nursing – AQuAS Blog

Specialised health training and indicators to measure the quality of teaching

7 Jun

To work as a specialist in the health system -in any speciality in medicine, pharmacy, psychology, nursing or other- not only do you need to have a university degree but also the corresponding specialist qualification. To get it you need to pass the selective test traditionally known as the MIR in Spain (national specialisation examination) for specialist doctors, PIR for psychologists, FIR for hospital pharmacists, to give some examples and which has been done annually for more than 30 years. The training of specialists in the Health System is done in public and private health centres and teaching venues, previously accredited, to which professionals have access once they have passed the selection process, in rigorous order of registration.

The allocation of chosen places for this year recently finalised and the residents took up their places at the end of May. The specialist health press has made use of all kinds of headlines, commenting on the results of autonomous communities, the most sought after specialties by residents or the best positioned centres. Nevertheless, not all the comments that have been published, sometimes too hastily, contain an accurate and rigorous analysis. The ability of centres to attract teaching staff in Catalonia has not regressed nor changed much in recent years; the hospitals and teaching centres most sought after in Family and Community Care by new residents are still the same at a state level.

Why is it important to be an attractive teaching centre for residents? Obviously, because all centres aspire to have the students with the best marks, not only for the prestige that this has or for the base of knowledge they have shown to have, but also because of the possibility of retaining them and contracting them at the end of their residency. The lower the mark in the MIR, the greater the chances are of abandoning a speciality and in practice a significant number of foreign residents are seen as having greater difficulties for future employment.

To promote the intrinsic and perceived quality in specialised training given to residents, the Department of Health of the Generalitat de Catalunya has implemented a Management Plan of Teaching Quality and within this, a set of structural, procedural and results indicators related to the places offered, which have been published in a report since last year at the Central de Resultats (Results Centre, Catalan Health System Observatory) under the auspices of the AQuAS.

Furthermore, a survey of satisfaction is carried out with all residents in Catalonia which has had an effective participation of 76% this year and which offers complementary information to that of the Plan of Quality. Both instruments, beyond the fact of generating transparency and information regarding a healthy specialist training, make it possible to benchmark different centres with the aim of achieving greater competitivity and improved teaching in Catalonia.

Ultimately, guaranteeing profiles of excellence of specialist health professionals is the permanent aspiration of the Health Authority via a learning process based on supervised and mentored practice to attain the necessary professional skills to offer a safe and high quality practice. In this way, the health system will be capable of training better specialists to meet the needs of the population in health.

Post written by Alícia Avila, Assistant Director-General of Professional Planning and Development. Health Department.

Conversations on gender in the nursing context

10 May

Marc Fortes, Núria Rodríguez-Valiente, Mercè Salvat

Like every 12 May, the International Nurses Day is celebrated and to commemorate this date, three colleagues in the profession, Mercè Salvat, Marc Fortes and Nuria Rodríguez got together to talk about the relationship between gender and giving care.

We would like to share our reflections on how socially, the profession has been related to vocation, altruism, submissiveness and invisibility…, in short, to the social stereotypes of the female gender.

Questions arose during this conversation such as why the term caregiving is associated with women in our society, why this care does not have nor has had social recognition when opinion is favourable in the processes of health-illness, how the men who have chosen this profession experience it and finally, how it would be possible to “deconstruct” this social and cultural construct.

Let’s take it a step at a time.

Why is the concept of caregiving associated with women in our society?

It is a historical fact that in our patriarchal society, women have been linked to the function of reproduction and taking care of the home. This care should be seen in its widest sense: from the routine chores of housekeeping, to curing and maintaining the health of older people, babies and family members who are ill. At the same time, they have been attributed with a whole series of connotations such as servitude, self-sacrifice, unconditional commitment and in short, of little value. On the other hand, in this context, men have been linked to productivity and the economic sustenance of the family and associated with professionalism and social prestige.

Why does this caregiving not have nor has had social prestige?

This deeply rooted social construct has normalised the idea of caregiving as something feminine. It is taken a step further by establishing stereotypes between that which is feminine, caregiving and the social vocation-intuition-servitude-invisibility. Finally, a symbolic association with essential professions in the care of people is made; this would be the case of nursing. In fact, the stereotyped identification of the profession is replicated socially and the role of the nurse is a professional continuation of home care (Germán, 2004).

In addition, to this collective worldview mentioned previously, we also need to add the sexual-recreational perspective of the profession which unfortunately continues to be present. An example, in the most recent cases, is the flu campaign of 2017 by the Ministry of Health and the TV programme Telepasión – El Musical 2017.

How do the men who have chosen this profession experience it?

This is a question we male nurses have always asked ourselves: What problem is there in carrying out this career? Would anybody have questioned my decision had I decided to be a doctor or pharmacist? This is the first battle to be fought by the men who decide to give care professionally to other people. It is not a battle against themselves but rather against established social prejudices. We will attempt to briefly summarise some of these prejudices:

– “To be able to care for someone, a special sensitivity is needed which only women have.” It appears that men are strong, do not waste time on feelings and of course never cry. Luckily, many of us have shown that professional care requires a set of skills which in the first place can be trained and which secondly do not depend on gender whatsoever, or, as Joan Tronto, the political scientist puts it: “Giving care is not more natural for women; they do it as a privilege for men.”

– As we mentioned earlier, the social construct says that “men are the economic pillar of the family”. Nowadays, the average salary of a male nurse might not be enough to sustain a family. In our present day society we need to consider shared responsibility in family management.

– “Men that choose a profession of this type are not very masculine”; the social construct means that some men do not go into these professions because, from a social viewpoint, it is thought that their masculinity might be questioned and consequently, the superiority of gender too. What is more, this idea leads to the attribution of a sexual orientation because of belonging to this collective.

How can this social and cultural construct be deconstructed?

The “deconstruction” of this social construct should lead us towards the revolution of equating caregiving with healing from a human perspective and not from a gender perspective. To be able to give care, it is without doubt necessary to have a predisposition towards solidarity, an emotional commitment and flexibility but these grand values belong to humanity and not to any gender or profession. The perspective of gender is in itself enriching and should bestow on men and women the condition of equality when carrying out their chosen professions regardless of their gender.

In order to “deconstruct” the stereotype of gender in our patriarchal society, we should learn that giving care is a skill that people have and that it has nothing to do with the dichotomy of gender (Barragán, 2009). A feminine or masculine view regardless of sex is necessary in order to look at our profession historically and in terms of the future (Chamizo, 2004) and what is more, we feel the need to add that it is necessary in order to deal with the present and future of society.

In this respect, our proposals are a step towards the definition of a common strategic line proposed by professional colleges of health, where the democratic values which are imbued in taking care and in giving care are promoted.

Post written by Núria Rodríguez-Valiente, Marc Fortes and Mercè Salvat.

Towards research in nursing with a (greater) impact

15 Mar

What is it that makes a particular research have an impact on society beyond the strictly academic and which is truly transformative? Can a whole series of actions be planned in the way that one follows a cooking recipe which leads directly to the desired social impact? Unfortunately, the answer is no. The impact is multifactorial and depends on so many different elements and actors that it is difficult to establish a formula to guarantee it.

However, having said that, the fact that there is research which has a particular social impact does not mean that it is a totally random phenomenon and that there is no way of predicting, facilitating or promoting it. Years ago, from the Research Assessment group at the Agency for Health Quality and Assessment of Catalonia (AQuAS), and with the help and complicity of the International School on Research Impact Assessment, ISRIA, we identified a series of facilitators with regards the impact of research.

A fundamental facilitator is people, and the values, culture and capacity of leadership they have. Two identical results of research can have different impacts if the capacity of leadership, drive and will to get beyond academic impact is different. But this is still not enough. The strategy, organisation, collaborations and openness that institutions have will be a great facilitator or barrier for the researchers that have carried out the research.

Finally, both people and institutions will need two indispensable elements in order to aspire to having an impact: on the one hand, a close and effective communication with the different social actors that can play a role in transferring the results of research, and on the other, an approach focused on the participation of all these key players.

To paraphrase Confucius when he said “explain it to me and I will forget, show me and maybe I will remember, involve me and I will understand”, it is all about involving all the necessary actors to bring about a real change and make research transformative.

It is in this context that SARIS (Catalan acronym) came into being, the Assessment System of Research and Innovation in Health. It is a strategic tool which emerged from the PERIS (Strategic Plan for Research and Innovation in Health 2016-2020) with the aim of assessing the research carried out in health in Catalonia from the perspective of always wanting to facilitate and influence so that it has an impact beyond academia. To do this, the motivation and involvement of actors has been defined as a key factor for its development.

Last November, we started a series of participative sessions with nurses who were selected from the PERIS 2017 call in which a line of intensification of nursing professionals was financed.

It is important to emphasise that launching this line with nursing research makes full sense for three reasons: on the one hand, one of the thematic priorities of the PERIS is clearly that of “the development of clinical and translational research which facilitates the growth of scientific and technological knowledge, putting special emphasis on primary care agents and research in nursing”. In addition, the PERIS 2017 nursing fund has been the first to come to an end and it was appropriate to address ourselves to them first and foremost.

Last but not least, the conditions in which nursing research is carried out, with patients and their recovery as its central goal, makes it especially appropriate to ensure that this research has a direct impact on health. Hence, it is important that the research done in nursing be capable of demonstrating the impact that this group of professionals has because it can give it a comparative advantage with regards other biomedical disciplines. Indeed, nursing research is intrinsically translational.

Therefore, the first session centred on identifying the influential actors and in empowering the nurse to carry out an effective communication which amplifies the productive interactions needed to transform the results obtained into benefits for a better and improved health for patients.

We would like to express our deepest gratitude to the nurses for their participation (readiness and motivation) who attended of their own free will and in their time off work ensuring thus that the session was a success. This demonstrates that from the AQuAS we have leverage to give support to those researchers who are motivated to driving the impact of their research.

At present, we are preparing other sessions that will enable mutual learning between researchers and the assessment agents at the AQuAS.

Post written by Núria Radó Trilla (@nuriarado).

Jornada SARIS: Participación en recerca Barcelona, April 4th 2018.

PERIS and people: research assessment by AQuAS

30 Mar

The first call of the Strategic Plan for Research and Innovation in Health 2016-2020 (PERIS in Catalan) for funding research and innovation, still pending resolution, prioritizes programmes which foster talent and employability and programmes of excellence in knowledge.

Accordingly, four actions have been initiated by competitive tendering to finance:

The inclusion of scientists and technicians in national research groups
The increase of nursing professionals in order to free up some of their workday so they can do research work
Research projects aimed at primary care
Major programmes focusing on four different subjects: personalised medicine, regenerative medicine, cooperative independent clinical research and cohort studies.

How are the PERIS calls assessed to determine which applications deserve funding?

The criteria for assessment are defined by the order of the requirements, forgive the repetition, and the requirements of each call. This is the instrument that sets out the rules to determine which projects or people are susceptible to receiving finance. Some will always be discarded and, depending on the specific criteria and resources available, others chosen which are considered worthy of funding.

Deciding which criteria to use and how they are assessed/rated/applied is a powerful science policymaking tool to design the research system it aspires to be: excellence, the subject, the discipline, the age of the applicants, the territoriality of the organisations or foreseeable impact are different variables to bear in mind when deciding who is worthy of being able to develop their research.

The Research Team at AQuAS has been commissioned to manage this process of assessment. This is why we accompanied the General Manager for Research and Innovation of the Health Department, Dr Andreu, in the public presentations he gave in different health research institutions linked to hospitals. We were impressed by the attendance at these informative sessions.

The assessment has been done by a panel of experts involving a total of 42 research professionals throughout Catalonia and Spain. It has required intense activity given that more than 490 applications of a very high level were received.

Looking back after having completed the assessment of the this first call, we feel, more than ever, that we made the right decision by putting people in the centre of the PERIS logo, large and circled by a prominent colour.

It is not only the plan itself which has been designed like this, to promote research with people at its centre, involving and motivating a great variety of professional profiles. PERIS has been a catalyst for mobilisation in the health system and in health research, even before the starting gun was fired, as seen in the packed informative presentations and in the involvement of the participants in the assessment panels, working deep into the night.

As can be expected, getting the staff at the Agency for Health Quality and Assessment of Catalonia (AQuAS) involved, has not been difficult either. We are eager to contribute to this strategic project by using a key tool for selection, accountability, continuous analysis and improvement of opportunities which is what assessment is all about.

Long life to PERIS!

Post written by Núria Radó (@nuriarado) and Paula Adam (@PaulaAdam4).

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Elderly person with stroke: integrated care from the acute phase to the return home

9 Dec

Stroke has a high incidence, a growing prevalence and is the pathology with the second highest impact in the world in terms of disability among adults. Despite important advances in acute stroke management, which have led to a progressive decrease in acute stroke deaths, in terms of residual disability, stroke continues to have an extremely high impact on survivors, their families, their caregivers and on society in general.

Evidence shows that the approach to patients throughout the process of care in stroke, from the acute phase to the rehabilitation phase, needs to be multidisciplinary since patients have multiple health care and social needs which require a strong coordination between the different levels of healthcare. However, the tendency is still to organise conferences and congresses focused on only one speciality or level of healthcare.

On the other hand, and in self-criticism, even though stroke is one of the main reasons for using intermediate or long-term healthcare services, this sector almost never takes part in the decision making process of stroke care organisation. Neither does it do much research in stroke and in general, tends to put little thought into improving knowledge in treatments or in innovating the organisation of services compared to, for example, other conditions such as thighbone fractures.

This is why the Parc Sanitari Pere Virgili organised a monothematic symposium on 27 October, two days before the World Stroke Day. It focused on the treatment and management of stroke in elderly people from a different perspective: we traced the trajectory from the “needle” of the thrombolysis in the acute phase, passing through rehabilitative care and “reablement” in the post-acute phase, to the transition back to home life, describing the care given to patients especially, but not forgetting the attention caregivers need.

The presentations reflected and reinforced the need for a multidisciplinary approach in all phases of stroke. As an added value, in all cases the speakers not only combined recommendations derived from literature with their own practical healthcare experience but also provided data from their own research or innovation projects, in many cases with data published recently.

Among the speakers there was a varied representation from very different disciplines which included neurologists, geriatricians, physiotherapists, occupational therapists, speech therapists, social workers, a health economist and the representative of the stroke patients association who chaired a roundtable.

Some of the items that were highlighted most strongly during the symposium were:

The large amount of increasingly more accurate data available on all phases of stroke management. In Catalonia, this data is being provided by the Results Centre, which encourages transparency and allows for benchmarking thereby facilitating a reduction in variability and the sharing of best practices.
Despite improvements in the treatment of acute stroke patients using mechanical thrombectomy together with systemic thrombolysis, 40% of patients are left with a considerable disability as a consequence of stroke. This “glass half-full” should therefore encourage more to be done in terms of acute stroke management, and also in post-acute care which is still vital.
In acute care, age should not be a discriminating factor. This is in line with the concept that chronological age does not correspond necessarily to biological age and that two elderly people of the same age can have a totally different “functional potential” (a concept which in practice in the field of geriatrics is understood as meaning more or less “frail”).
Advances have not only been made in acute care but also in the field of primary and secondary preventive care. Accordingly, the development, the approval of and the use of NOACs (new oral anticoagulants) have been a determining factor since they offer an alternative for those patients where traditional anticoagulants are not a therapeutic option.
The rehabilitation prognosis is multifactorial. A recent proposal stemming from a multi-centre Catalan study led by our hospital and published recently, is based on a simple algorithm which incorporates the social factor (presence of the caregiver) together with the severity of the stroke (using the NIHSS score), functional status (according to the Barthel index) and cognitive function (a result of the Rancho Los Amigos scale). This allows patients to be classified in three levels of rehabilitation complexity, but who might evolve differently, with different needs for intervention, both in the rehabilitation process and regarding their return home.
Integrated interventions in geriatric rehabilitation can be home-based for certain patients as an alternative to a hospital admission. This model, deeply rooted in England and which has proven to be beneficial, is producing good results in our context in different pathologies including stroke. Innovative formulas such as “Comprehensive Home-based Hospitalisation” have, in our context, come about from the alliance between home-based geriatric care teams (doctor, nurse and social worker) and those of home-based rehabilitation (rehabilitation doctor, physiotherapist, occupational therapist and speech therapist).
In terms of physiotherapy, treatments should be more standardised and their efficacy demonstrated. During the symposium, interesting evidence was presented on the control of the trunk and its importance throughout the rehabilitation process in stroke.
Dysphagia is a very prevalent risk condition in patients who have suffered a stroke. Different proposals of scales for assessment at the bedside were shown which can be applied by nurses, reserving the speech therapist’s intervention for the most complex cases which require a more specialised assessment.
In rehabilitation, the support from the ICT (“telerehabilitation” which patients can receive following the instructions and programme configuration of the physiotherapist) allows treatments to be extended in time and intensity along with face-to-face treatment.
Working with caregivers is important. Apart from guiding them within the system, the availability of support groups for exchanging personal experiences, for a social worker, for example, could have an impact on the adaptation of the caregiver to the new situation. To this effect, an innovative experience was developed in our centre with a high degree of acceptance by patients and their families.
Continuity in the recovery process is key and the integration of health and social services guarantees an added value. The pilot “Return Programme” in the city of Barcelona, the result of the alliance between the Catalan Health Service and the City Council of Barcelona was presented. It allows for the direct activation of social services, from acute care and long-term care hospitals so that patients can receive the necessary aid when they return home and thus avoid unnecessary and dangerous delays.

In summary, much progress has been made in the treatment of stroke, especially in the acute phase, but innovation is also being carried out in the successive phases and the symposium showcased different experiences which have been implemented in our context. Drawing conclusions from the symposium, the take home messages are that a comprehensive view of the entire process is key, as well as an integrated and coordinated approach between the different levels of healthcare and social services. On the other hand, more research needs to be carried out especially in the post-acute and chronic phases resulting from the disease and this poses a challenge because of the difficulty in designing and implementing complex interventions where designs such as standard clinical trials are not the solution.

Post written by Marco Inzitari (@marcoinzi) and Laura Mónica Pérez, Parc Sanitari Pere Virgili, Barcelona.