Operational failures and how they influence the work of GPs: a qualitative study in primary care

BACKGROUND

Operational failures, defined as inadequacies or errors in the information, supplies, or equipment needed for patient care, are known to be highly consequential in hospital environments. Despite their likely relevance for GPs' experiences of work, they remain under-explored in primary care.

AIM

To identify operational failures in the primary care work environment and to examine how they influence GPs' work.

DESIGN AND SETTING

Qualitative interview study in the East of England.

METHOD

Semi-structured interviews were conducted with GPs (n = 21). Data analysis was based on the constant comparison method.

RESULTS

GPs reported a large burden of operational failures, many of them related to information transfer with external healthcare providers, practice technology, and organisation of work within practices. Faced with operational failures, GPs undertook 'compensatory labour' to fulfil their duties of coordinating and safeguarding patients' care. Dealing with operational failures imposed significant additional strain in the context of already stretched daily schedules, but this work remained largely invisible. In part, this was because GPs acted to fix problems in the here-and-now rather than referring them to source, and they characteristically did not report operational failures at system level. They also identified challenges in making process improvements at practice level, including medicolegal uncertainties about delegation.

CONCLUSION

Operational failures in primary care matter for GPs and their experience of work. Compensatory labour is burdensome with an unintended consequence of rendering these failures largely invisible. Recognition of the significance of operational failures should stimulate efforts to make the primary care work environment more attractive.

Periodic Kinesthetic Guidance Cannot Expedite Learning Surgical Skills

Introduction. Connecting multiple haptic devices in a master-slave fashion enables us to deliver kinesthetic (haptic) feedback from 1 person to another. This study examined whether inter-user feedback delivered from an expert to a novice would facilitate skill acquisition of the novice in learning laparoscopic surgery and expedite it compared to traditional methods. Methods. We recruited fourteen novices and divided them into 1 of 2 training groups with 6 half-hour training sessions. The task was precision cutting adopted from one of the tasks listed in Fundamentals of Laparoscopic Surgery using laparoscopic instruments. In the haptic feedback group (haptic), 8 subjects had the chance to passively feel an expert's performance before they started to practice in each training session. In the self-learning group (control), 6 subjects watched a video before practicing. Each session was video recorded, and task performance was measured by task completion time, number of grasper adjustments, and instrument crossings. Cutting accuracy, defined as the percentage of deviation of the cutting line from the predefined line, was analyzed via computer analysis. Results. Results show no significant difference among performance measures between the 2 groups. Participants performed similarly when practicing alone or with periodic haptic feedback. Discussion. Further research will be needed for improving our way of integrating between-person haptic feedback with skills training protocol.

Addressing the Needs of Mothers with Infants in the Neonatal Intensive Care Unit: A Qualitative Secondary Analysis

PURPOSE

Mothers of infants hospitalized in neonatal intensive care units (NICUs) need to be recognized as essential partners of the care team as their presence and involvement are key to infants' health and developmental outcomes. Addressing mothers' perceived needs is beneficial for the improvement of supportive nursing care; however, little qualitative research on their unmet needs has been conducted in South Korea. This study assessed mothers' perspectives on their NICU experiences and their unmet needs within the South Korean cultural context.

METHOD

A cross-sectional, multicentered, secondary analysis study was conducted using the written responses to an open-ended questionnaire. Of the 344 NICU-experienced mothers, 232 throughout South Korea (seven cities and five provinces) voluntarily completed the questionnaire via smartphone-based or web-based surveys. Their narrative responses were analyzed using thematic content analysis guided by the critical incident technique.

RESULTS

Four themes emerged. NICU-experienced mothers of preterm infants referred to the "family-friendly environment" (16.4%) as a positive experience. The greatest unmet need was "relationship-based support" (58.2%), followed by "information and education-based support" (20.0%) and "system-level challenges" (5.4%).

CONCLUSION

The importance of creating a family-friendly NICU environment should be emphasized by ensuring 24-hour unrestricted access and encouraging active parental involvement in infant care, as well as actively supporting NICU families through supportive words and actions. The assurance of antiinfection management and better staffing levels should be fundamentally guaranteed to NICU staff.

The Modified Strain Index: A Composite Measure of Injury Risk for Signers

Up to 81% of individuals who are fluent in sign language (signers) report pain. Non-native signers (with non-signing, non-deaf parents) report greater pain than natives (≥1 signing, deaf parent). The goal of this study was to develop a composite measure of injury risk (the modified Strain Index for signers) based on previously identified biomechanics unique to signers and examine scores across sub-groups of natives and non-natives. Non-natives were hypothesized to have greater pain and higher composite scores than natives. Ten natives and 15 non-natives used a numeric scale to rate pain while signing. Measures included 'micro' rests, muscle activation, ballistic signing, non-neutral joint angle, and work envelope. Descriptive statistics were used to create categorical ratings and backward elimination multiple linear regression to establish rank order of the biomechanical tasks. Participant performance was rated, and the product of the multipliers across tasks created a score. Pain intensity was associated with the composite score (r = 0.46; p = 0.02), however there was no difference between natives (score = 13.39 ± 3.1) and non-natives (score = 19.55 ± 4.7; p = 0.34). This work presents an approach to incorporate multiple biomechanical factors into a single, composite measure unique to signers, however further evidence-based adjustments are needed to enhance its robustness.

Is Low-Frequency Electrical Stimulation a Tool for Recovery after a Water Rescue? A Cross-Over Study with Lifeguards

This study aimed to evaluate the degree to which transcutaneous electrical stimulation (ES) enhanced recovery following a simulated water rescue. Twenty-six lifeguards participated in this study. The rescue consisted of swimming 100 m with fins and rescue-tube: 50 m swim approach and 50 m tow-in a simulated victim. Blood lactate clearance, rated perceived effort (RPE), and muscle contractile properties were evaluated at baseline, after the water rescue, and after ES or passive-recovery control condition (PR) protocol. Tensiomiography, RPE, and blood lactate basal levels indicated equivalence between both groups. There was no change in tensiomiography from pre to post-recovery and no difference between recovery protocols. Overall-RPE, legs-RPE and arms-RPE after ES (mean ± SD; 2.7 ± 1.53, 2.65 ± 1.66, and 2.30 ± 1.84, respectively) were moderately lower than after PR (3.57 ± 2.4, 3.71 ± 2.43, and 3.29 ± 1.79, respectively) (p = 0.016, p = 0.010, p = 0.028, respectively). There was a significantly lower blood lactate level after recovery in ES than in PR (mean ± SD; 4.77 ± 1.86 mmol·L^-1 vs. 6.27 ± 3.69 mmol·L^-1; p = 0.045). Low-frequency ES immediately after a water rescue is an effective recovery strategy to clear out blood lactate concentration.

Non-Spatial Impairments Affect False-Positive Neglect Diagnosis Based on Cancellation Tasks

OBJECTIVE

To diagnose egocentric neglect after stroke, the spatial bias of performance on cancellation tasks is typically compared to a single cutoff. This standard procedure relies on the assumption that the measurement error of cancellation performance does not depend on non-spatial impairments affecting the total number of cancelled targets. Here we assessed the impact of this assumption on false-positive diagnoses.

METHOD

We estimated false positives by simulating cancellation data using a binomial model. Performance was summarised by the difference in left and right cancelled targets (R-L) and the Centre of Cancellation (CoC). Diagnosis was based on a fixed cutoff versus cutoffs adjusted for the total number of cancelled targets and on single test performance versus unanimous or proportional agreement across multiple tests. Finally, we compared the simulation findings to empirical cancellation data acquired from 651 stroke patients.

RESULTS

Using a fixed cutoff, the rate of false positives depended on the total number of cancelled targets and ranged from 10% to 30% for R-L scores and from 10% to 90% for CoC scores. The rate of false positives increased even further when diagnosis was based on proportional agreement across multiple tests. Adjusted cutoffs and unanimous agreement across multiple tests were effective at controlling false positives. For empirical data, fixed versus adjusted cutoffs differ in estimation of neglect prevalence by 13%, and this difference was largest for patients with non-spatial impairments.

CONCLUSIONS

Our findings demonstrate the importance of considering non-spatial impairments when diagnosing neglect based on cancellation performance.

Technical-Tactical Behaviors Analysis of Male and Female Judo Cadets' Combats

This brief research report showed technical-tactical behaviors of male and female judo cadets during combats, comparing the frequency and time of judo combat actions, techniques and penalties. The data was composed for 3,240 sequential technical-tactical behavior analysis from 108 female and 300 male cadet combats recorded of public judo championships. Combat, standing combat moments, approach action, gripping action, attack, groundwork actions and pause moment were observed and determinant technical-tactical behaviors (frequencies of actions, penalties and type of attacks) analysis were done with FRAMI software, followed by Mann-Whitney and Student's t-test, p ≤ 0.05. Our main results indicated that male cadets with 58.66s ± 50.26s demonstrated longer gripping action than female with 38.44s ± 30.44s, as standing combat (tachi-waza) had differences between male with 96.8s ± 72s and female athletes with 75.85s ± 56.97s. Moreover, male cadets had higher sacrifice techniques (sutemi-waza) actions than female athletes. This information could be used to a best performance associated with "psyching-up" as much as it could be used on physical training and technical-tactical ability of female and male cadets.

Gamified Motor Training With Tangible Robots in Older Adults: A Feasibility Study and Comparison With the Young

Background: An increasing lifespan and the resulting change in our expectations of later life stages are dependent on a good health state. This emphasizes the importance of the development of strategies to further strengthen healthy aging. One important aspect of good health in later life stages is sustained skilled motor function.

Objective: Here, we tested the effectiveness of robotic upper limb motor training in a game-like scenario assessing game-based learning and its transfer potential.

Methods: Thirty-six healthy participants (n = 18 elderly participants, n = 18 young controls) trained with a Pacman-like game using a hand-held Cellulo robot on 2 consecutive days. The game-related movements were conducted on a printed map displaying a maze and targets that had to be collected. Gradually, the task difficulty was adjusted between games by modifying or adding different game elements (e.g., speed and number of chasing ghosts, additional rules, and haptic feedback). Transfer was assessed by scoring simple robot manipulation on two different trajectories.

Results: Elderly participants were able to improve their game performance over time [t₍₈₇₄₎ = 2.97, p < 0.01]. The applied game elements had similar effects on both age groups. Importantly, the game-based learning was transferable to simple robot manipulation that resembles activities of daily life. Only minor age-related differences were present (smaller overall learning gain and different effects of the wall-crash penalty rule in the elderly group).

Conclusions: Gamified motor training with the Cellulo system has the potential to translate into an efficient and relatively low-cost robotic motor training tool for promoting upper limb function to promote healthy aging.

Reliability of instruments that measure situation awareness, team performance and task performance in a simulation setting with medical students

OBJECTIVES

The assessment of situation awareness (SA), team performance and task performance in a simulation training session requires reliable and feasible measurement techniques. The objectives of this study were to test the Airways-Breathing-Circulation-Disability-Exposure (ABCDE) checklist and the Team Emergency Assessment Measure (TEAM) for inter-rater reliability, as well as the application of Situation Awareness Global Assessment Technique (SAGAT) for feasibility and internal consistency.

DESIGN

Methodological approach.

SETTING

Data collection during team training using full-scale simulation at a university clinical training centre. The video-recorded scenarios were rated independently by four raters.

PARTICIPANTS

55 medical students aged 22-40 years in their fourth year of medical studies, during the clerkship in anaesthesiology and critical care medicine, formed 23 different teams. All students answered the SAGAT questionnaires, and of these students, 24 answered the follow-up postsimulation questionnaire (PSQ). TEAM and ABCDE were scored by four professionals.

MEASURES

The ABCDE and TEAM were tested for inter-rater reliability. The feasibility of SAGAT was tested using PSQ. SAGAT was tested for internal consistency both at an individual level (SAGAT) and a team level (Team Situation Awareness Global Assessment Technique (TSAGAT)).

RESULTS

The intraclass correlation was 0.54/0.83 (single/average measurements) for TEAM and 0.55/0.83 for ABCDE. According to the PSQ, the items in SAGAT were rated as relevant to the scenario by 96% of the participants. Cronbach's alpha for SAGAT/TSAGAT for the two scenarios was 0.80/0.83 vs 0.62/0.76, and normed χ² was 1.72 vs 1.62.

CONCLUSION

Task performance, team performance and SA could be purposefully measured, and the reliability of the measurements was good.

Ending MMA Combat, Specific Grappling Techniques According to the Type of the Outcome

This study compared grappling motor actions of male mixed martial arts (MMA) athletes considering outcome types from Ultimate Fighting Championship ( UFC) bouts. A validated protocol of technical-tactical analysis was utilized as in previous studies addressing MMA performance analysis, and Kruskall Wallis and U Mann-Whitney tests were applied to compare effects of types of outcome decisions (Split vs. Unanimous Decision vs. Knockout-KO/Technical-knockout-TKO vs. Submission). Unanimous Decision showed higher frequencies of takedowns attempted/round than KO/TKO and Submission outcomes (p ≤ 0.05; 1.9 ± 1.9 vs. 1.3 ± 1.4 vs. 1.0 ± 1.1 attempts). Bouts with Split Decision demonstrated higher takedowns/round than bouts ended by Submission (p = 0.048; 0.4 ± 0.7 vs. 0.2 ± 0.6 attempts). TKO/KO showed lower values of sweeps/round (p = 0.008, 0.0 ± 0.0 vs. 0.1 ± 0.3 attempts) and takedowns attempted/round (p = 0.014, 1.3 ± 1.4 vs. 2.0 ± 1.6 attempts) than bouts ending by Split Decision. The Submission outcome showed a higher frequency of submissions attempted/round than KO/TKO and Unanimous Decision (p ≤ 0.041, 0.3 ± 0.7 vs 0.2 ± 0.5 vs 0.2 ± 0.5). These results show a large specificity in the type of grappling attack/situation according to the strategy to end the combat. These results also show that the grappling strategy and tactics are variable depending on the strengths and weaknesses of the athletes, and can be used by coaches and athletes to develop specific training programs.

The Future of Health Care: Protocol for Measuring the Potential of Task Automation Grounded in the National Health Service Primary Care System

Background

Recent advances in technology have reopened an old debate on which sectors will be most affected by automation. This debate is ill served by the current lack of detailed data on the exact capabilities of new machines and how they are influencing work. Although recent debates about the future of jobs have focused on whether they are at risk of automation, our research focuses on a more fine-grained and transparent method to model task automation and specifically focus on the domain of primary health care.

Objective

This protocol describes a new wave of intelligent automation, focusing on the specific pressures faced by primary care within the National Health Service (NHS) in England. These pressures include staff shortages, increased service demand, and reduced budgets. A critical part of the problem we propose to address is a formal framework for measuring automation, which is lacking in the literature. The health care domain offers a further challenge in measuring automation because of a general lack of detailed, health care–specific occupation and task observational data to provide good insights on this misunderstood topic.

Methods

This project utilizes a multimethod research design comprising two phases: a qualitative observational phase and a quantitative data analysis phase; each phase addresses one of the two project aims. Our first aim is to address the lack of task data by collecting high-quality, detailed task-specific data from UK primary health care practices. This phase employs ethnography, observation, interviews, document collection, and focus groups. The second aim is to propose a formal machine learning approach for probabilistic inference of task- and occupation-level automation to gain valuable insights. Sensitivity analysis is then used to present the occupational attributes that increase/decrease automatability most, which is vital for establishing effective training and staffing policy.

Results

Our detailed fieldwork includes observing and documenting 16 unique occupations and performing over 130 tasks across six primary care centers. Preliminary results on the current state of automation and the potential for further automation in primary care are discussed. Our initial findings are that tasks are often shared amongst staff and can include convoluted workflows that often vary between practices. The single most used technology in primary health care is the desktop computer. In addition, we have conducted a large-scale survey of over 156 machine learning and robotics experts to assess what tasks are susceptible to automation, given the state-of-the-art technology available today. Further results and detailed analysis will be published toward the end of the project in early 2019.

Conclusions

We believe our analysis will identify many tasks currently performed manually within primary care that can be automated using currently available technology. Given the proper implementation of such automating technologies, we expect considerable staff resources to be saved, alleviating some pressures on the NHS primary care staff.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11232

Suggestions for Judo Training with Pacing Strategy and Decision Making by Judo Championship Phases

The present study aimed to compare pacing and decision making of athletes competing in judo, with particular attention paid to effort-pause ratios occurring in the championship phases of the Olympic Games and non-Olympic Games. The sample was composed of 53,403 sequential actions analyzed during 611 performances of the non-Olympic Games (eliminatory n = 330, quarterfinals n = 60, semi-final n = 88, repechage n = 21, third place playoff n = 26, and final n = 79) and 163 from the Olympic Games (eliminatory n = 71, quarterfinals n = 13, semi-final n = 26, repechage n = 20, third place playoff n = 24, and final n = 14). The analysis of effort-pause ratios included separating bouts into states of approach, gripping, attack, groundwork and pause, according to frequency and time. A Markov multi-state model and analysis of variance were applied (p ≤ 0.05). Approach time presented differences of the eliminatory Olympic Games (7.3 ± 3.2 s) versus final non-Olympic Games (6.0 ± 2.2s), and the third place playoff Olympic Games (8.1 ± 2.3 s) versus semi-final (6.2 ± 2.4 s) and third place playoff (5.9 ± 2.1 s) of the non-Olympic Games, and the semi-final Olympic Games (8.6 ± 2.3 s) versus eliminatory (6.5 ± 2.3 s), quarter-finals (6.5 ± 1.7 s), semi-final (6.2 ± 2.4 s), repechage (6.2 ± 2.2 s), third place playoff (5.9 ± 2.1 s), and final (6.0 ± 2.0 s) of the non-Olympic Games. Pause time presented differences of the semi-final Olympic Games (6.8 ± 2.1 s) versus eliminatory (5.1 ± 3.1 s). The present data suggest a focus on pacing strategy during championship phases, which mimic the requirements of judo combats.

The Effect of Heart Rate on Jump-Shot Accuracy of Adolescent Basketball Players

Basketball is a team sport, where fundamental skills - fundamentals - are key determinants for success. Jump-shot (JS) is a basketball fundamental used frequently during game. It is interesting to spread light on the relationship between effort intensity and JS ability. Study aim was to investigate different heart rates (HRs) effect on JS accuracy (JS%) in 22 male youth (15.7 ± 0.9 years) players. Experimental sessions consisted of 10 JSs from five spots 5 m from basket at three different HRs: rest (0HR) and after warm-up (50% [50HR] and 80% maximal HR [80HR]). Analysis of variance showed differences in JS% over sessions (42.27 ± 14.78% at 0HR, 38.18 ± 10.53% at 50HR, and 30.00 ± 16.62% at 80HR; P = 0.018). Least significant difference test did not show any significant difference between 50HR and 0HR JS% (P = 0.343), while 80HR elicited significantly lower values with respect to both 0HR (P = 0.006) and 50HR (P = 0.049). Study provided practical indications on maintaining high JS%: preliminary warm-up (even if injury-protecting) does not improve JS%, because between 50HR and 0HR difference was not significant; and 80HR significantly decreases JS%. Therefore, to maximize JS scoring players have to rest as much as possible during game-play pauses, and coaches should manage timeouts and substitutions accordingly, especially during final minutes of close games.

Task-Data Taxonomy for Health Data Visualizations: Web-Based Survey With Experts and Older Adults

Background

Increasingly, eHealth involves health data visualizations to enable users to better understand their health situation. Selecting efficient and ergonomic visualizations requires knowledge about the task that the user wants to carry out and the type of data to be displayed. Taxonomies of abstract tasks and data types bundle this knowledge in a general manner. Task-data taxonomies exist for visualization tasks and data. They also exist for eHealth tasks. However, there is currently no joint task taxonomy available for health data visualizations incorporating the perspective of the prospective users. One of the most prominent prospective user groups of eHealth are older adults, but their perspective is rarely considered when constructing tasks lists.

Objective

The aim of this study was to construct a task-data taxonomy for health data visualizations based on the opinion of older adults as prospective users of eHealth systems. eHealth experts served as a control group against the bias of lacking background knowledge. The resulting taxonomy would then be used as an orientation in system requirement analysis and empirical evaluation and to facilitate a common understanding and language in eHealth data visualization.

Methods

Answers from 98 participants (51 older adults and 47 eHealth experts) given in an online survey were quantitatively analyzed, compared between groups, and synthesized into a task-data taxonomy for health data visualizations.

Results

Consultation, diagnosis, mentoring, and monitoring were confirmed as relevant abstract tasks in eHealth. Experts and older adults disagreed on the importance of mentoring (χ²₄=14.1, P=.002) and monitoring (χ²₄=22.1, P<.001). The answers to the open questions validated the findings from the closed questions and added therapy, communication, cooperation, and quality management to the aforementioned tasks. Here, group differences in normalized code counts were identified for “monitoring” between the expert group (mean 0.18, SD 0.23) and the group of older adults (mean 0.08, SD 0.15; t₉₆=2431, P=.02). Time-dependent data was most relevant across all eHealth tasks. Finally, visualization tasks and data types were assigned to eHealth tasks by both experimental groups.

Conclusions

We empirically developed a task-data taxonomy for health data visualizations with prospective users. This provides a general framework for theoretical concession and for the prioritization of user-centered system design and evaluation. At the same time, the functionality dimension of the taxonomy for telemedicine—chosen as the basis for the construction of present taxonomy—was confirmed.

Use of Automated Performance Metrics to Measure Surgeon Performance during Robotic Vesicourethral Anastomosis and Methodical Development of a Training Tutorial

PURPOSE

We sought to develop and validate automated performance metrics to measure surgeon performance of vesicourethral anastomosis during robotic assisted radical prostatectomy. Furthermore, we sought to methodically develop a standardized training tutorial for robotic vesicourethral anastomosis.

MATERIALS AND METHODS

We captured automated performance metrics for motion tracking and system events data, and synchronized surgical video during robotic assisted radical prostatectomy. Nonautomated performance metrics were manually annotated by video review. Automated and nonautomated performance metrics were compared between experts with 100 or more console cases and novices with fewer than 100 cases. Needle driving gestures were classified and compared. We then applied task deconstruction, cognitive task analysis and Delphi methodology to develop a standardized robotic vesicourethral anastomosis tutorial.

RESULTS

We analyzed 70 vesicourethral anastomoses with a total of 1,745 stitches. For automated performance metrics experts outperformed novices in completion time (p <0.01), EndoWrist® articulation (p <0.03), instrument movement efficiency (p <0.02) and camera manipulation (p <0.01). For nonautomated performance metrics experts had more optimal needle to needle driver positioning, fewer needle driving attempts, a more optimal needle entry angle and less tissue trauma (each p <0.01). We identified 14 common robotic needle driving gestures. Random gestures were associated with lower efficiency (p <0.01), more attempts (p <0.04) and more trauma (p <0.01). The finalized tutorial contained 66 statements and figures. Consensus among 8 expert surgeons was achieved after 2 rounds, including among 58 (88%) after round 1 and 8 (12%) after round 2.

CONCLUSIONS

Automated performance metrics can distinguish surgeon expertise during vesicourethral anastomosis. The expert vesicourethral anastomosis technique was associated with more efficient movement and less tissue trauma. Standardizing robotic vesicourethral anastomosis and using a methodically developed tutorial may help improve robotic surgical training.

Variability and dimensionality of students' and supervisors' mini-CEX scores in undergraduate medical clerkships - a multilevel factor analysis

BACKGROUND

The mini clinical evaluation exercise (mini-CEX)-a tool used to assess student-patient encounters-is increasingly being applied as a learning device to foster clinical competencies. Although the importance of eliciting self-assessment for learning is widely acknowledged, little is known about the validity of self-assessed mini-CEX scores. The aims of this study were (1) to explore the variability of medical students' self-assessed mini-CEX scores, and to compare them with the scores obtained from their clinical supervisors, and (2) to ascertain whether learners' self-assessed mini-CEX scores represent a global dimension of clinical competence or discrete clinical skills.

METHODS

In year 4, medical students conducted one to three mini-CEX per clerkship in gynaecology, internal medicine, paediatrics, psychiatry and surgery. Students and clinical supervisors rated the students' performance on a 10-point scale (1 = great need for improvement; 10 = little need for improvement) in the six domains history taking, physical examination, counselling, clinical judgement, organisation/efficiency and professionalism as well as in overall performance. Correlations between students' self-ratings and ratings from clinical supervisors were calculated (Pearson's correlation coefficient) based on averaged scores per domain and overall. To investigate the dimensionality of the mini-CEX domain scores, we performed factor analyses using linear mixed models that accounted for the multilevel structure of the data.

RESULTS

A total of 1773 mini-CEX from 164 students were analysed. Mean scores for the six domains ranged from 7.5 to 8.3 (student ratings) and from 8.8 to 9.3 (supervisor ratings). Correlations between the ratings of students and supervisors for the different domains varied between r = 0.29 and 0.51 (all p < 0.0001). Mini-CEX domain scores revealed a single-factor solution for both students' and supervisors' ratings, with high loadings of all six domains between 0.58 and 0.83 (students) and 0.58 and 0.84 (supervisors).

CONCLUSIONS

These findings put a question mark on the validity of mini-CEX domain scores for formative purposes, as neither the scores obtained from students nor those obtained from clinical supervisors unravelled specific strengths and weaknesses of individual students' clinical competence.

Kinematic upper extremity performance in people with near or fully recovered sensorimotor function after stroke

Background: Clinical scales for upper extremity motor function may not capture improvement among higher functioning people with stroke. Objective: To describe upper extremity kinematics in people with stroke who score within the upper 10% of the Fugl-Meyer Assessment (FMA-UE) and explore the ceiling effects of the FMA-UE. Design: A cross-sectional study design was used. Participants: People with stroke were included from the Stroke Arm Longitudinal Study at University of Gothenburg together with 30 healthy controls. The first analysis included participants who achieved FMA-UE score > 60 within the first year of stroke (assessed at 3 days, 2 weeks, 4 weeks, 3 months, or 12 months post stroke). The second analysis included participants with submaximal FMA-UE (60-65 points, n = 24) or maximal FMA-UE score (66 points, n = 21) at 3 months post stroke. Measurements: The kinematic analysis of a standardized drinking task included movement time, velocity and strategy, joint angles of the elbow, and shoulder and trunk displacement. Results: The high FMA-UE stroke group showed deficits in seven of eight kinematic variables. The submaximal FMA-UE stroke group was slower, had lower tangential and angular peak velocity, and used more trunk displacement than the controls. In addition, the maximal FMA-UE stroke group showed larger trunk displacement and arm abduction during drinking and lower peak angular velocity of the elbow. Conclusions: Participants with near or fully recovered sensorimotor function after stroke still show deficits in movement kinematics; however, the FMA-UE may not be able to detect these impairments.

Critical incident technique analysis applied to perianesthetic cardiac arrests at a university teaching hospital

OBJECTIVE

To apply the critical incident technique (CIT) methodology to a series of perianesthetic cardiac arrest events at a university teaching hospital to describe the factors that contributed to cardiac arrest.

STUDY DESIGN

CIT qualitative analysis of a case series.

ANIMALS

A group of 16 dogs and cats that suffered a perioperative cardiac arrest between November 2013 and November 2016.

METHODS

If an arrest occurred, the event was discussed among the anesthesiologists. The discussion included a description of the case, a description of the sequence of events leading up to the arrest and a discussion of what could have been done to affect the outcome. A written description of the case and the event including animal signalment and a timeline of events was provided by the supervising anesthesiologist following discussion among the anesthesiologists. Only dogs or cats were included. After the data collection period, information from the medical record was collected. A qualitative document analysis was performed on the summaries provided about each case by the supervising anesthesiologist, the medical record and any supporting documents. Each case was then classified into one or more of the following: animal, human, equipment, drug and procedural factors for cardiac arrest.

RESULTS

The most common factor was animal (n=14), followed by human (n=12), procedural (n=4), drugs (n=1) and equipment (n=1). The majority (n=11) of animals had multiple factors identified.

CONCLUSIONS AND CLINICAL RELEVANCE

Cardiac arrests during anesthesia at a referral teaching hospital were primarily a result of animal and human factors. Arrests because of procedural, drug and equipment factors were uncommon. Most animals experienced more than one factor and two animals arrested after a change in recumbency. Future work should focus on root cause analysis and interventions designed to minimize all factors, particularly human ones.

Just-in-Time Feedback in Diet and Physical Activity Interventions: Systematic Review and Practical Design Framework

Background

The integration of body-worn sensors with mobile devices presents a tremendous opportunity to improve just-in-time behavioral interventions by enhancing bidirectional communication between investigators and their participants. This approach can be used to deliver supportive feedback at critical moments to optimize the attainment of health behavior goals.

Objective

The goals of this systematic review were to summarize data on the content characteristics of feedback messaging used in diet and physical activity (PA) interventions and to develop a practical framework for designing just-in-time feedback for behavioral interventions.

Methods

Interventions that included just-in-time feedback on PA, sedentary behavior, or dietary intake were eligible for inclusion. Feedback content and efficacy data were synthesized descriptively.

Results

The review included 31 studies (15/31, 48%, targeting PA or sedentary behavior only; 13/31, 42%, targeting diet and PA; and 3/31, 10%, targeting diet only). All studies used just-in-time feedback, 30 (97%, 30/31) used personalized feedback, and 24 (78%, 24/31) used goal-oriented feedback, but only 5 (16%, 5/31) used actionable feedback. Of the 9 studies that tested the efficacy of providing feedback to promote behavior change, 4 reported significant improvements in health behavior. In 3 of these 4 studies, feedback was continuously available, goal-oriented, or actionable.

Conclusions

Feedback that was continuously available, personalized, and actionable relative to a known behavioral objective was prominent in intervention studies with significant behavior change outcomes. Future research should determine whether all or some of these characteristics are needed to optimize the effect of feedback in just-in-time interventions.

Effect of Heart rate on Basketball Three-Point Shot Accuracy

The three-point shot (3S) is a fundamental basketball skill used frequently during a game, and is often a main determinant of the final result. The aim of the study was to investigate the effect of different metabolic conditions, in terms of heart rates, on 3S accuracy (3S%) in 24 male (Under 17) basketball players (age 16.3 ± 0.6 yrs). 3S performance was specifically investigated at different heart rates. All sessions consisted of 10 consecutive 3Ss from five different significant field spots just beyond the FIBA three-point line, i.e., about 7 m from the basket (two counter-clockwise “laps”) at different heart rates: rest (0HR), after warm-up (50%HRMAX [50HR]), and heart rate corresponding to 80% of its maximum value (80%HRMAX [80HR]). We found that 50HR does not significantly decrease 3S% (−15%, P = 0.255), while 80HR significantly does when compared to 0HR (−28%, P = 0.007). Given that 50HR does not decrease 3S% compared to 0HR, we believe that no preliminary warm-up is needed before entering a game in order to specifically achieve a high 3S%. Furthermore, 3S training should be performed in conditions of moderate-to-high fatigued state so that a high 3S% can be maintained during game-play.

A systematic review of intraoperative process mapping in surgery

Process mapping has been identified as a strategy to improve surgical efficiency but has been inconsistently applied in the literature and underutilised in surgical practice. In this journal, we recently described our utilisation of these approaches when applied to breast reconstruction. We showed that in surgery as complex as autologous breast reconstruction, process mapping can improve efficiency, and may improve surgical teaching, education and audit. The intraoperative period specifically is an area that can be applied not only to breast reconstruction, but to a much broader range of surgical procedures. A systematic review was undertaken of the databases Ovid MEDLINE, Allied and Complementary Medicine Database, Embase and PsychINFO. Manual searching of the references from articles identified was also conducted. Data items relating to the review aims were extracted from articles' methods, applications, and outcomes. A descriptive analysis was carried out to synthesise the information on the current usage of process mapping in the intraoperative period. Seventeen of 1,488 studies were eligible for review, with all of non-randomised study design. Studies had overlap in components of the intraoperative period to which process mapping was applied. Common areas of improvement were identified. Outcome measures were assessed in ten studies that implemented interventions based on the improvement areas to increase surgical efficiency. As such, process mapping has been used as part of larger quality improvement methods, albeit with inconsistent nomenclature, to improve surgical efficiency. While it has been applied to a range of surgical specialties, there is a lack of application to the surgical component of the intraoperative period. Greater consistency in the reporting and description of process mapping will enable further research for evidence of its benefits.

A quality improvement initiative to increase the safety of pediatric emergency airway management

BACKGROUND

Emergency airway management is commonly associated with life-threatening hypoxia and hypotension which may be preventable.

AIMS

The aim of this quality improvement study was to reduce the frequency of intubation-related hypoxia and hypotension.

METHODS

This prospective quality improvement study was conducted over 4 years in the Emergency Department of The Royal Children's Hospital, Melbourne, Australia. A preintervention cohort highlighted safety gaps and was used to design study interventions, including an emergency airway algorithm, standardized airway equipment, a preintubation checklist and equipment template, endtidal carbon dioxide monitoring, postintubation team debriefing, and multidisciplinary team training. Following implementation, a postintervention cohort was used to monitor the impact of study interventions on clinical process and patient outcome. Process measures were as follows: use of a preintubation checklist, verbalization of an airway plan, adequate resuscitation prior to intubation, induction agent dose titration, use of apneic oxygenation, and use of endtidal carbon dioxide to confirm endotracheal tube position. The primary outcome measure was first pass success rate without hypoxia or hypotension. Potential harms from study interventions were monitored.

RESULTS

Forty-six intubations were included over one calendar year in the postintervention cohort (compared to 71 in the preintervention cohort). Overall clinical uptake of the 6 processes measures was 85%. First pass success rate without hypoxia or hypotension was 78% in the postintervention cohort compared with 49% in the preintervention cohort (absolute risk reduction: 29.0%; 95% confidence interval 12.3%-45.6%, number needed to treat: 3.5). No significant harms from study interventions were identified.

CONCLUSION

Quality improvement initiatives targeting emergency airway management may be successfully implemented in the emergency department and are associated with a reduction in adverse intubation-related events.

Attrition from Web-Based Cognitive Testing: A Repeated Measures Comparison of Gamification Techniques

BACKGROUND

The prospect of assessing cognition longitudinally and remotely is attractive to researchers, health practitioners, and pharmaceutical companies alike. However, such repeated testing regimes place a considerable burden on participants, and with cognitive tasks typically being regarded as effortful and unengaging, these studies may experience high levels of participant attrition. One potential solution is to gamify these tasks to make them more engaging: increasing participant willingness to take part and reducing attrition. However, such an approach must balance task validity with the introduction of entertaining gamelike elements.

OBJECTIVE

This study aims to investigate the effects of gamelike features on participant attrition using a between-subjects, longitudinal Web-based testing study.

METHODS

We used three variants of a common cognitive task, the Stop Signal Task (SST), with a single gamelike feature in each: one variant where points were rewarded for performing optimally; another where the task was given a graphical theme; and a third variant, which was a standard SST and served as a control condition. Participants completed four compulsory test sessions over 4 consecutive days before entering a 6-day voluntary testing period where they faced a daily decision to either drop out or continue taking part. Participants were paid for each session they completed.

RESULTS

A total of 482 participants signed up to take part in the study, with 265 completing the requisite four consecutive test sessions. No evidence of an effect of gamification on attrition was observed. A log-rank test showed no evidence of a difference in dropout rates between task variants (χ22=3.0, P=.22), and a one-way analysis of variance of the mean number of sessions completed per participant in each variant also showed no evidence of a difference (F2,262=1.534, P=.21, partial η2=0.012).

CONCLUSIONS

Our findings raise doubts about the ability of gamification to reduce attrition from longitudinal cognitive testing studies.

Testing fine motor coordination via telehealth: Effects of video characteristics on reliability and validity

Background There is limited research about the effects of video quality on the accuracy of assessments of physical function. Methods A repeated measures study design was used to assess reliability and validity of the finger-nose test (FNT) and the finger-tapping test (FTT) carried out with 50 veterans who had impairment in gross and/or fine motor coordination. Videos were scored by expert raters under eight differing conditions, including in-person, high definition video with slow motion review and standard speed videos with varying bit rates and frame rates. Results FTT inter-rater reliability was excellent with slow motion video (ICC 0.98-0.99) and good (ICC 0.59) under the normal speed conditions. Inter-rater reliability for FNT 'attempts' was excellent (ICC 0.97-0.99) for all viewing conditions; for FNT 'misses' it was good to excellent (ICC 0.89) with slow motion review but substantially worse (ICC 0.44) on the normal speed videos. FTT criterion validity (i.e. compared to slow motion review) was excellent (β = 0.94) for the in-person rater and good ( β = 0.77) on normal speed videos. Criterion validity for FNT 'attempts' was excellent under all conditions ( r ≥ 0.97) and for FNT 'misses' it was good to excellent under all conditions ( β = 0.61-0.81). Conclusions In general, the inter-rater reliability and validity of the FNT and FTT assessed via video technology is similar to standard clinical practices, but is enhanced with slow motion review and/or higher bit rate.

Time allocation and temporal focus in nursing management: an integrative review

AIM

To describe the time allocation and temporal focus in nursing management.

BACKGROUND

There is limited information about the time allocation and temporal focus of nursing management activities. The role of nurse administrators is changing, resulting in challenges related to time management.

METHODS

Published literature in 2005-2014 related to the time allocation or temporal focus of nurse administrators' management activities was retrieved from five databases, and an integrative review was conducted. Data extraction, quality assessment and quantitative content analysis were performed for eight reviewed articles.

RESULTS

Daily reactive management activities and administrative routines were dominant in the nurse administrators' work, and strategic, proactive activities were scarce. Their daily work was fragmented by a variety of activities and numerous interruptions.

CONCLUSION

Little information exists about time allocation or temporal focus in nurse administrators' management activities. Further research on this topic is needed. The evidence was fairly modest, although the studies' results were generally similar.

IMPLICATIONS FOR NURSING MANAGEMENT

These results can be used to clarify the job descriptions of nurse administrators and to plan and focus their education and training. Organisations need to use evidence to standardise the job descriptions of different levels of nurse managers and directors.