Definition of Specific Functions and Procedural Skills Required by Cuban Specialists in Intensive Care and Emergency Medicine

INTRODUCTION Medical specialties’ core curricula should take into account functions to be carried out, positions to be fi lled and populations to be served. The functions in the professional profi le for specialty training of Cuban intensive care and emergency medicine specialists do not include all the activities that they actually perform in professional practice. OBJECTIVE Defi ne the specifi c functions and procedural skills required of Cuban specialists in intensive care and emergency medicine. METHODS The study was conducted from April 2011 to September 2013. A three-stage methodological strategy was designed using qualitative techniques. By purposive maximum variation sampling, 82 professionals were selected. Documentary analysis and key informant criteria were used in the fi rst stage. Two expert groups were formed in the second stage: one used various group techniques (focus group, oral and written brainstorming) and the second used a three-round Delphi method. In the fi nal stage, a third group of experts was questioned in semistructured in-depth interviews, and a two-round Delphi method was employed to assess priorities. RESULTS Ultimately, 78 specifi c functions were defi ned: 47 (60.3%) patient care, 16 (20.5%) managerial, 6 (7.7%) teaching, and 9 (11.5%) research. Thirty-one procedural skills were identifi ed. The specifi c functions and procedural skills defi ned relate to the profession’s requirements in clinical care of the critically ill, management of patient services, teaching and research at the specialist’s different occupa-


INTRODUCTION
Postgraduate specialty training enables university graduates to acquire, update, deepen and improve the professional competencies required by their jobs, in accordance with a country's needs for economic, social and cultural development.It is also intended to meet requirements of particular occupational profi les to achieve a high degree of professional development.[1] In medicine, specialty training is understood as building on undergraduate studies, as part of continuing and specialized medical education, essential to achieving high performance; solid social, ethical and moral principles; and excellent scientifi c and technical qualifi cations.
In Cuba, medical specialty curriculum design is formulated within a national framework, grounded in the country's history and culture.In accordance with the country's economic development and social needs, it is intended to link theory with practice, education with work, and patient care with research.It also includes other essential components such as management, teaching and research.Furthermore, the design is based on the concept of education as a guide for specialists-in-training to become independent and creative persons with values, knowledge and actions that contribute to cultural advancement in the context of cooperation and human solidarity.[2] Curriculum development starts from a vision or model of the desired specialist, including values, personal qualities and philosophy.The professional profi le provides specifi c guidelines for the educational process.It includes the profession's objective, as well as the functions and tasks the professional is expected to perform, the types of jobs to be fi lled, populations served, and the required skills and abilities that will be developed through training.[2,3] The professional profi le should be dynamic and mobile, in constant change and adjustment, responding to social demands; working conditions; and scientifi c, technological, ethical and sociological changes.This profi le guides curriculum development in constant dialogue among educational institutions, workplace settings and professionals in the fi eld, generating guidance for curricular adjustments.[3,4] The term function is used in the context of the profession, position or job, to designate a person's set of duties and responsibilities.It arises from the very nature of the social process of work, allowing us to identify a profession's contribution to society.[5] Intensive care medicine is a specialty characterized by its ability to dynamically identify and manage clinical situations of critically ill patients, requiring strict monitoring and use of special and immediate treatments.Since its emergence in the mid-20th century, it has undergone rapid scientifi c and technological changes.The specialty is now framed within a multidisciplinary context, demanding harmonious relationships among human, technological, pharmacological and architectural resources.[6] Intensive care medicine started in Cuba in the late 1960s at the initiative of dedicated pediatricians, internists and anesthesiologists.Some intensive care units (ICU) were created in the 1970s in hospitals of major Cuban cities. [7,8] As a result of a dengue hemorrhagic fever epidemic in 1981, [8,9] several more ICUs were built and others remodeled and expanded.Complete modules of equipment, supplies and medications were acquired, and training was expedited to provide full-time specialists and nurses for these units.[7,8] Peer Reviewed

Original Research
In the 1980s, the fi rst Cuban texts on intensive care medicine were published.Specialists permanently engaged in intensive care were required to pass a national one-year course conducted in several ICUs accredited for teaching.Once they graduated, these specialists improved the level of intensive care provided and expanded it throughout the country.[7,8] In 1999, the specialty was offi cially created under the name of intensive care and emergency medicine (IEM).This combined intensive therapeutics and monitoring with emergency and urgent care [10] in a three-year residency with two profi les: adult and pediatric.[11] In the fi rst decade of the 21st century, the IEM specialty sphere expanded with the creation of municipal units for intensive care and life support in community-based polyclinics and municipalities that did not yet have hospital ICUs, increase in the specialized work of mobile medical emergency teams, creation of monovalent ICUs for cardiac and cerebrovascular diseases, and a distinction made in hospitals between urgent and emergency care.Simultaneously, Cuba increased its international solidarity with several countries seeking experienced IEM specialists for urgent care, emergency wards and ICUs.[6,12,13] The core IEM curriculum for the current professional profi le includes four basic functions: patient care, administration, teaching and research.These, in turn, are broken down into specifi c functions: 12 patient care, 2 administration, 5 teaching, and 3 research.[11] Since these do not encompass all activities performed by intensive care physicians in practice, the objective of this study was to derive a new defi nition of IEM specialists' specifi c functions and procedural skills, corresponding to current requirements of critically ill patients and related responsibilities.

Study type and participants
A developmental study was conducted throughout Cuba between April 2011 and September 2013, using qualitative techniques: questionnaires, interviews and consultations with experts.
Eighty-two professionals, including key informants and experts, were involved in different stages.A purposive maximum-variation sampling strategy was used to identify features common among participants; its strength lay in the selection of well-informed individuals, professionals whose opinions were backed by experience and who could provide authoritative and competent judgments.[14,15] Participants included members of the National IEM Expert Group; board members of the Cuban Society of Intensive Care and Emergency Medicine and presidents of its provincial chapters; the president and members of the IEM residency and specialty advisory committee; heads of several ICUs; IEM professors; offi cials of the Ministry of Public Health's (MIN-SAP) Department of Urgent Care, Emergency Medicine and Transplantation, who manage urgent ambulatory care, emergencies, intensive care, mobile medical emergency services and transplantation logistics in Cuba; as well as deans and vice deans with experience in academic training in medical faculties offering the IEM specialty.

Data sources and collection
Instruments were developed for each method of collecting scientifi c evidence, and databases were created for statistical processing.

Study variables
IEM specialist Medical doctor who has successfully completed the IEM medical residency's academic program, or a professional in another medical specialty who has met requirements for receiving the title of second-degree specialist (a Cuban higher-level specialty credential) in IEM.[16] Functions Set of activities, tasks, duties and responsibilities that determine the practice of a profession, position or employment.[5] IEM specialists' specifi c functions The set of duties, responsibilities, activities and tasks that determine IEM specialist practice, classifi ed within four general functions (patient care, administration, teaching and research).
IEM specialists' procedural skills Skills these specialists must utilize, according to one or more of the functions, and in which they perform technological procedures to provide direct medical care to critically ill patients.
Procedural skills were separated from specifi c functions, since procedures can apply to one or more functions.[5] Study Design The algorithm used as a methodological strategy to defi ne the specifi c functions and procedural skills required of IEM specialists (Figure 1) was developed in the three stages described below.

Stage 1: Identifi cation of specifi c functions and procedural skills
• Document review and analysis: Cuba's Postgraduate Education Regulations, [1] Regulation of Health Sciences Residency Regime, [17] Residency Program in Intensive Care and Emergency Medicine, [11] General Hospital Regulations, [18] General Polyclinic Regulations, [19]  These fi ve experts employed several group techniques, including three two-hour focus group sessions.[20] These alternated with other techniques, such as oral and written brainstorming, [15] using a discussion list called Competenciasmie, created on Infomed (Cuba's digital health information network) for email communication.This enabled exchanges among participants without frequent meetings.In the end, a list of specifi c functions and procedural skills was obtained for our research objectives.
Information validation.This was done through a three-round Delphi process with a second expert group of 25 Cuban IEM professionals from across the country, following the methods described in detail by Véliz.[21] Stage 3: Validation by NHS leaders and UCMH academics For this stage, a third expert group of 10 professionals was convened, consisting of senior managers who were policy, managerial, academic and methodological decisionmakers in Cuba's NHS and UCMH.The purposes of the study were explained to all, as were their contributions and roles within it.A semistructured, in-depth interview was conducted with each about the IEM specialty curriculum and its practical implementation, and participants were asked to take part in a Delphi process.All participants had a competence coeffi cient of 0.9 or greater, considered very high.[22,23] Of the 10, 7 completed the Delphi method; the remaining 3 were excluded from the study.
For this Delphi process, the specifi c functions and procedural skills defi ned in the earlier phases were listed in a questionnaire, and a fi ve-column or Likert-type rating scale was applied.[24] The seven participants were asked to rate the importance of each item by selecting one of the fi ve columns: unimportant, slightly important, important, very important, and essential, with values of one to fi ve in the same order.Two rounds of consultation were held and consensus obtained on the relative importance of the various functions.
Distribution tables were created with the four general functions and procedural skills as rows and the experts' answers as columns.The Friedman test was conducted to estimate the homogeneity of the experts' answers.
Data were collected in Excel and SPSS 21 for Windows databases, and descriptive statistical analysis was applied using absolute and relative values, contingency tables, and the Friedman test.In all cases, a confi dence level of 95% was employed, pre-establishing the critical rejection level (alpha) as p <0.05.The information was summarized in statistical tables and texts.
The use of different qualitative techniques in the third group of experts to validate the information obtained by the two preceding groups allowed data triangulation and comparison of the different information sources.[25] Triangulation is an enriching tool that confers rigor, depth and complexity to a study and makes it possible to assign varying degrees of consistency to the fi ndings, reducing bias and increasing understanding of phenomena under study.[26] Ethics Participants' confi dentiality, written informed consent and voluntariness were assured.Anonymity of individual opinions was guaranteed in shared summary feedback and fi nal formulation of the Delphi processes.The study was approved by the ethics committee of UCMH's Comandante Manuel Fajardo Medical Sciences Faculty.

RESULTS
Stage 1 Key informants in the national workshops concluded that all functions in the current curriculum [11]  The specifi c functions defi ned by the methodology used are shown in Table 2 and the procedural skills in Table 3.

DISCUSSION
This is the fi rst Cuban study to defi ne the specifi c functions and procedural skills required of IEM specialists in the current context.It clarifi es the duties, tasks and activities that an IEM physician can and should perform in multiple work settings, which are more numerous and diverse today than they were when the specialty was created.
Defi ning functions enables increased productivity and rational use of personnel by promoting a more effective and productive organization; determining the duties, responsibilities and reporting relationships; improving interpersonal communication; and eliminating task duplication as well as jobs with insuffi cient content to fi ll the workday.[14] Specifi c functions related to patient care predominated.This is consistent with Article 65 of the Residency Regime Regulation in Health Sciences, [17] because patient care is the essence of this specialty.
The newly defi ned patient care functions include those in the existing curriculum, [11]  The new managerial functions defi ned include the two that were already in the specialty program.We believe that the increase by 14 is very important.It was based on the premise that administration is a social science aiming to achieve shared objectives and goals through plan-

PATIENT CARE
1.In the system for care of seriously ill patients, give priority to health programs and continuous improvement of care.2. Provide comprehensive medical care to patients with urgencies and emergencies and to critically ill patients, and implement immediate and protocol-based, stepped treatment according to the most advanced techniques and procedures available, prioritizing patients who are in immediate life-threatening danger.*3. Care for patients' health in a personalized manner; respect their values, customs and beliefs; and ensure their care is in accordance with medical ethics.4. Provide comprehensive health care, including primary and secondary prevention. 5. Establish and maintain good doctor-patient-family relations.6. Keep patients and their families duly informed on patient health status during the medical interview and in medical reports, and whenever the need for new approaches, conducts or procedures arises.7. Document in the patient record all information available on the problems identifi ed, with emphasis on clinical reasoning and rationale for medical decisions.8. Work in a team, complying with the institution's organizational and procedural handbooks as well as the goals of the team.9.In an interdisciplinary approach, participate with other specialists in collective decision-making on severely ill patients.10.Follow the principles established in the specialty care protocols and practice guidelines.11.Ensure compliance with medical ethics and prevailing labor legislation, informed consent for medical procedures involving risk, and consensus decisionmaking.12. Indicate, and on occasions perform, invasive clinical tests, laboratory, imaging and electrocardiographic studies; and interpret, consult and treat disorders so detected, as well as their complications.13.Perform and control procedures for monitoring vital signs and invasive and noninvasive techniques of the specialty, as well as secondary complications.14.Decide on placement and retention of tubes and drains, and control of related fl uid intake and output.15.Assess and monitor electrolyte balance as needed and perform medical actions after its interpretation.16.Identify electrolyte and acid-base disorders; prescribe corrective action, ensure compliance and evaluate results.17.Assess patient nutritional status on admission, implement and monitor nutritional balance and evaluate results.

MANAGERIAL
1. Know and apply the organizational and functional structure of the unit and institution.2. Implement and enforce compliance with the basic governing documents of the unit, such as organizational and procedures manuals, protocols and practice guidelines.3. Plan, organize and manage medical care in the unit.4. Supervise and advise nurses and technicians working in the unit.5. Properly implement standards and criteria for admission, transfer and discharge in patient care units.6. Effi ciently plan, organize and control human and material resources, according to scope of responsibility.3 IEM: intensive care and emergency medicine ning, organizing, managing, coordinating and monitoring activities (by marshaling human and material resources to meet these organizational objectives), bearing in mind that quality and safety are paramount for the health care system.[29] In the context of health services delivery, enhancing quality and safety requires appropriate reorganization of teamwork, organizational structure, processfollowup and control; discussing and learning from errors; detecting potential risks; and evaluating results and indicators.[30] IEM specialists' duties also include supervising and advising nurses and technicians working in the wards; analyzing economic indicators; managing basic resources; and assessing the competence, suitability, and performance of subordinates; as well as developing and monitoring compliance with individual development plans of professionals under his or her direction.Three of the six teaching functions arrived at were similar to those already in the curriculum: teaching methodologies for active and creative learning, evaluation techniques, and identifi cation of learning needs that promote continuing education.[11] Based on the premise that the teaching function should be general, the functions defi ned emphasize the learning objectives for undergraduate and postgraduate students.The need to develop basic teaching skills for planning and implementing training activities was stressed, as was the use of new information technologies (which were not as developed and available when the IEM curriculum was originally drafted).
Concerning research functions, two of those in the program remained, with slight change, since application of methodological principles of scientifi c research must include not only planning and implementing clinical studies, but also their organization and monitoring.Likewise, the function of organizing scientifi c and research activities necessary to achieve knowledge, dissemination and updating of the specialty was separated from that of making objective critiques of scientifi c studies reviewed.Research on specialty-and institution-related issues confronted in daily practice [28] is considered essential for the specialty's development, as is participation in multicenter studies and clinical trials.
Procedural skills defi ned in our study are included in the IEM curriculum, either as methods, techniques or theoretical content.[11] We followed Torres' example [5] and separated procedural skills from specifi c functions, because procedures are conducted to fulfi ll different functions.
In Cuba, very few studies have been published on specifi c professional functions in the medical sciences [5,31] and thus, we cannot compare ours with previous ones exploring the same research objectives.
Intensive care medicine has experienced a rapid expansion in recent years throughout the world, but since national training programs differ widely, [28,32,33]  First, a wide range of training programs, structures and processes for intensive care specialists was identifi ed.[33] Subsequently, 102 specifi c competencies were distinguished within the 12 core competencies, [34] compatible with many European national programs and already implemented in many countries of the region.[32,[35][36][37] Elsewhere, in the USA, the Multisociety Task Force identifi ed 276 specifi c competencies for pulmonary medicine and 327 for critical care medicine, starting points for changes in these specialties' curricula.[38] We do not propose to compare our work with the CoBaTrICE international studies or other academic programs for several reasons: • There is wide variability in national residency programs [28,32,33,38] and in their implementation.[39] • While elsewhere in the world, intensive care medicine and the urgent-care and emergency specialty have been clearly defi ned as two different clinical fi elds, in Cuba they are still part of a single specialty.The Cuban model focuses on continuous and progressive care of the patient with surgical or clinical urgencies and/or emergencies of any kind; the IEM specialist is trained to work in all scenarios through which the patient progresses, providing highly specialized care and treatment in all.
[6] • The curricula previously mentioned [28,32,33,38] have identifi ed and defi ned the core and specifi c competencies of the specialty.These are conceived as a system of knowledge, skills, attitudes, and values that enable satisfactory performance in professional practice; [3,20,40] while in our study, we have only defi ned the specifi c functions and procedural skills-as the set of duties, responsibilities, activities, tasks and procedures that determine the practice of this specialist in Cuba.
Our study's defi nition of patient care, managerial, teaching and research functions, together with procedural skills, constitutes the fi rst stage of a methodological strategy to eventually identify, defi ne, standardize and evaluate the professional competencies of the IEM specialist in Cuba in two future steps (fi rst, identification and defi nition, then standardization and evaluation) to be undertaken by the National IEM Expert Group; and the Cuban Society of Intensive Care and Emergency Medicine.
Occupational, functional, and constructivist analyses [3,20,40] are among the several methods put forward to identify competencies, but the CEDAS workshop participants observed that the three methods overlap.Cuba's undergraduate and postgraduate programs set out professional expectations starting from functional analysis to identify competencies.[40] Regarding the methodological strategy used, key informant opinions enabled us to explore the sustainability of the functions stated in the residency program and to provide a draft for consultation and expert review, taking into account that, in qualitative research, there is often overlap of the exploratory and the confi rmatory phases.Its inductive and hypothesis-generating nature usually results in processes in which patterns observed in initial phases become clearer as the investigation progresses.[15] A methodological strategy using qualitative techniques has proven effective in research.Its dialectical and participatory nature allows each stage to inform the following one.The use of various techniques by the fi rst expert group enabled gathering of experts' views of the specialty and their experiences in the realities of clinical practice and teaching, as well as their suggestions for improving the resindency's academic program.Application of the Delphi method (described in detail in Véliz) [21] provided greater objectivity than in the previous group.And triangulation with the third expert group proved to be an effi cient method for combining several methodological options (Delphi method and semistructured and in-depth interviews) to collect evidence supporting results of the previous two groups.
One limitation of this research is that defi nitions of several specifi c patient care functions are fairly generic, making it more diffi cult to assess them and to proceed to later phases in which specifi c competencies are defi ned for the Cuban IEM specialist.However, the study has considerable importance for professional practice because it defi nes, using a holistic approach, the actions, duties, obligations, activities, and technical skills required for the IEM specialist to meet the needs of Cuba's health system.
Thus, this research is useful because: • It provides a better understanding of the functions, specifi c characteristics and scope of the IEM specialty in Cuba from a scientifi c perspective.• It proposes more rational use of intensive care physicians in clinical practice and describes their role within the NHS.• The defi nition of specifi c professional functions has methodological usefulness for developing managerial and educational interventions.• The methodological strategy applied is a theoretical and technological contribution for future research to be conducted in IEM.
• It provides MINSAP with a product useful for revising documents governing the specialty program, several postgraduate programs, and intensive-care physician performance.• It provides a starting point for identifying the full range of IEM specialist competencies.

Original Research
Peer Reviewed It has been recommended to MINSAP that these study results be included in the imminent reforms of the IEM specialty curriculum and in systematic evaluations of related services.

CONCLUSIONS
The scientifi cally derived specifi c functions and procedural skills of the IEM specialist constitute a tool to improve teaching, research, management and patient care in this specialty in Cuba.They are theoretical, practical, methodological and social contributions to future curriculum reform and for achieving better performance by IEM specialists in comprehensive patient care.

Figure 1 :
Figure 1: Strategy for defi ning specifi c functions and procedural skills of Cuban IEM specialists Stages

7 . 8 .
Collaborate and work appropriately with other team members to achieve common objectives and create an environment of mutual support.Interpret and use quality-of-care indicators for the critically ill patient aimed at effective and effi cient medical attention.9. Participate in or direct area or institution quality committees for evaluating the results of patient care.10.Prepare work plans to comply with programs established for care of critically ill patients.11.Participate in or lead meetings of the service, with emphasis on analysis of patient care and economic indicators.Peer Reviewed Original Research were relevantsince they respond to societal needs, meet demands for health services, and are adaptable to institutional modernization processes.They considered that these functions can be effi ciently and successfully carried out in practice, and adequate resources are available for the training, managerial, and leadership functions but not for patient care, mainly because some technological resources are lacking.The experts proposed 113 additional specifi c functions: 60 patient care, 21 managerial, 15 teaching and 17 research.In interviews, the seven participants agreed that: • The specialty curriculum must be changed in view of current knowledge and scientifi c and technological advances.• Resident training should be better monitored, to ensure scientifi c and technical rigor.• The current IEM residency rotations are still relevant and must be maintained, but new ones should be added to cover areas that will be part of the revised occupational profi le.• Training in prehospital urgencies and emergencies, coordination and management of mobile medical emergency teams, comprehensive trauma care, and other elements and skills of urgent care and emergency medicine should be strengthened in the residency, with rotations included.• The one-year diploma course in intensive care should be eliminated.• The IEM professional profi le should respond to social needs, contain all the functions performed by the IEM specialist, list the required professional competencies, and encompass the range of occupational settings.
remained on the list with little change: eight patient care, both managerial, all fi ve teaching, and all three research functions.Patient care functions increased by 32; managerial by 12; teaching by 4; and research by 10.Forty-one procedural skills were defi ned, which we believe could be categorized further, and some are not specifi c to the The opinions gathered through the interviews with experts support the relevance of this research as a fi rst step toward future studies to inform reorganization of the IEM residency program.The results of the Delphi questionnaire answered by the third expert group, regarding the degree of importance of each specifi c function, are shown in Table1.Of 546 possible responses on the 78 functions defi ned by the previous groups, the

Table 1 : Third-stage IEM-function validation by NHS managers and senior
*n × number of functions in category IEM: intensive care and emergency medicine

Table 2 : Specifi c functions of IEM specialists (fi nal product of three stages)
Diagnose death and prepare the corresponding legal documents.42.Diagnose brain death and stabilize and maintain donor vital status.43.Solve the most common technical problems arising in the operation of medical equipment, applying basic knowledge of the specialty.44.Comply with the infection control system related to disinfection in all care units for critically ill patients.45.Be familiar with the microbiological map of the institution and apply the correct antimicrobial policy.46.Ensure safety and proper care during transportation of critically ill patients.47.Use early-warning scales for hospitalized patients to ensure timely admission to ICU.

Table 3 : Procedural skills in IEM (fi nal product)
Conduct research related to problems of the specialty and those identifi ed by the institution.3. Organize scientifi c and research activities needed to advance knowledge and its dissemination, as well as to update the specialty.4. Participate in implementation of clinical trials.5. Communicate research results in various formats.6. Read medical literature in English to develop research and to update scientifi c knowledge.7. Use basic statistical tools in developing research.8. Direct research towards studies that lead to higher-level academic and research categories.9. Design and participate in national and international multicenter studies.12. Be familiar with essential elements to evaluate professional competence, suitability and performance.13.Prepare and monitor compliance with the individual development plan of every professional in the unit.14.Be familiar with and/or execute the unit's and institution's human resource strategies, such as selection, education, development, training and employment.15.Apply principles of strategic and participatory management by objectives in providing medical attention to critically ill patients.16.Comply with and monitor compliance with patient safety programs.
comparisons are not easily made.The Competency-Based Training in Intensive Care Medicine in Europe study (CoBaTrICE) was an important effort to harmonize specialty curricula in Europe.Participants included organizations responsible for intensive care training in Europe and six other geographic regions.