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

Quantifying the efficacy of an automated facial coding software using videos of parents

IntroductionThis work explores the use of an automated facial coding software - FaceReader - as an alternative and/or complementary method to manual coding.MethodsWe used videos of parents (fathers, n = 36; mothers, n = 29) taken from the Avon Longitudinal Study of Parents and Children. The videos—obtained during real-life parent-infant interactions in the home—were coded both manually (using an existing coding scheme) and by FaceReader. We established a correspondence between the manual and automated coding categories - namely Positive, Neutral, Negative, and Surprise - before contingency tables were employed to examine the software’s detection rate and quantify the agreement between manual and automated coding. By employing binary logistic regression, we examined the predictive potential of FaceReader outputs in determining manually classified facial expressions. An interaction term was used to investigate the impact of gender on our models, seeking to estimate its influence on the predictive accuracy.ResultsWe found that the automated facial detection rate was low (25.2% for fathers, 24.6% for mothers) compared to manual coding, and discuss some potential explanations for this (e.g., poor lighting and facial occlusion). Our logistic regression analyses found that Surprise and Positive expressions had strong predictive capabilities, whilst Negative expressions performed poorly. Mothers’ faces were more important for predicting Positive and Neutral expressions, whilst fathers’ faces were more important in predicting Negative and Surprise expressions.DiscussionWe discuss the implications of our findings in the context of future automated facial coding studies, and we emphasise the need to consider gender-specific influences in automated facial coding research

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

The impact of routines on emotional and behavioural difficulties in children and on parental anxiety during COVID-19

BackgroundThe Covid-19 pandemic and related public health measures, including lockdowns and school closures, have impacted on mental health of children.Aims and hypothesisWe hypothesised that there would be an association between maintaining a routine during lockdown and both lower emotional and behavioural difficulties in children and lower parental anxiety. Routine was taken as keeping to the same basic activities such as mealtimes and bedtimes. We also hypothesised that children of ‘keyworker’ parents would have fewer emotional and behavioural symptoms due to having maintained more normal routines. The key reason was that children of keyworkers still attended school or nursery and parents would have been getting up and coming home at the same times as pre-Covid. Keyworker status was defined as those whose work was essential to Covid-19 response, including work in health and social care and other key sectors.MethodsWe used data from the Avon Longitudinal Study of Parents and Children (ALSPAC) to explore associations between maintaining a routine, and emotional and behavioural difficulties in children, using linear regression models. All eligible ALSPAC-G2 participants were sent the survey and the responders are representative of the eligible G2 population. We included measures of parental anxiety. We separately explored associations with having a keyworker parent. We used the Carey Infant Temperament Questionnaire and the Revised Rutter Parent Scale for Preschool Children to establish levels of emotional and behavioural difficulties. The measures were chosen to match previous waves in multi-generations in ALSPAC where they had been shown to be predictive of later mental health in children. The scales measure emotional and behavioural problems.ResultsTwo hundred eighty-nine parents completed questionnaires about their 411 children. Keeping a routine was associated with emotional and behavioural difficulty scores 5.0 points lower (95% CI −10.0 to −0.1), p = 0.045 than not keeping a routine. Parents who reported keeping a routine had anxiety scores 4.3 points lower (95% CI −7.5 to −1.1), p = 0.009 than those who did not. Children of keyworkers tended to have lower emotional and behavioural difficulty scores [−3.1 (95%CI −6.26 to 0.08), p = 0.056] than children of non-keyworkers. All models were adjusted for relevant potential confounders.ConclusionMaintaining a routine may be beneficial for both child emotional wellbeing and parental anxiety, although it is also possible that lower parental anxiety levels made maintaining a routine easier. Being the child of a keyworker parent during lockdown may have been protective for child emotional wellbeing

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

Zombies, time machines and brains: Science fiction made real in immersive theatres

Critical thought on immersive theatres is gathering in pace with many arguments centred on explorations of audience/performer interaction and the unique relationship these theatres create. Within this paper I look beyond these debates in order to consider the implications of immersive theatres within contemporary culture, with the aim of furthering the ways in which immersive theatres are presently being framed and discussed. Theatre and science fiction have shared a somewhat limited relationship compared to their burgeoning usage within other forms of entertainment. This paper focuses on how the conceits of science fiction are being staged within this theatrical setting. Primary focus is given to Punchdrunk's… and darkness descended (2011) and The Crash of the Elysium (2011–2012). This is considered alongside The Republic of the Imagination's (TROTI) Cerebellium (2012–14), an original narrative created for the performance which has been subsequently developed over a three-year period to date. This discussion is presented and framed through my personal experience as both a performer in Cerebellium and (later) as audience member. The particular use of dystopian narratives and alternate worlds is given consideration, with reflection on the way these works destabilize and call into question the audience's sense of self either through their ability to survive or understand their sense of self. By making evident the spectrum of practice, I endeavour to delve further into identifying and de-mystifying immersive theatres and their differences to conventional theatre