N

NANP see National Association of Non-Principals

NARRATIVE REVIEW The process of synthesing primary studies and exploring heterogenicity descriptively rather than statistically (that is buy means of a meta analysis)

NATIONAL ASSOCIATION OF NON-PRINCIPALS (NANP) www.nanp.org.uk

NATIONAL CARE RECORD SERVICE (NCRS) This will effectively over time become the national electronic patient record system – sometimes referred to as the spine. The Directory of Services will sit on the NCRS and be accessed by GPs and the PCTs and the BMS via the electronic booking system.

NATIONAL GUIDELINE CLEARINGHOUSE™ (NGC), a public resource for evidence-based clinical practice guidelines. NGC is sponsored by the Agency for Health Care Policy and Research in partnership with the American Medical Association and the American Association of Health Plans. http://www.guideline.gov/index.asp

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE): National body that provides patients, health professionals and the public with authoritative, robust and reliable guidance on ‘best practice’ in relation to public health, drugs, treatments and services across the NHS. (Until April 2005, it was known as the National Institute for Clinical Excellence and did not cover public health issues.)

NATIONAL PRIMARY CARE RESEARCH & DEVELOPMENT CENTRE: has different roles but is developing quality indicators for common conditions in general practice. www.npcrdc.man.ac.uk

NATIONAL SERVICE FRAMEWORK (NSF): National document which sets out the pattern and level of service that should be provided for a major care area or disease group such as mental health or heart disease.

NATURAL HISTORY OF DISEASE The course of a disease from onset to resolution. Many diseases have well defined stages: 1. Stage of pathological onset. 2. Presymptomatic stage: from onset to the first appearance of symptoms and/or signs. SCREENING may detect the disease at this stage. 3. Clinically manifest disease, which may regress spontaneously leading to recovery, or may be subject to remissions and relapses or progress to a fatal termination. Detection and intervention has the aim of altering the natural history of the health problem so that it has the least impact on the person's health.

NEED (Syn: need for health) The need for improving health status. NEED is goal-orientated and requires a statement of a norm. Also used as `need for health care'. NEED requires a specification as `need for . . .'. NEEDS can be specific for a health problem (NEED for mobility after hip replacement), or generic (NEED for preventive services). Health outcome measures are available for many dimensions of NEED.

NEEDS ASSESSMENT METHODS Any systematic approach to collecting and analysing information about individuals in terms of what is and what should be. It can be classified into seven main types, each of which can take many different forms in practice. Gap or discrepancy analysis. This formal method involves comparing performance with stated intended competencies- by self assessment, peer assessment, or objective testing -and planning education accordingly. Reflection on action and reflection in action Reflection on action is an aspect of experiential learning and involves thinking back to some performance, with or without triggers (such as videotape or audiotape), and identifying what was done well and what could have been done better. The latter category indicates learning needs. Reflection in action involves thinking about actual performance at the time that it occurs and requires some means of recording identified strengths and weaknesses at the time. Self assessment by diaries, journals, log books, weekly reviews This is an extension of reflection that involves keeping a diary or other account of experiences. However, practice might show that such documents tend to be written nearer the time of their review than the time of the activity being recorded. Peer review This is rapidly becoming a favourite method. It involves doctors assessing each other's practice and giving feedback and perhaps advice about possible education, training, or organisational strategies to improve performance. The Good CPD Guide describes five types of peer review internal, external, informal, multidisciplinary, and physician assessment. The last of these is the most formal, involving rating forms completed by nominated colleagues, and shows encouraging levels of validity, reliability, and acceptability. Observation In more formal settings doctors can be observed performing specific tasks that can be rated by an observer, either according to known criteria or more informally. The results are discussed, and learning needs are identified. The observer can be a peer, a senior, or a disinterested person if the ratings are sufficiently objective or overlap with the observer's area of expertise (such as communication skills or management). Critical incident review and significant event auditing Although this technique is usually used to identify the competencies of a profession or for quality assurance, it can also be used on an individual basis to identify learning needs. The method involves individuals identifying and recording, say, one incident each week in which they feel they should have performed better, analysing the incident by its setting, exactly what occurred, and the outcome and why it was ineffective. Practice review A routine review of notes, charts, prescribing, letters, requests, etc, can identify learning needs, especially if the format of looking at what is satisfactory and what leaves room for improvement is followed.

NEEDS ASSESSMENT: a formal assessment of the problems e.g. the population health needs or the gaps in your knowledge or skill. Types include Real Needs- a deficiency that actually exists as opposed to one that is thought to exist. Blind Needs- identified through audits, records, reports, and key informant interviews with authority sources/decision makers/ these are need of which learners are initially unaware until the needs are presented following analysis of the data. Shared needs identified by both learners and authority sources/decision makers. Hidden Needs reported by learners or needs assessment inputs that are not readily known or identified by authority sources/decision makers. Comparative needs- comparing the characteristics of those in receipt of a good or service with those who are not. Methods of needs assessment can be classified into seven main types, each of which can take many different forms in practice. Gap or discrepancy analysis This formal method involves comparing performance with stated intended competencies, self assessment, peer assessment, or objective testing and planning education accordingly. Reflection on action and reflection in action. Reflection on action is an aspect of experiential learning and involves thinking back to some performance, with or without triggers (such as videotape or audiotape), and identifying what was done well and what could have been done better. The latter category indicates learning needs. Reflection in action involves thinking about actual performance at the time that it occurs and requires some means of recording identified strengths and weaknesses at the time. The Canadian MOCOMP programme uses formalised reflection as its basic process. Similarly, PUNs and DENs are well known in British general practice. Self assessment by diaries, journals, log books, weekly reviews

This is an extension of reflection that involves keeping a diary or other account of experiences. However, practice might show that such documents tend to be written nearer the time of their review than the time of the activity being recorded. Peer review .This is rapidly becoming a favourite method. It involves doctors assessing each other's practice and giving feedback and perhaps advice about possible education, training, or organisational strategies to improve performance. The Good CPD Guide describes five types of peer review internal, external, informal, multidisciplinary, and physician assessment. The last of these is the most formal, involving rating forms completed by nominated colleagues, and shows encouraging levels of validity, reliability, and acceptability. Observation In more formal settings doctors can be observed performing specific tasks that can be rated by an observer, either according to known criteria or more informally. The results are discussed, and learning needs are identified. The observer can be a peer, a senior, or a disinterested person if the ratings are sufficiently objective or overlap with the observer's area of expertise (such as communication skills or management). Critical incident review and significant event auditing. Although this technique is usually used to identify the competencies of a profession or for quality assurance, it can also be used on an individual basis to identify learning needs. The method involves individuals identifying and recording, say, one incident each week in which they feel they should have performed better, analysing the incident by its setting, exactly what occurred, and the outcome and why it was ineffective. Practice review

A routine review of notes, charts, prescribing, letters, requests, etc, can identify learning needs, especially if the format of looking at what is satisfactory and what leaves room for improvement is followed.

LEARNING NEED ASSESSMENTS: If you are planning your CME for the next academic year, here is some practical information on how you learn, how to assess yourself, and how you can assess a study day or course before you spend your money? How to assess yourself? Self assessment can answer questions like Am I doing a good job? Can I do better? and Am I up to date with current literature? To answer the question “Am I doing a good job? You must know what a good job looks like. The GMC, GPC and RCGP try to describe the job and the RCGP has translated the descriptions into the criteria in Membership by Performance (MAP) and Fellowship by assessment (FBA) of the RCGP. Some sort of formal self assessment, linked with continuing medical education relevant to your practice of medicine will be an important part of the GMC revalidation process. You can do this either by self reflection on personal experience or a self administered test that evaluates your professional knowledge, competence or performance. Which is better? In self administered tests you use formats and media ranging from Journals with photographs and MCQs, through multimedia self assessment programmes on CD ROM (like the RCGP PEP programme) to skills laboratories that use advanced multimedia technology (the virtual reality environment or medical ‘flight’ simulator). In self assessment by practice reflection, you identify the need to learn after managing a particular problem (reflection in action) or after reflecting on the management of several patients with similar problems (reflection on action) and comparing your management with what is considered best practice. The process of reflection leads to identification of your learning needs and commitment to change. Either type of self assessment plays a key role in identifying your needs, making a commitment to change and adopting new practices. Studies suggest that self assessment by practice reflection generates more learning that is more likely to result in commitment to change than formal self assessment programmes. Self assessment programmes when offered as a precourse exercise to participants makes the courses developed from self assessed needs more effective. How do you learn? Ask yourself what you learn from drug representatives? On the one hand you may not trust the information the pharmaceutical representatives give you, while on the other, you are told the pharmaceutical industry influences doctors inappropriately. There is a paradox. . How can you be misled by information you mistrust? A study interviewing a randomly selected sample of doctors in N America has explored this paradox and suggested an answer in terms of adult learning theory. If the doctor is to learn solutions to clinical problems of importance to him/her three things must occur: the problem must be clearly identified; the doctor must reflect on the information offered in resolution of the problem and this must all be done in a way respectful of the fact that the doctor has multiple demands on his/her time. Viewed from this perspective otherwise knowledgeable doctors can leave interactions with representatives with inefficient and ineffective solutions to their problems because the interaction failed to address the principles of adult learning. This failure can result in deranged outcomes ranging from misinterpretation of information through frank communication of incorrect messages. There was a striking difference in the perceived credibility of what doctors learn from representatives as a function of whether the information is simply offered by the representatives or is in response to the doctors questions: unsolicited representative information tends not to be credible while information offered in response to doctors questions is much more credible! These differences in credibility of information can be understood using Adult Learning Theory ALT. If the physician –representative interaction is an opportunity for doctors to exercise their abilities as learners, doctors will likely learn if They address problems they already have (i.e. you only wants solutions to the problems you already have), They participate actively in their own learning (i.e. you ask questions), All of this occurs in a manner respectful of they fact that doctors have multiple demands on their lives ( i.e. you are busy and do not want your time wasted). If doctors report that the information they received from a drug representative was credible it is likely that the principles of adult learning theory have been met. How to assess a study day or course? Before you send any money to reserve a place on a study day you should check what you are likely to get for your money. In line with best educational practice (in N America) the CME provider should have a written statement of their CME mission, which includes the CME purpose, content areas, target audience, type of activities provided, and expected results of the programme. There should be clear planning processes that link identified educational needs with a desired result in the provision of all its CME activities. For each course needs assessment data should be used to plan CME activities, the learner (before participating in the activity) should be informed of the purpose or objectives of the activity, the effectiveness of the CME activities should be evaluated in meeting the identified educational needs and the effectiveness of the overall CME program should be evalulated and improvements made to the program. You are unlikely to find many study days that operate at this standard, so translating your self assessed needs into learning opportunities will continue to be a major challenge for everyone in the next few years.

NEEDS, HEALTH CARE (Syn: health needs) Requirements in existing health care perceived by patients and/or professionally defined by consensus or research. They may be further described as being "met" or "unmet", "felt" (syn: "wants") or "expressed". Needs always reflect prevailing value judgements and expectations.

NEGLIGENCE: negligent adverse events represent a subset of preventable adverse events that satisfy legal criteria used in determining negligence

NEIGHBOURHOOD RENEWAL: A national initiative under which areas with significant deprivation develop plans to tackle these problems.

NEONATAL MORTALITY RATE is used differently according to whether it is in clinical medicine or in vital statistics:1. In clinical research the term is used to describe the cumulative MORTALITY RATE of live-born infants within 28 days of age.2. In VITAL STATISTICS, it describes the number of deaths in infants under 28 days of age in a given period (i.e. a year) per 1000 live births in the same period.

NEONATAL PERIOD This period includes the first 28 days after birth.

NETWORK OF EXPERTISE in relation to professional performance refers to a peer group who will take forward the continuing policy and practice in return to work

NEWSLETTER – ongoing publication, produced at set times eg monthly/quarterly, which showcases developments in the service and is sent to a requested mailing list

NHS DATA DICTIONARY & MANUAL VERSION 1.2 NHS Data Dictionary & Manual. The NHS Data Dictionary & Manual replaces both the NHS Data DictionaryVersion 3.3 and the NHS Data Manual Version Version 5.3. http://www.nhsia.nhs.uk/datastandards/pages/dd_m.asp

NHS SUPPORT FOR SCIENCE: The scheme by which it is intended that the NHS will fund the service support and overhead costs of research, developed following the publication in March 2000 of Research & Development for a First Class Service: R&D in the New NHS.

NICE National Institute for Health and Clinical Excellence (see definition)

NMET (Non-medical Education and training) fund- administered by NHS training consortia. One of the NHS funding streams for training (MADEL, SIFT. NMET)

nMRCGP Enhanced trainers record – record of assessments held by the learner as part of the e-portfolio but the trainer may want to keep a copy.

NOMENCLATURE (Syn: terminology) Classified system of technical or scientific names.

NOMINAL SCALE A scale in which the numeric values assigned to the scale levels are arbitrary and have no numeric value and do not represent a ranking order (e.g. male= 1, female=2). A BINOMINAL SCALE consists of two divisions. See SCALE.

NON PARAMETRIC TEST A distribution-free method not depending on the underlying distribution of data.

NON-COMMERCIAL: Work that will contribute to the goals of the NHS and its partners in health and social care, or to the Government’s goals for public support for science and technology. (Government policy is that industry should meet the full costs of work that the NHS undertakes for industry under contract).

NON-PARTICIPANTS (Syn: non-responders) Members of a population or a study group who do not take part in an activity or study aimed at them.

NORM (OR PEER) BASED EXAMINATION: Success in an assessment based on your position compared to the other people who took the test (see criteria based), eg you pass if you are among the 50% of candidates who score the highest marks, this means 50% of candidates always fail.

NORM This term has two distinct meanings: 1. It can mean `what is usual' in a given society at a given time regarding treatment of a certain health problem, behaviour, etc. 2. It can mean `what is desirable'. What one finds to be a desirable standard for treatment of a certain health problem, behaviour, etc. In this latter sense norms can be used in MEDICAL AUDIT, as a GOLD STANDARD, to which performance, investigations or results of treatment can be measured against.

NORMAL DISTRIBUTION (Syn: Gaussian distribution) The continuous frequency distribution of infinite range which have the following properties:1. It is a continuous, symmetrical distribution where both tails extend to infinity. 2. The arithmetic mean and the median are identical. 3. Its shape is completely determined by the mean j and standard deviation.

NORMAL This term have three different meanings: 1. Within the usual range of variation in a population, i.e. within a range extending from two standard deviations below to two standard deviations above the mean or between the l0th and the 90th percentiles of the distribution. 2. In good health. For a diagnostic or screening test, a `normal' result is in a range where the probability of a health problem is low. 3. With regard to distribution see NORMAL DISTRIBUTION.

NORMATIVE Derived from the standard textbooks and the work of experts. The `best' level of care.

NORMATIVE STANDARDS Those derived from traditional sources of orthodox medical standards.

NOSOCOMIAL A new health problem arising in relation to being in hospital and unrelated to the patient's primary reason for being there.

NOSOLOGY The classification of diseases into groups by whatever criteria, based on agreement as to the boundaries of the groups.

NULL HYPOTHESIS A term used in statistical theory. The hypothesis expresses that groups are equal regarding a chosen parameter on distribution, presence of a determinant, occurrence of an event or outcome measure. The NULL HYPOTHESIS is tested with statistical techniques considering probability theory with quantitative thresholds that are set beforehand. If the NULL HYPOTHESIS is rejected it means that it is unlikely that the groups are equal. This is evidence that it is worthwhile considering that the two groups are different with regard to the variable which was compared. A NULL HYPOTHESIS is intended to be rejected, i.e. the groups are not expected to be equal. If one expects that groups are equal and intends to corroborate that expectation, a measure of agreement should be used. See P-VALUE, STATISTICAL SIGNIFICANCE.

NUMBER NEEDED TO HARM NNH : the number of patients who, if they received the experimental treatment, would lead to one additional person being harmed compared with patients who receive the control treatment; calculated as 1/ARI.

NUMBER NEEDED TO TREAT (NNT). The number of patients who nee to be treated to prevent one more adverse event.

NUMBER NEEDED TO TREAT NNT: the number of patients who need to be treated to create one additional improved outcome in comparison with the control treatment (or prevent one additional bad outcome); calculated as 1/ARR, rounded up to the next highest whole number, and accompanied by its 95% CI.

NUMERATOR The upper portion of a fraction used to calculate a rate or a ratio.