Ratings of the performances of practicing internists by hospital-based registered nurses

PURPOSE: To examine the feasibility and reliability of ratings completed by hospital-based registered nurses of the humanistic qualities, communication skills, and selected aspects of the clinical skills of practicing internists. METHOD: In 1988-1989, registered nurses who worked in the same 175 hospitals as 232 internists with admitting privileges at these hospitals rated the internists' performances. The nurses were selected from medicine floors, specialty floors, and intensive care units and/or critical care units, using lists provided by head nurses. A total of 1,877 rating questionnaires with 13 performance categories were collected (with a mean of 8.01 nurses per internist). The ratings were analyzed to determine measurement characteristics and the relationships of the nurses' demographic characteristics to the ratings. In addition, for each of ten performance categories for 152 of the internists, the average rating each internist received from nurses was compared with the average rating each internist received from peer physicians. Statistical analysis used Pearson correlations, canonical correlations, factor analyses, Student's t-tests, analysis of variance, and stepwise multiple regression. Finally, the internists themselves, including physicians who were not actually rated by the nurses, were asked to complete a brief questionnaire that included questions about their opinions of the use of nurses' ratings. RESULTS: The nurses' ratings correlated moderately strongly with the peer physicians' ratings and had a common structure. However, the nurses' ratings were lower for several humanistic qualities, including respect, integrity, and responsibility, and their ratings were higher for medical knowledge and verbal communications. Across the 13 performance categories, approximately 10-15 ratings from nurses were needed to obtain a reliable assessment of an internist's humanistic qualities and communication skills. Many internists felt that nurses' ratings should be used equally with, or at least as a lesser contribution to, ratings by peer physicians of humanistic qualities and communication skills. CONCLUSION: Nurses' ratings appear to provide a feasible and reliable method of evaluating the internists' communication skills and humanistic qualities, when used in conjunction with ratings by peer physicians.     

Attention, attraction, and individual differences in reaction to criticism.

82 female undergraduates were classified as repressors or sensitizers (by scores on the Repression-Sensitization Scale) and led to expect either some future interaction or no future interaction with negative and positive evaluators. It was predicted that repressors would avoid attending to negative evaluators when no future interaction was anticipated more than sensitizers would, but that the groups would not differ when interaction was anticipated. This first prediction was not confirmed: The negative evaluator received more attention than the positive evaluator across all conditions. It was also predicted that repressors would react more positively to the negative evaluator than sensitizers when there was a prospect of future interaction, but that repressors would react less positively to the negative evaluator than sensitizers when there was no prospect of future interaction. This prediction was confirmed. Utility and individual differences in perception processes are discussed. (34 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinician variation in findings of competence to stand trial.

Are some forensic evaluators more likely than others to find criminal defendants incompetent to stand trial (IST)? Although studies report aggregate IST rates of around 20% across large samples of criminal defendants, these aggregate rates tell us little about the patterns of findings among individual evaluators. This study uses 2 statewide samples to present the first available data addressing how individual clinicians vary in rates of IST opinions. Across 60 clinicians who conducted a combined total of more than 7,000 evaluations, the rates of IST findings varied considerably (range: 0% to 62%). Results suggested that some of the variability across evaluators may be attributable to the evaluator's discipline and how the evaluator considered the relationship between competence and psychosis. However, these findings raise questions about the many other evaluator, system, and policy-level characteristics that may influence evaluator variability. Thus, we suggest a research agenda that may better identify explanations for some of the variability in IST findings across evaluators. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree?

BACKGROUND: The complex environment and technology of intensive care unit (ICU) care may impair the ability of patients to participate in medical decision making or give informed consent. We studied the agreement of the intuitive assessments of residents and nurses of ICU patients' cognition, judgment, and decision-making capacity, and whether those assessments agreed with abbreviated formal mental status testing. METHODS: Using a prospective survey case study, we assessed 200 English-speaking patients within 24 hours of their ICU admission. Formal assessment of cognition, judgment, and insight was performed by a research assistant. We obtained independent intuitive ratings by nurses and residents of patient cognition, judgment, and ability to participate in medical decision making or give informed consent. RESULTS: Residents' and nurses' assessment of cognition and judgment showed a high degree of agreement with weighted ks of greater than 0.76. Assessments of cognition by residents and nurses agreed with Folstein Mini-Mental State Examination in 70% and 73.6% of cases, respectively. Forty percent of the population had an unimpaired Mini-Mental State Examination score of greater than 23, and an additional 12% of the subjects were mildly impaired with scores of 20 to 23. When asked whether they would approach patient or family for consent for an invasive procedure, nurses and physicians said they would request informed consent from 66% and 62% of the patients, respectively. CONCLUSIONS: Residents and nurses caring for patients newly admitted to the ICU agree in their assessment of cognition, judgment, and capacity to participate in medical decision making, and are not unduly influenced by ventilator status. Their assessments correlate highly with abbreviated formal mental status testing.     

Generation II knee bracing for severe medial compartment osteoarthritis of the knee

OBJECTIVE: The tolerability of clonazepam in geropsychiatric inpatients was examined in patients with and without a diagnosis of dementia. DESIGN: Forward-looking retrospective study comprising consecutive patients placed on clonazepam. SETTING: A geropsychiatry unit of a large Veterans Affairs Medical Center. PATIENTS: All geropsychiatry inpatients placed on clonazepam over a 21-month period of time. MEASURE: Mini-Mental State Examination, Brief Psychiatric Rating Scale, Cohen-Mansfield Agitation Inventory and the Rating Scale for Side Effects were performed at admission and discharge as part of an ongoing database. RESULTS: Twenty-four geropsychiatric inpatients were treated with clonazepam (mean dose of 1.2 mg for a minimum of 2 weeks) during the 21 months studies. About one half of the patients had a primary diagnosis of dementia and the remainder had a diagnosis of an affective or psychotic disorder. Two of these patients were discontinued because they had responded to the acute need for clonazepam and a third patient was discontinued because of the development of sedation and confusion. For the remaining 21 patients, scores improved significantly on the Brief Psychiatric Rating Scale (p = 0.017), the Cohen-Mansfield Agitation Inventory (p = 0.011), the Rating Scale for Side Effects (0.004) and the Global Assessment of Functioning (p < 0.000), with no differences in amount of improvement between demented and non-demented patient groups. Scores on the Mini-Mental State Examination remained unchanged. CONCLUSIONS: Clonazepam shows promise as a benzodiazepine with good tolerability in the elderly.     

Complex polymorphisms in an approximately 330 kDa protein are linked to chloroquine-resistant P. falciparum in Southeast Asia and Africa

This article describes the use of the NIMH prospective life-charting methodology (NIMH LCM-p) in the context of a formal double-blind, clinical trial and provides preliminary evidence of its reliability and validity. Subjects included in this report were 30 outpatients with bipolar I and II disorder who completed the first 2 years of a long-term maintenance study: 1 year on carbamazepine or lithium and a crossover to the other in the second year. The LCM-p follows the same types of guidelines and principles utilized in the previously described retrospective life-chart process, allowing for continuity of illness assessment prior and subsequent to study entry. In the LCM-p, daily ratings of severity of mood symptoms based on the degree of associated functional incapacity, provide a more detailed topography of manic and depressive fluctuations. Inter-rater reliability was examined by comparing the severity of daily LCM-p ratings assigned by two raters. In order to assess the validity, we correlated the LCM-p ratings with well-standardized scales, including Hamilton and Beck Depression Ratings, Young Mania Ratings and the Global Assessment Scale (GAS). The Kappa scores for inter-rater reliability demonstrated significant and satisfactory strength of agreement with no fall off over 14 days prior to the rating interview. Strong correlations were found: (1) between the LCM-p average severity for depression rating and the mean Hamilton Depression Rating (r = 0.86, p < .001), and the Beck Depression Inventory (r = 0.73, p < .001); 2) between the LCM-p average severity for mania rating and the Young Mania Rating Scale (r = 0.61, p < .001); and (3) between the LCM-p average severity and the GAS (r = -0.81, p < .001). These preliminary data suggest the reliability and validity of the NIMH-LCM-p in assessing manic and depressive episode severity. It also provides a useful continuous daily measure of affective illness-related symptom fluctuations that allows for detailed prospective assessment of frequency and pattern of illness, treatment response, and continuity with retrospective life chart assessments.     

Pain and cognitive status in the institutionalized elderly: perceptions & interventions

The purposes of this study were to examine the relationship between: (1) nurses' ratings of pain and corresponding administration of pain medication to elderly long-term care residents, and (2) cognitive status of the elderly and pain medication orders/administration. Participants were 83 residents, 60 years of age and older, in two groups: cognitively impaired (n = 64), and cognitively intact (n = 19). For comparison purposes, 19 of the cognitively impaired subjects were matched on age and diagnosis to provide control for potentially painful conditions. A retrospective medication review of the resident's charts was conducted to compare medication orders and administration on analgesics that were scheduled and p.r.n. (given as needed). The pain ratings of 25 RNs using a visual analogue scale were correlated with pain medications given to the resident on the day of the rating. Results indicated that RNs' ratings of resident pain and the administration of pain medications were not significantly correlated. In addition, cognitively impaired residents were prescribed significantly less scheduled medication and received significantly less pain medication (either p.r.n. or scheduled) than the cognitively intact elderly. Implications for practice and research are discussed.     

Effect of evaluator and resident gender on the American Board of Internal Medicine evaluation scores

OBJECTIVE: To examine the effects of resident and attending physician gender on the evaluation of residents in an internal medicine training program. DESIGN: Cross-sectional study. SETTING: Large urban academic internal medicine residency program. PARTICIPANTS: During their first 2 years of training, 132 residents (85 men, 47 women) received a total of 974 evaluations from 255 attending physicians (203 men, 52 women) from 1989 to 1995. MEASUREMENTS: The primary measurements were the numerical portions of the American Board of Internal Medicine evaluation form. Separate analyses were performed for each of the nine evaluation dimensions graded on a scale of 1 to 9. The primary outcome was the difference in the average scores received by each resident from male versus female attending physicians. RESULTS: Compared with female trainees, male residents received significantly higher scores from male attending physicians than from female attending physicians in six of the nine dimensions: clinical judgment, history, procedures, relationships, medical care, and overall. Similar trends, not reaching conventional levels of statistical significance, were observed in the other three categories: medical knowledge, physical exam, and attitude. These differences ranged from 0.24 to 0.60 points, and were primarily due to higher grading of male residents by male attending physicians than by female attending physicians. CONCLUSIONS: In one academic training program, we found a significant interaction in the grading process between the gender of internal medicine residents and the gender of their attending evaluators. This study raises the possibility that subtle aspects of gender bias may exist in medical training programs.     

Peer evaluation in self-managing work groups.

A series of 3 experiments with business students examined how a rater's relative performance affects peer ratings. In Study 1, with 36 groups consisting of 178 Ss, outstanding contributors were the most discriminating evaluators. In Study 2, with 39 groups consisting of 186 Ss, individuals rated their own performance as well as that of their peers. Once again, outstanding contributors were the most discriminating evaluators, and self-evaluations were higher than the respective ratings received from peers. In Study 3, with 12 groups consisting of 61 Ss, below-average and average contributors may have discounted their individual performance outcomes by making allowances for external factors that affected their contributions. Together, these studies indicate that self–other comparisons in a work group influence peer-performance evaluations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparative review of family rating scales: Guidelines for clinicians and researchers.

Evaluates 8 rating procedures used in the assessment of family functioning, using 7 criteria of properties of scales, 2 of rater competence and training, and 3 of psychometric validity and reliability. The following scales are included: Beavers-Timberlawn Family Evaluation Scale and Centripetal/Centrifugal Family Style Scale, McMaster Clinical Rating Scale, Family Assessment Measure Clinical Rating Scale, Global Family Interaction Scales, Clinical Rating Scale for the Circumplex Model of Marital and Family Systems, Global Coding Scheme, and Family Interaction Q-Sort. Psychometric concerns and methodological dilemmas are addressed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Locus of control and interpersonal evaluations.

21 male and 21 female undergraduates took Rotter's internal-external (I-E) scale, then participated in a group test with 2 peers during which they exchanged evaluations of one another's answers. The evaluations Ss received were experimentally controlled so that they received mostly positive evaluations from 1 peer (positive evaluator) and mostly negative evaluations from the other peer (negative evaluator). As a manipulation of the perceived controllability of others' evaluations, 1/2 of the Ss were told that the test measured an ability and that there were right and wrong answers to the items (ability condition), and 1/2 were told that the answers represented personal opinions and that there were no right and wrong answers (opinion condition). Differences in Ss' evaluations of the answers given by the positive and negative evaluators showed that externals reciprocated more than internals and that this difference tended to be stronger in the opinion condition than in the ability condition. (16 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pulsus paradoxus: an objective measure of severity in croup

We used a noninvasive monitor of arterial pressure to determine the utility of pulsus paradoxus (PP) as an objective severity measure in croup. We performed a prospective, blinded comparison of PP in children with croup versus healthy control subjects, analyzed the relationship between PP and Westley croup score (WCS), and observed the effect of racemic epinephrine (RE) on PP and WCS in a subgroup of patients with severe croup. The PP and WCS were measured at presentation and in severe patients after treatment with RE. Mean PP was 6.1 +/- 1.8 (SD) mm Hg (n = 29) in control subjects compared with a mean of 17.8 +/- 11.2 (SD) mm Hg (n = 28) in patients with croup (p < 0.00001). There was significant concordance between baseline WCS and PP (Spearman's rho: 0.68; p = 0.0001). The mean decrease in PP after RE was 7.5 +/- 11.8 (SD) mm Hg (p = 0.05; n = 12). The magnitude of decrease in PP after RE has significant concordance with the concurrent decrease in WCS (Spearman's rho: 0.73; p < 0.007). PP is elevated in children with croup, and the magnitude of elevation correlates with severity as measured by the WCS. PP may have utility as a research tool to objectively measure the severity of upper airway obstruction in croup.     

The perceived influence of clinical pharmacy services on physician prescribing behavior: a matched-pair comparison of pharmacists and physicians

In contrast with cross-sectional designs used in previous studies, this exploratory study compared survey data from 127 matched pairs of clinical pharmacists and physicians working together. Physicians' perceptions of the importance of clinical pharmacy activities for patient care and the competence of pharmacists performing the activities were examined for their influence on prescribing behavior in an institutional setting. Data from a national survey showed that physicians rated pharmacists higher regarding recommendations based on drug use evaluations (p = 0.004) and competency to provide all clinical pharmacy services. Scores for pharmacokinetics ratings were similar between pharmacists and physicians (p = 0.168). Pharmacists rated the importance of recommendations based on cost-effectiveness higher than physicians (p = 0.012). Overall, physicians' perceptions of activity importance for patient care and pharmacist competency appear to dictate pharmacists' influence on physician prescribing behavior (R = 0.723).     

Clinical utility of the Test of Variables of Attention (TOVA) in the diagnosis of attention-deficit/hyperactivity disorder

Ability of the Test of Variables of Attention (TOVA) to distinguish between referred children with attention-deficit/hyperactivity disorder (ADHD) and other (OTHER) clinical diagnoses were studied. The ADHD group differed from the OTHER group on TOVA variables and most measures from the Revised Conners Teacher Rating Scale (RCTRS) and ADD-H Comprehensive Teacher's Rating Scale (ACTeRS). The criteria of any one TOVA variable > 1.5 standard deviations from age and sex adjusted means correctly identified 80% of the sample with attention deficit disorders and 72% of the sample without attention deficit disorder. Cases misclassified by teacher ratings were often correctly classified by the TOVA and conversely. The TOVA makes a unique and important contribution to diagnostic evaluations.     

How characteristics of student essays influence teachers' evaluations.

Explored the question of why competent evaluators award the ratings they do to college students' expository essays. Essays were rewritten to be stronger or weaker in 4 categories: content, organization, sentence structure, and mechanics. 12 evaluators first used a 4-point holistic rating scale to judge the essays' quality. Then they rated whether each of the 4 rewriting categories in each rewritten essay was strong or weak (perceptions). ANOVAs revealed content and organization to affect ratings most (p?p?p?     

Using standardized patients and standardized physicians to improve patient-care quality: results of a pilot study

BACKGROUND: We conducted evaluation research with a sample of registered professional staff nurses in a large, inner-city, tertiary medical center for a pilot study of videotaped case scenarios using standardized patients and standardized physicians to enhance nurses' communication and collaboration skills. METHOD: Change scores from pre-test to post-test on a self-reported rating scale to assess nurse-physician-patient interactions and communications for 28 nurses were compared with a control group of 38 nurses who did not participate in the videotaped sessions. RESULTS: Repeated measures of analysis of variance (ANOVA) detected no statistically significant differences between the intervention and control groups. However, positive changes were noted in some aspects of nurse-physician and nurse-patient interactions in the intervention group. Immediate feedback from the videotaped scenarios heightened nurses' awareness of the impact of their body language. CONCLUSIONS: Nurses must continuously practice and enhance their collaborative and communication skills. This pilot study suggests that it is beneficial to use videotaping with standardized patients and standardized physicians to enhance such nurses' skills.     

Mothers' and fathers' perceptions of child deviance: Roles of child behavior, parental depression, and marital satisfaction.

Investigated relationships among parental adjustment, parental perception of child behavior, and an independent measure of child behavior, using 61 consecutive referrals to a university psychology clinic of 5–14 yr olds with home or school problems. 61 mothers (41 of whom were married) and 41 fathers completed the Beck Depression Inventory, the Marital Adjustment Test, and the Conners Parent Rating Scale. Children's teachers completed the Conners Teacher Rating Scale. Mothers' ratings of their children's behavior were significantly correlated with teachers' ratings, but fathers' ratings were not. A stepwise multiple regression analysis showed that teachers' ratings accounted for the greatest amount of variance in the prediction of mothers' ratings of child externalizing problems, followed by maternal depression. Results confirm earlier findings of a relation of maternal depression to maternal perception of child externalizing behavior problems but indicate a stronger correlation between maternal ratings and independent measures of child behavior. (20 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nurse coaching and cartoon distraction: an effective and practical intervention to reduce child, parent, and nurse distress during immunizations

Evaluated a low cost and practical intervention designed to decrease children's, parents', and nurses' distress during children's immunizations. The intervention consisted of children viewing a popular cartoon movie and being coached by nurses and parents to attend to the movie. Ninety-two children, 4-6 years of age, and their parents were alternatively assigned to either a nurse coach intervention, a nurse coach plus train parent and child intervention, or a standard medical care condition. Based on previous findings of generalization of adult behaviors during medical procedures, it was hypothesized that training only the nurses to coach the children would cost-effectively reduce all participants levels of distress. Observational measures and subjective ratings were used to assess the following dependent variables: children's coping, distress, pain, and need for restraint; nurses' and parents' coaching behavior; and parents' and nurses' distress. Results indicate that, in the two intervention conditions, children coped more and were less distressed, nurses and parents exhibited more coping promoting behavior and less distress promoting behavior, and parents and nurses were less distressed than in the control condition. Although neither intervention was superior on any of the variables assessed in the study, nurse coach was markedly more practical and cost-effective. Therefore, nurses' coaching of children to watch cartoon movies has great potential for dissemination in pediatric settings.