Facing hierarchy: a qualitative study of residents\u27 experiences in an obstetrical simulation scenario

BACKGROUND: Residents in surgical specialties face a steep hierarchy when managing medical crises. Hierarchy can negatively impact patient safety when team members are reluctant to speak up. Yet, simulation has scarcely been previously utilized to qualitatively explore the way residents in surgical specialities navigate this challenge. The study aimed to explore the experiences of residents in one surgical specialty, obstetrics and gynecology (Ob/Gyn), when challenging hierarchy, with the goal of informing future interventions to optimize resident learning and patient safety. METHODS: Eight 3rd- and 4th-year Ob/Gyn residents participated in a simulation scenario in which their supervising physician made an erroneous medical decision that jeopardized the wellbeing of the labouring mother and her foetus. Residents participated in 30-45 min semi-structured interviews that explored their approach to managing this scenario. Transcribed interviews were analysed using qualitative thematic inquiry by three research team members, finalizing the identified themes once consensus was reached. RESULTS: Study results show that the simulated scenario did create an experience of hierarchy that challenged residents. In response, residents adopted three distinct communication strategies while confronting hierarchy: (1) messaging - a mere reporting of existing clinical information; (2) interpretive - a deliberate construction of clinical facts aimed at swaying supervising physician\u27s clinical decision; and (3) advocative - a readiness to confront the staff physician\u27s clinical decision. Furthermore, residents utilized coping mechanisms to mitigate challenges related to confronting hierarchy, namely deflecting responsibility, diminishing urgency, and drafting allies. Both these communication strategies and coping mechanisms shaped their practice when challenging hierarchy to preserve patient safety. CONCLUSIONS: Understanding the complex processes in which residents engage when confronting hierarchy can serve to inform the development and study of curricular innovations. Informed by these processes, we must move beyond solely teaching residents to speak up and consider a broader curriculum that targets not only residents but also faculty physicians and the learning environment within the organization

Do technical skills correlate with non-technical skills in crisis resource management: a simulation study

Background Both technical skills (TS) and non-technical skills (NTS) are key to ensuring patient safety in acute care practice and effective crisis management. These skills are often taught and assessed separately. We hypothesized that TS and NTS are not independent of each other, and we aimed to evaluate the relationship between TS and NTS during a simulated intraoperative crisis scenario. Methods This study was a retrospective analysis of performances from a previously published work. After institutional ethics approval, 50 anaesthesiology residents managed a simulated crisis scenario of an intraoperative cardiac arrest secondary to a malignant arrhythmia. We used a modified Delphi approach to design a TS checklist, specific for the management of a malignant arrhythmia requiring defibrillation. All scenarios were recorded. Each performance was analysed by four independent experts. For each performance, two experts independently rated the technical performance using the TS checklist, and two other experts independently rated NTS using the Anaesthetists' Non-Technical Skills score. Results TS and NTS were significantly correlated to each other (r=0.45, P<0.05). Conclusions During a simulated 5 min resuscitation requiring crisis resource management, our results indicate that TS and NTS are related to one another. This research provides the basis for future studies evaluating the nature of this relationship, the influence of NTS training on the performance of TS, and to determine whether NTS are generic and transferrable between crises that require different T

Barriers and facilitators to implementing a regional anesthesia service in a low-income country: a qualitative study

Introduction:&nbsp;regional anesthesia is a safe alternative to general anesthesia. Despite benefits for perioperative morbidity and mortality, this technique is underutilized in low-resource settings. In response to an identified need, a regional anesthesia service was established at the University Teaching Hospital of Kigali (CHUK), Rwanda. This qualitative study investigates the factors influencing implementation of this service in a low-resource tertiary-level teaching hospital. Methods:&nbsp;following service establishment, we recruited 18 local staff at CHUK for in-depth interviews informed by the “Consolidated Framework for Implementation Research” (CFIR). Data were coded using an inductive approach to discover emergent themes. Results:&nbsp;four themes emerged during data analysis.&nbsp;Patient experience and outcomes:&nbsp;where equipment failure is frequent and medications unavailable, regional anesthesia offered clear advantages including avoidance of airway intervention, improved analgesia and recovery and cost-effective care. Professional&nbsp;satisfaction:&nbsp;morale among healthcare providers suffers when outcomes are poor. Participants were motivated to learn techniques that they believe improve patient care.&nbsp;Human and material shortages:&nbsp;clinical services are challenged by high workload and human resource shortages. Advocacy is required to solve procurement issues for regional anesthesia equipment.&nbsp;Local engagement for sustainability:&nbsp;participants emphasized the need for a locally run, sustainable service. This requires broad engagement through education of staff and long-term strategic planning to expand regional anesthesia in Rwanda. Conclusion:&nbsp;while the establishment of regional anesthesia in Rwanda is challenged by human and resource shortages, collaboration with local stakeholders in an academic institution is pivotal to sustainability

Expanding luminescence horizons in macropolyhedral heteroboranes

Luminescence is observed in three novel macropolyhedral nineteen- and eighteen-vertex chalcogenaboranes: Se2B17H17 (1), SeB17H19 (3) and SeB18H20 (4). This led us to the recognition that previously published macropolyhedral heteroborane species might also exhibit luminescence. Thus, the known nineteen- and eighteen-vertex dithiaboranes S2B17H17 (2), n-S2B16H16 (5) and i-S2B16H16 (6) were synthesised and also found to exhibit a range of luminescent properties. These macropolyhedral species are very different from the previously unique fluorescent binary borane B18H22 in terms of their structural architectures, by the presence of borane cluster hetero atoms, and, as in the cases of 5 and 6, that their synthetic origins are not derived simply through the modification of B18H22 itself. They consequently greatly expand the possibilities of finding new luminescent inorganic borane species

Transfer of learning and patient outcome in simulated crisis resource management : a systematic review

PURPOSE: Simulation-based learning is increasingly used by healthcare professionals as a safe method to learn and practice non-technical skills, such as communication and leadership, required for effective crisis resource management (CRM). This systematic review was conducted to gain a better understanding of the impact of simulation-based CRM teaching on transfer of learning to the workplace and subsequent changes in patient outcomes. SOURCE: Studies on CRM, crisis management, crew resource management, teamwork, and simulation published up to September 2012 were searched in MEDLINE(®), EMBASE™, CINAHL, Cochrane Central Register of Controlled Trials, and ERIC. All studies that used simulation-based CRM teaching with outcomes measured at Kirkpatrick Level 3 (transfer of learning to the workplace) or 4 (patient outcome) were included. Studies measuring only learners' reactions or simple learning (Kirkpatrick Level 1 or 2, respectively) were excluded. Two authors independently reviewed all identified titles and abstracts for eligibility. PRINCIPAL FINDINGS: Nine articles were identified as meeting the inclusion criteria. Four studies measured transfer of simulation-based CRM learning into the clinical setting (Kirkpatrick Level 3). In three of these studies, simulation-enhanced CRM training was found significantly more effective than no intervention or didactic teaching. Five studies measured patient outcomes (Kirkpatrick Level 4). Only one of these studies found that simulation-based CRM training made a clearly significant impact on patient mortality. CONCLUSIONS: Based on a small number of studies, this systematic review found that CRM skills learned at the simulation centre are transferred to clinical settings, and the acquired CRM skills may translate to improved patient outcomes, including a decrease in mortality

Assessment of child or young person with a possible eating disorder

Assessing young people with possible eating disorders can be complex for a variety of reasons, including managing confidentiality and risk (for example, a young person not wanting their parent to be involved, or a parent presenting with concerns about their child), the young person or parent not being aware of the severity of the illness, and difficulty in knowing how questions can be sensitively phrased. This Practice Pointer will offer advice on building therapeutic relationships in consultation with a child or young person, and with their parent(s), what information to gather and how to do so sensitively, and how to discuss the role of the parent or carer in treatment. We recommend that it is read alongside the accompanying Clinical Update for detailed notes on examination, investigations, when to refer, and risk. The advice is based on expert experience. We use the female pronoun throughout as eating disorders are more prevalent in females, but it should be noted that they can and do also occur in males

Measuring practice leadership in supported accommodation services for people with intellectual disability: Comparing staff-rated and observational measures

Background Studies incorporating staff-rated or observational measures of practice leadership have shown that where practice leadership is stronger, active support is better implemented. The study aim was to compare measures of practice leadership used in previous research to determine the extent of their correspondence. Method A subset of data from a longitudinal study regarding 29 front-line managers working across 36 supported accommodation services in Australia was used. An observed measure of practice leadership, based on an interview and observation of a front-line manager, was compared with ratings of practice leadership completed by staff. The quality of active support was rated after a 2-hour structured observation. Results Correlations between staff-rated and observed measures were non-significant. Only the observed measure was correlated with the quality of active support. Conclusions This study provides evidence to support using an observational measure of practice leadership rather than reliance on staff ratings

Electrical Components for Marine Renewable Energy Arrays: A Techno-Economic Review

This paper presents a review of the main electrical components that are expected to be present in marine renewable energy arrays. The review is put in context by appraising the current needs of the industry and identifying the key components required in both device and array-scale developments. For each component, electrical, mechanical and cost considerations are discussed; with quantitative data collected during the review made freely available for use by the community via an open access online repository. This data collection updates previous research and addresses gaps specific to emerging offshore technologies, such as marine and floating wind, and provides a comprehensive resource for the techno-economic assessment of offshore energy arrays

Recent trends in publication of basic science and clinical research by United States investigators in anesthesia journals

<p>Abstract</p> <p>Background</p> <p>United States anesthesia research production declined sharply from 1980-2005. Whether this trend has continued despite recent calls to improve output is unknown. We conducted an observational internet analysis to quantify American basic science and clinical anesthesia research output in 14 anesthesia journals with impact factors greater than one at three-year intervals during the past decade.</p> <p>Results</p> <p>American investigators published 1,486 (21.7%) of the total of 6,845 research articles identified in anesthesia journals in 2001, 2004, 2007, and 2010. Approximately two-thirds of all US articles were published in <it>Anesthesiology </it>and <it>Anesthesia and Analgesia</it>. There was a significant correlation (r²= 0.316; P = 0.036) between the number of articles published by American authors in each anesthesia journal and the corresponding journal's impact factor in 2010. Significantly (P < 0.05; Pearson's Chi-square) fewer basic science articles were published in 2007 and 2010 compared with 2001. US clinical research output also declined in 2007 (201; 15.7%) compared with 2001 (266; 19.1%) and 2004, but an increase occurred in 2010 (279; 21.8%, P < 0.05 versus 2007).</p> <p>Conclusions</p> <p>The results indicate that US anesthesia research output continued to decrease from 2001 to 2007. An increase in clinical but not basic science research was observed in 2010 compared with 2007, suggesting that a modest recovery in clinical research production may have begun.</p