pendant la discussion.

CompréhensionPendant cette étape, en qualité de responsables du débrief-

ing, nous cherchons à analyser le point de vue de l’apprenant sur les événements du scénario.

Les résultats sont le fruit des actions, et ces dernières sont le produit de l’état d’esprit ou des « fenêtres cognitives » que nous avons. Pendant l’immersion clinique, en tant qu’observateur, nous pouvons constater les actions qui ont eu lieu et leurs résultats, mains nous ne pouvons pas voir les cadres qui ont mené à ces actions (ou plus souvent, aux inactions) [7,9]. Ne présumez jamais que vous connaissez les cadres d’un apprenant.

Nos cadres sont construits à partir de divers facteurs, dont nos hypothèses, nos impressions, nos objectifs, nos règles, telles que nous les comprenons, notre base de connaissances, notre connaissance de la situation et l’influence du contexte.

En fin de compte, si nous pouvons déceler le cadre d’un apprenant à l’aide d’une analyse, nous pouvons alors orienter les apprenants vers de nouvelles perspectives, de nouvelles compréhensions et de nouvelles compétences.



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Analyse des cadres Les cadres sont mieux analysés à l’aide d’un énoncé et d’une

étude, c’est-à-dire une recherche de données [9].L’utilisation d’un énoncé reflète un point de vue. C’est une

observation suivie d’une préoccupation ou d’une appréciation.

• J’airemarquéque...• J’aiconstatéque...• J’aivu...• Jesuispréoccupéparceque... • J’aipenséquec’étaitbonparceque...

Immédiatement après nos énoncés, nous devrions faire notre recherche d’information. Il s’agit de l’utilisation de questions courtes et ouvertes afin de révéler le point de vue de l’apprenant. La recherche de données comporte des questions visant à analyser les processus mentaux des apprenants.

Voici quelques exemples de recherche d’information :• Jemedemandeceàquoitupensaisalors?• Quellesétaienttespensées?• Àquoipensais-tu?

Une fois que les cadres des apprenants ont été établis, notre objectif consiste maintenant à essayer d’harmoniser les cadres existants ou à en créer de nouveaux, à l’aide d’une discussion, d’enseignement et de généralisation.

Récapitulation

Pendant l’étape de récapitulation du débriefing, votre objectif consiste à extraire clairement les leçons apprises que l’apprenant pourra utiliser [7].

Pour ce faire, la discussion porte sur ce qui suit : • Qu’est-cequiabienfonctionné?• Quefaut-ilchangerlaprochainefois?• Principauxélémentsàéliminer

Les objectifs d’un responsable du débriefingPendant le débriefing, notre but consiste à percevoir

les choses du point de vue de l’apprenant. Nous espérons établir un contexte pour l’apprentissage et le changement. De même, nous espérons fournir l’information, la motivation et les applications nécessaires au changement. Et, comme résultat final, nous espérons certainement relier ce qui a été appris dans la simulation au monde concret.

Des études ont révélé qu’en observant les expériences cliniques simulées, les apprenants n’arrivent pas souvent à reconnaître ou à déceler indépendamment les résultats d’apprentissage les plus intéressants tirés de cette expérience. Ainsi, la réflexion sur les événements d’apprentissage est un élément clé de l’apprentissage expérientiel [2,3,10]. La plupart des spécialistes recommandent de prévoir que le débriefing dure de deux à trois fois plus longtemps que le scénario [4].

En comblant les lacunes et en formulant des solutions, notre capacité globale d’aborder des sujets difficiles est également renforcée grâce au débriefing.

La simulation continue de nous révéler sa valeur pour améliorer la capacité des praticiens à utiliser leurs compétences cliniques et à réagir de façon appropriée à des événements critiques dans le milieu clinique. En concevant adéquatement les scénarios des cas et en mettant en œuvre des stratégies de débriefing optimales, nous pouvons maximiser les gains de nos apprenants. La simulation est une méthode éducative puissante et efficace pour la croissance d’une équipe et la formation des étudiants.

RÉFÉRENCES

1. Birkhoff, S.D. et Donner, C. Enhancing Pediatricx Clinical Competency with High-Fidelity Simulation. J Contin Educ Nurs, 2010; 41(9): 418-423.

2. Rudolph, J. W., Simon, R., et Raemer, D. B. Which Reality Matters? Questions on the Path to high Engagement in healthcare Simulation. Simulation in Healthcare, 2007; 2:161-163.

3. Miller, K.K, Riley, W, Davis, S, Hansen, H.E. In Situ Simulation: A method of experiential learning to promote safety and team behavior. J Perinat Neonat Nurs, 2008;22(2): 105-113.

4. Kyle, R.R et Murray, W.B, editors. Clinical Simulation: Operations, Engineering and Management. Academic Press: Boston, 2008.

5. Arafeh, J. et al. Debriefing in simulation-Based Learning: Facilitating a Reflective Discussion. J Perinat Neonat Nurs. 2010; 24 (4): 302-309.

6. The Center for Medical Simulation. Institute for Medical Simulation Comprehensive Instructor Workshop Participant Resources, Cambridge, MA, 2012.

7. Rudolph, J. W., Simon, R., Raemer, D. B. and Eppich, W. J. Debriefing as Formative Assessment: Closing Performance Gaps in Medical Education. Academic Emergency Medicine, 2008;15: 1010–1016.

8. Russell, J. A circumplex model of affect. Journal of Personality and Social Psychology, 1980;39:1161-1178.

9. Rudolph, J. W., Simon, R., Dufresne R.L. et Raemer, D. B. There’s No Such Thing as a ”Non-Judgmental Debriefing: a Theory and Method for Debriefing With Good Judgment. Simulation in Healthcare, 2006;1:49-55.

10. Kolb, D.A. Experiential Learning: Experience as The Source of Learning and Development. Prentice-Hall Inc: Englewood Cliffs, NJ, 1984.



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Misrepresentation of randomized controlled trials in Press releases and News coverage: A cohort Study

Amélie Yavchitz1,2,3, Isabelle Boutron1,2,3*, Aida Bafeta1,2,3, Ibrahim Marroun4, Pierre Charles4, Jean Mantz5,

Philippe Ravaud1,2,3

1 INSERM, U738, paris, France, 2 Centre d’Épidémiologie Clinique, Ap-Hp (Assistance publique des Hôpitaux de

paris), Hôpital Hôtel Dieu, paris, France, 3 Université paris Descartes, Sorbonne paris Cité, Faculté de Médecine, paris,

France, 4 Department of Internal Medicine, Hôpital Foch, Suresnes, France, 5 Department of Anesthesiology and Critical Care, Beaujon University Hospital, Clichy, France

Featured in PLOS Clinical Trials

BACkGROUNDPrevious studies indicate that in published reports, trial results can be distorted by the use of “spin” (specific reporting strategies, intentional or unintentional, emphasizing the beneficial effect of the experimental treatment). We aimed to (1) evaluate the presence of “spin” in press releases and associated media coverage; and (2) evaluate whether findings of randomized controlled trials (RCTs) based on press releases and media coverage are misinterpreted.

METHODS AND FINDINGS We systematically searched for all press re leases indexed in the EurekAlert! database between December 2009 and March 2010. Of the 498 press releases retrieved and screened, we included press releases for all two-arm, parallel-group RCTs (n = 70). We obtained a copy of the scientific article to which the press release related and we systematically searched for related news items using Lexis Nexis.

“Spin,” defined as specific reporting strategies (inten-tional or unintentional) emphasizing the beneficial effect of the experimental treatment, was identified in 28 (40%) scientific article abstract conclusions and in 33 (47%) press releases. From bivariate and multivariable analysis assessing the journal type, funding source, sample size, type of treat-ment (drug or other), results of the primary outcomes (all nonstatistically significant versus other), author of the press release, and the presence of “spin” in the abstract conclusion, the only factor associated, with “spin” in the press release was “spin” in the article abstract conclusions (relative risk [RR] 5.6, [95% CI 2.8–11.1], p<0.001). Findings of RCTs based on press releases were overestimated for 19 (27%) reports. News items were identified for 41 RCTs; 21 (51%) were reported with “spin,” mainly the same type of “spin” as those identified in the press release and article abstract conclusion. Findings of RCTs based on the news item was overestimated for ten (24%) reports.

CONCLUSION“Spin” was identified in about half of press releases and media coverage. In multivariable analysis, the main factor associated with “spin” in press releases was the presence of “spin” in the article abstract conclusion.

A low resting heart rate at diagnosis predicts favourable long-term outcome in pulmonary

arterial and chronic thromboembolic pulmonary hy-pertension. A prospective observational study

Florian F Hildenbrand, Ivan Fauchère, Lars C Huber, Stephan Keusch, Rudolf Speich and Silvia Ulrich Respiratory Research 2012, 13:76 doi:10.1186/

1465-9921-13-76

Published: 3 September 2012

ABSTRACT (pROvISIONAL) BACkGROUND

A low resting heart rate (HR) is prognostically favourable in healthy individuals and in patients with left heart disease. In this study we investigated the impact of HR at diagnosis on long-term outcome in patients with differently classified precapillary pulmonary hypertension (pPH).

METHODSpPH patients diagnosed as pulmonary arterial (PAH) or inoperable chronic thromboembolic pulmonary hypertension (CTEPH) were registered and regularly followed at our centre Baseline characteristics and events defined as either death or lung transplantation were noted. The prognostic value of HR was analysed using Kaplan Meier estimates, live tables and Cox regression.

RESULTS206 patients with PAH (148) and inoperable CTEPH (58) were included. The median HR was 82 bpm. pPH with a HR below 82 bpm had a significantly longer overall event-free survival (2409 vs.1332 days, p = .000). This advantage was similarly found if PAH and CTEPH were analysed separately. Although a lower HR was associated with a better hemodynamic and functional class, HR was a strong and independent prognostic marker for transplant free survival even if corrected for age, sex, hemodynamics and functional status.

CONCLUSIONWe show that resting HR at diagnosis is a strong and independent long-term prognostic marker in PAH and CTEPH. Whether reducing HR by pharmacological agents would improve outcome in pPH has to be assessed by future trials with high attention to safety.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

ABSTRACTS



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How air pollution influences clinical management of respiratory diseases. A case-crossover study in Milan

Pierachille Santus, Antonio Russo, Enzo Madonini, Luigi Allegra, Francesco Blasi, Stefano Centanni, Antonio Miadonna, Gianfranco Schiraldi and Sandro Amaducci

Respiratory Research 2012, 13:95 doi: 10.1186/1465-9921-13-95

Published: 18 October 2012


Environmental pollution is a known risk factor for multiple diseases and furthermore increases rate of hospitalisations. We investigated the correlation between emergency room admissions (ERAs) of the general population for respira-tory diseases and the environmental pollutant levels in Milan, a metropolis in northern Italy.

METHODSWe collected data from 45770 ERAs for respiratory diseases. A time-stratified case-crossover design was used to investigate the association between air pollution levels and ERAs for acute respiratory conditions. The effects of air pollutants were investigated at lag 0 to lag 5, lag 0--2 and lag 3--5 in both single and multi-pollutant models, adjusted for daily weather variables.

RESULTSAn increase in ozone (O3) levels at lag 3--5 was associat-ed with a 78% increase in the number of ERAs for asthma, especially during the warm season. Exposure to carbon monoxide (CO) proved to be a risk factor for pneumonia at lag 0--2 and in the warm season increased the risk of ERA by 66%. A significant association was found between ERAs for COPD exacerbation and levels of sulphur dioxide (SO2), CO, nitrate dioxide (NO2), and particulate matter (PM10 and PM2.5). The multipollutant model that includes all pollutants showed a significant association between CO (26%) and ERA for upper respiratory tract diseases at lag 0--2. For chronic obstructive pulmonary disease (COPD) exacerba-tions, only CO (OR 1.19) showed a significant association.

CONCLUSIONSExposure to environmental pollution, even at typical low levels, can increase the risk of ERA for acute respiratory diseases and exacerbation of obstructive lung diseases in the general population.

A gene expression signature of emphysema-related lung destruction and its

reversal by the tripeptide gHK

Joshua D Campbell, John E McDonough, Julie E Zeskind, Tillie L Hackett, Dmitri V Pechkovsky, Corry-Anke Brandsma,

Masaru Suzuki, John V Gosselink, Gang Liu, Yuriy O Alekseyev, Ji Xiao, Xiaohui Zhang, Shizu Hayashi,

Joel D Cooper, Wim Timens, Dirkje S Postma, Darryl A Knight, Marc E Lenburg, James C Hogg and Avrum Spira

Genome Medicine 2012, 4:67 doi:10.1186/gm367

Published: 31 August 2012


Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease consisting of emphysema, small airway obstruction, and/or chronic bronchitis that results in significant loss of lung function over time.

METHODSIn order to gain insights into the molecular pathways under-lying progression of emphysema and explore computational strategies for identifying COPD therapeutics, we profiled gene expression in lung tissue samples obtained from regions within the same lung with varying amounts of emphyse-matous destruction from smokers with COPD (8 regions x 8 lungs = 64 samples). Regional emphysema severity was quantified in each tissue sample using the mean linear intercept (Lm) between alveolar walls from micro-CT scans.

RESULTSWe identified 127 genes whose expression levels were significantly associated with regional emphysema severity while controlling for gene expression differences between individuals. Genes increasing in expression with increasing emphysematous destruction included those involved in inflammation, such as the B-cell receptor signaling pathway, while genes decreasing in expression were enriched in tissue repair processes, including the transforming growth factor beta (TGF beta) pathway, actin organization, and integrin signaling. We found concordant differential expression of these emphysema severity-associated genes in four cross-sectional studies of COPD. Using the Connectivity Map, we identified GHK as a compound that can reverse the gene-expression signature associated with emphysematous destruction and induce expression patterns consistent with TGF beta pathway activation. Treatment of human fibroblasts with GHK recapitulated TGF beta-induced gene-expression patterns, led to the organization of the actin cytoskeleton, and elevated the expression of integrin beta1. Furthermore, addition of GHK or TGF beta restored collagen I contraction and remodeling by fibroblasts derived from COPD lungs compared to fibroblasts from former smokers without COPD.

CONCLUSIONSThese results demonstrate that gene-expression changes associ-ated with regional emphysema severity within an individual’s lung can provide insights into emphysema pathogenesis and identify novel therapeutic opportunities for this deadly disease. They also suggest the need for additional studies to examine the mechanisms by which TGF beta and GHK each reverse the gene-expression signature of emphysematous destruction and the effects of this reversal on disease progression.



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