How theories of complexity and resilience affect interprofessional simulation-based education: a qualitative analysis of facilitators' perspectives

Background Quality of care and patient safety rely on the ability of interprofessional teams to collaborate effectively. This can be trained through interprofessional simulation-based education (IPSE). Patient safety also relies on the ability to adapt to the complexity of such situations, an ability termed resilience. Since these needs are not explicitly addressed in IPSE, the aim of this study was to explore how central concepts from complexity-theory and resilience affect IPSE, from facilitators’ perspective, when applied in debriefings. Methods A set of central concepts in complexity-theory and resilience were introduced to facilitators on an IPSE course for nursing and medical students. In five iterations of focus groups interviews the facilitators discussed their application of these concepts by reviewing video recordings of their own debriefings. Video recordings of the interviews were subjected to coding and thematic analysis. Results Three themes were identified. The first, Concepts of complexity and resilience are relevant for IPSE, points to the applicability of these concepts and to the fact that students often need to deviate from prescribed guidelines/algorithms in order to solve cases. The second theme, Exploring complexity, shows how uncertainty could be used as a cue to explore complexity. Further, that individual performance needs to account for the context of actions and how this may lead to certain outcomes. Moreover, it was suggested that several ways to approach a challenge can contribute to important insight in the conditions for teamwork. The third theme, Unpacking how solutions are achieved, turns to needs for handling the aforementioned complexity. It illustrates the importance of addressing self-criticism by highlighting how students were often able to overcome challenges and find solutions. Finally, this theme highlights how pre-defined guidelines and algorithms still work as important resources to help students in transforming perceived messiness into clarity. Conclusions This study suggests that IPSE provides the possibility to explore complexity and highlight resilience so that such capability can be trained and improved. Further studies are needed to develop more concrete ways of using IPSE to account for complexity and developing resilience capacity and to evaluate to what extent IPSE can provide such an effect.publishedVersio

Refractory angina pectoris. Patient characteristics, safety and long-term effects of spinal cord stimulation

Refractory angina pectoris has been defined as severe angina pectoris due to coronary artery disease which cannot be controlled by conventional pharmacological or surgical therapy. The epidemiology of this condition is virtually unknown. During the last decades, additional treatment options have been developed for this condition. One of these is spinal cord stimulation (SCS), which has been used for approximately 20 years as an additional symptom-relieving treatment for patients with severe angina pectoris. SCS has an anti-ischaemic effect and has been shown to be a safe and effective treatment modality. The occurrence of refractory angina pectoris among patients who had undergone coronary angiography was assessed in a defined geographic area. In order to characterise the patients with regard to concurrent diseases, treatment, functional class, quality of life, morbidity and fatality, the refractory angina patients were compared with patients with severe angina pectoris who were accepted for revascularisation. Within three years, 146 patients were identified, comprising 2.1% of all patients undergoing coronary angiography due to stable angina pectoris. The patients with refractory angina pectoris had more severe cardiac disease as well as coronary artery disease than the patients in the revascularisation group. Some of the patients in the refractory group appear to be in a fairly good condition with regard to extracardiac diseases but there is a subpopulation in the refractory group with severe cardiac as well as extracardiac diseases. The main reasons for rejection for revascularisation were unsuitable coronary anatomy and a potential risk of damaging existing grafts. After one year of follow-up the refractory patients had a higher fatality rate but a lower frequency of cerebrovascular morbidity than the revascularisation group. The refractory patients had more severe angina and lower quality of life with regard to physical function and impact of angina symptoms, compared with the revascularisation group. However, the mental health of the refractory patients was not affected compared with the revascularisation group. The patients in the so-called ESBY study (Electrical Stimulation versus Coronary Bypass Surgery in Severe Angina Pectoris, a randomised comparison of SCS and coronary artery bypass grafting (CABG) in 104 patients with severe angina pectoris and increased surgical risk) were followed up with regard to neurological and neuropsychological complications, morbidity and cost-effectiveness. There were more patients in the CABG group who developed neurological and neuropsychological complications than in the SCS group. Furthermore, presence of deep white matter disease on cerebral magnetic resonance imaging was shown to be a predictor of cerebrovascular complications after CABG. During two years of follow-up, health care costs and cardiac morbidity was lower in the SCS group than in the CABG group. However, the groups did not differ with regard to mortality or causes of death. There were no serious complications related to the SCS treatment. CONCLUSION Refractory angina pectoris appears to be a considerable problem. This patient group has a high fatality rate and low quality of life compared with revascularised patients. SCS, which is one of the recommended treatment option for these patients, was found to be safe (in terms of mortality, morbidity and absence of serious complications) and effective (in terms of symptom relief and cost-effectiveness) during long-term treatment. Furthermore, presence of deep white matter disease on cerebral magnetic resonance imaging seems to be a predictor of cerebrovascular complications after CABG

Insomnia Symptoms and Chronic Pain among Patients Participating in a Pain Rehabilitation Program—A Registry Study

Insomnia and chronic pain are prevalent health complaints. Previous research has shown that they are closely associated, but their interaction and causality are not completely understood. Further research is needed to uncover the extent to which a treatment strategy focusing on one of the conditions affects the other. This study aimed to map the prevalence of insomnia symptoms among patients in interdisciplinary pain rehabilitation program (IPRP) and investigate associations between the degree of insomnia at baseline and the treatment outcome regarding pain intensity, physical function, social function, mental well-being, anxiety, and depression. Of the 8515 patients with chronic pain, aged 15–81 who were registered in the Swedish Quality Registry for Pain Rehabilitation during 2016–2019 and participated in IPRP, 7261 had follow-up data after treatment. Logistic regression analysis was used to investigate associations. The prevalence of clinical insomnia, according to Insomnia Severity Index (ISI), among chronic pain patients in IPRP was 66%, and insomnia symptoms were associated with both country of birth and educational level. After IPRP, the prevalence of clinical insomnia decreased to 47%. There were statistically significant associations between the degree of insomnia symptoms before IPRP and physical function (p < 0.001), social function (p = 0.004) and mental well-being (p < 0.001). A higher degree of insomnia symptoms at baseline was associated with improvement after IPRP. In conclusion, IPRP seem to have beneficial effects on insomnia symptoms in chronic pain patients. Nevertheless, almost half of the patients still suffer from clinical insomnia after IPRP. The possible effect of systematic screening and treatment of insomnia for improving the effect of IPRP on pain is an important area for future research

How theories of complexity and resilience affect interprofessional simulation-based education: a qualitative analysis of facilitators’ perspectives

Abstract Background Quality of care and patient safety rely on the ability of interprofessional teams to collaborate effectively. This can be trained through interprofessional simulation-based education (IPSE). Patient safety also relies on the ability to adapt to the complexity of such situations, an ability termed resilience. Since these needs are not explicitly addressed in IPSE, the aim of this study was to explore how central concepts from complexity-theory and resilience affect IPSE, from facilitators’ perspective, when applied in debriefings. Methods A set of central concepts in complexity-theory and resilience were introduced to facilitators on an IPSE course for nursing and medical students. In five iterations of focus groups interviews the facilitators discussed their application of these concepts by reviewing video recordings of their own debriefings. Video recordings of the interviews were subjected to coding and thematic analysis. Results Three themes were identified. The first, Concepts of complexity and resilience are relevant for IPSE, points to the applicability of these concepts and to the fact that students often need to deviate from prescribed guidelines/algorithms in order to solve cases. The second theme, Exploring complexity, shows how uncertainty could be used as a cue to explore complexity. Further, that individual performance needs to account for the context of actions and how this may lead to certain outcomes. Moreover, it was suggested that several ways to approach a challenge can contribute to important insight in the conditions for teamwork. The third theme, Unpacking how solutions are achieved, turns to needs for handling the aforementioned complexity. It illustrates the importance of addressing self-criticism by highlighting how students were often able to overcome challenges and find solutions. Finally, this theme highlights how pre-defined guidelines and algorithms still work as important resources to help students in transforming perceived messiness into clarity. Conclusions This study suggests that IPSE provides the possibility to explore complexity and highlight resilience so that such capability can be trained and improved. Further studies are needed to develop more concrete ways of using IPSE to account for complexity and developing resilience capacity and to evaluate to what extent IPSE can provide such an effect

Suffering out of sight but not out of mind - interpreting experiences of sick leave due to chronic pain in a community setting : A qualitative study

OBJECTIVE: Chronic pain is a complex health problem affecting about one-fifth of the European population. It is a leading cause of years lived with disability worldwide, with serious personal, relational and socioeconomic consequences. Chronic pain and sick leave adversely affect health and quality of life. Thus, understanding this phenomenon is essential for reducing suffering, understanding the need for support and promoting a rapid return to work and an active lifestyle. This study aimed to describe and interpret persons' experiences of being on sick leave due to chronic pain. DESIGN: A qualitative study with semistructured interviews analysed using a phenomenological hermeneutic approach. SETTING: Participants were recruited from a community setting in Sweden. PARTICIPANTS: Fourteen participants (12 women) with experiences of part-time or full-time sick leave from work due to chronic pain were included in the study. RESULTS: Suffering out of sight but not out of mind was the main theme of the qualitative analysis. This theme implies that the participants' constant suffering was invisible to others, causing them to feel they were not being justly treated in society. Feeling overlooked led to a continuous struggle for recognition. Moreover, the participants' identities and their trust in themselves and their bodies were challenged. However, our study also revealed a nuanced understanding of the experiences of sick leave as a consequence of chronic pain, where the participants learnt important lessons, including coping strategies and re-evaluated priorities. CONCLUSIONS: Being on sick leave due to chronic pain threatens a person's integrity and leads to substantial suffering. An enhanced understanding of the meaning of sick leave due to chronic pain provides important considerations for their care and support. This study highlights the importance of feeling acknowledged and being met with justice in encounters with others

Time to gain trust and change : - experiences of attachment and mindfulness-based cognitive therapy among patients with chronic pain and psychiatric co-morbidity

The treatment of patients with chronic pain disorders is complex. In the rehabilitation of these patients, coping with chronic pain is seen as important. The aim of this study was to explore the meaning of attachment and mindfulness-based cognitive therapy (CT) among patients with chronic pain and psychiatric co-morbidity. A phenomenological approach within a lifeworld perspective was used. In total, 10 patients were interviewed after completion of 7- to 13-month therapy. The findings reveal that the therapy and the process of interaction with the therapist were meaningful for the patients’ well-being and for a better management of pain. During the therapy, the patients were able to initiate a movement of change. Thus, CT with focus on attachment and mindfulness seems to be of value for these patients. The therapy used in this study was adjusted to the patients’ special needs, and a trained psychotherapist with a special knowledge of patients with chronic pain might be required

Total opioid-free general anaesthesia can improve postoperative outcomes after surgery, without evidence of adverse effects on patient safety and pain management : A systematic review and meta-analysis

Background: Opioid-based treatment is used to manage stress responses during surgery and postoperative pain. However, opioids have both acute and long-term side effects, calling for opioid-free anaesthetic strategies. This meta-analysis compares adverse events, postoperative recovery, discharge time from post-anaesthesia care unit, and postoperative pain, nausea, vomiting, and opioid consumption between strict opioid-free and opioid-based general anaesthesia. Methods: We conducted a systematic review and meta-analysis. We searched PubMed, Embase, Cinahl, Cochrane Library, selected reference lists, and Google Scholar. We included randomised controlled trials (RCTs) published between January 2000 and February 2021 with at least one opioid-free study arm, i.e. no opioids administered preoperatively, during anaesthesia induction, before skin closure, or before emergence from anaesthesia. Results: The study comprised 1934 patients from 26 RCTs. Common interventions included laparoscopic gynaecological surgery, upper gastrointestinal surgery, and breast surgery. There is firm evidence that opioid-free anaesthesia significantly reduced adverse postoperative events (OR 0.32, 95% CI 0.22 to 0.46, I2 = 56%, p < 0.00001), mainly driven by decreased nausea (OR 0.27, (0.17 to 0.42), p < 0.00001) and vomiting (OR 0.22 (0.11 to 0.41), p < 0.00001). Postoperative opioid consumption was significantly lower in the opioid-free group (−6.00 mg (−8.52 to −3.48), p < 0.00001). There was no significant difference in length of post-anaesthesia care unit stay and overall postoperative pain between groups. Conclusions: Opioid-free anaesthesia can improve postoperative outcomes in several surgical settings without evidence of adverse effects on patient safety and pain management. There is a need for more evidence-based non-opioid anaesthetic protocols for different types of surgery as well as postoperative phases