Flawed Self-Assessment

Exploring Factors Associated With the Motivation of Clinical Pharmacists: A Focus on the South African Context

Introduction: Pharmacy practice in many middle to low-income countries has slowly transitioned from being product-focused to a more patient-focused clinical practice. Lack of motivation is one of the factors contributing to the scarcity of pharmacists in the wards. As little is known about motivation in clinical pharmacists, this study aimed to obtain insight into the quantity and quality of their work motivation and factors associated with it.

Methods: Self-determination Theory, used as the framework, describes autonomous motivation as being generated from within or through personal endorsement and controlled motivation as originating from external factors. An online questionnaire including the Academic Motivation Scale to measure autonomous motivation, controlled motivation and amotivation, was sent to clinical pharmacy graduates from 2000 to 2020 across South Africa, followed by interviews to explain some results. Independent t-test was used to analyze differences in motivation of clinical pharmacists to perform clinical services based on personal and environmental factors. Interview data were transcribed and analyzed to explain significant quantitative findings.

Results: Higher amotivation was found in graduates who are currently not practicing in dedicated clinical pharmacist positions, as well as in graduates who do not receive additional financial benefits for clinical services. We found no significant differences in the work motivation of clinical pharmacists based on their gender, age, current practice setting, work experience and additional training received. The interviews revealed that relatedness and autonomy are the most important factors for clinical pharmacists' work motivation.

Discussion: Overall participants had a high mean autonomous motivation, a high mean controlled motivation and low mean amotivation. In line with Self-determination Theory literature, considering the basic psychological needs for relatedness and autonomy could assist with designing interventions, like creating a supportive work environment, to optimize motivation. This could improve professional wellbeing, service implementation and prevent possible adverse events. Future research is necessary to understand barriers and facilitators of clinical pharmacists' work motivation.

How do gender disparities in entrepreneurial aspirations emerge in Pakistan? An approach to mediation and multi-group analysis

This cross-sectional study sought to identify gender differences in individual behavioral attitudes, personal traits, and entrepreneurial education based on planned behavior theory. The Smart partial least squares (PLS) structural equation model and PLS path modeling were used. A survey design was used to collect data from 309 samples using quantitative measures. The model was tested for validity and reliability and showed variance (full, R² = 58.9% and split, R² = 62.7% and R2 = 52.7%) in male and female model predictive power, respectively. Subjective norms (SN), personality traits (PT), and entrepreneurial education (EE) significantly impacted the male sample’s intention. Females’ intentions toward entrepreneurship was less affected by attitude toward behavior (ATB), subjective norms (SN), perceived behavioral control (PBC), and entrepreneurship education (EE). Further, attitudes, social norms, and behavioral controls as mediation variables indicate a significant and positive role of male and female intentions. These findings imply that behavioral beliefs (ATB, PBC, and SN) influence entrepreneurial intention-action translation. The results significantly supported the designed hypotheses and shed light on individual personality traits (PT) and entrepreneurship education (EE) underpinning enterprise intention. The study determined that EE and PT are the strongest predictors of intention, thus highlighting the role of these motives in the entrepreneurial process. This study contributes to the growing body of knowledge on youth entrepreneurs, expands our understanding of entrepreneurship as a practical career choice, and offers a novel account differentiating male and female PT. The drive to evaluate the effects of entrepreneurial intention among budding disparities in Pakistan requires a more profound knowledge of the aspects that endorse entrepreneurship as a choice of profession and enhances youth incentive abilities to engage in entrepreneurial activities based on exploitation.

Strengthening the clinical research workforce through a competency-based orientation program: Process outcomes and lessons learned across three academic health institutions

Clinical research coordinators are increasingly tasked with a multitude of complex study activities critical to scientific rigor and participant safety, though more than half report not receiving appropriate training. To determine the reproducibility of an established clinical research workforce orientation program, collaborative partners across Clinical and Translational Science Award institutions seeded core principles and structure from Mayo Clinic’s Clinical Research Orientation program within Penn State University and the University of Mississippi Medical Center from 2019 to 2021. Training concepts were established and tied to those domains deemed critical by the Joint Task Force for Clinical Trial Competency for the conduct of clinical research at the highest levels of safety and quality possible. Significant knowledge and confidence gains and high overall program satisfaction were reported across participants and partner sites, despite programs being required to pivot from traditional, in-person formats to entirely virtual platforms as a result of the COVID-19 pandemic. The successful standardization and translation of foundational clinical research training has important efficiency and efficacy implications for research enterprises across the USA.

Competence of medical and obstetric registrars in the management of systemic lupus erythematosus in pregnancy

Introduction

Systemic lupus erythematosus has a predilection for women of childbearing age. Globally a shortage of rheumatologists exists resulting in general physicians and obstetricians treating systemic lupus erythematosus in pregnancy.

Methods

We conducted a survey amongst medical and obstetric registrars in South Africa to assess their subjective and objective competence in managing pregnant women with systemic lupus erythematosus.

Results

The pass rate for the objective section was 70.8% with no statistically significant difference in the pass rate between medical and obstetric registrars. Participants felt unprepared to manage pregnant women with systemic lupus erythematosus, with a mean overall score of 3.4 out of 7 for the subjective section, based on four Likert scale type questions.

Conclusion

Trainees are not able to accurately assess their own levels of competence in order to identify their learning needs. Due to the shortage of rheumatologists and lack of obstetric physicians in South Africa, general physicians and obstetricians must be equipped to provide adequate care to pregnant women with systemic lupus erythematosus.

What do people mean when they talk about mindfulness?

Psychological theories cast mindfulness as a form of awareness in which accepting the presence of stressful thoughts and feelings facilitates engaged exploration and identification of adaptive responses. Critics of mindfulness' popularization suggest that lay people misconstrue acceptance as a passive endorsement of experience, undermining engaged problem-solving. To evaluate this criticism, we traced the contemporary semantic meaning of mindfulness in three of the most extensive linguistic corpora of English language and found that general public's depictions of mindfulness highlight engagement-related processes. We further analyzed the nomological network of mindfulness. While mindfulness theories suggest a general convergence of facets representing awareness and acceptance, in a meta-analysis (k = 145; N = 41,966) of the Five Facet Mindfulness Questionnaire only expert- and clinical samples reported convergence, whereas lay people showed absent or even antagonistic associations. Further, contrary to the synergistic model of awareness and acceptance contributing to greater engagement, empirical probes of two lay samples (N_total = 406) show that acceptance is either unrelated or inversely related to markers of engagement. To overcome resulting conceptual and methodological challenges, we highlight the need for a contextualized mindfulness framework whereby acceptance enables the process of engaging with life's challenges rather than avoiding them.

Paranoia, self-deception and overconfidence

Self-deception, paranoia, and overconfidence involve misbeliefs about the self, others, and world. They are often considered mistaken. Here we explore whether they might be adaptive, and further, whether they might be explicable in Bayesian terms. We administered a difficult perceptual judgment task with and without social influence (suggestions from a cooperating or competing partner). Crucially, the social influence was uninformative. We found that participants heeded the suggestions most under the most uncertain conditions and that they did so with high confidence, particularly if they were more paranoid. Model fitting to participant behavior revealed that their prior beliefs changed depending on whether the partner was a collaborator or competitor, however, those beliefs did not differ as a function of paranoia. Instead, paranoia, self-deception, and overconfidence were associated with participants' perceived instability of their own performance. These data are consistent with the idea that self-deception, paranoia, and overconfidence flourish under uncertainty, and have their roots in low self-esteem, rather than excessive social concern. The model suggests that spurious beliefs can have value-self-deception is irrational yet can facilitate optimal behavior. This occurs even at the expense of monetary rewards, perhaps explaining why self-deception and paranoia contribute to costly decisions which can spark financial crashes and devastating wars.

Visiting nearby natural settings supported wellbeing during Sweden's "soft-touch" pandemic restrictions

The coronavirus pandemic entailed varying restrictions on access, movement and social behavior in populations around the world. Knowledge about how people coped with "soft-touch" restrictions can inform urban spatial planning strategies that enhance resilience against future pandemics. We analyzed data from an online place-based survey on 2845 places across Sweden that respondents abstained from visiting, visited with similar frequency, or visited more frequently in spring 2020 as compared to before the pandemic. In spatial logistic regression models, we relate geographical and sociodemographic properties of places (fields, forests, water, residential population density and daytime population density) to self-perceived changes in wellbeing from visiting the given place less or more often, respectively. Abstaining from visiting places with natural features located in areas of high residential density was associated with a self-perceived negative influence on wellbeing. Yet, fields, forests and water were strongly associated with places people claimed wellbeing benefits from during pandemic restrictions. The further a visited place was from the respondent's home, the more likely it was to have a positive wellbeing influence. As an illustrative case, we map our models onto the landscape of Stockholm, showing that some neighborhoods are likely more resilient than others when coping with pandemic restrictions. Both the most and least resilient neighborhoods span the socio-economic spectrum. Urban planning will do well to enable equitable, easy access to natural settings by foot or bike, to increase pandemic preparedness as well as support climate change mitigation and biodiversity protection.

Educational Research Report Correlation between Student Self-Assessment and Proctor Evaluation in a Veterinary Surgical Laboratory

Self-assessment has been shown to facilitate learning, goal setting, and professional development. We sought to evaluate whether veterinary students in a surgical curriculum would have self-assessments that differed from proctor evaluations and whether high-performing students would differ from low-performing students in self-assessment characteristics. Student and proctor assessments were compared for 8 weeks of a spay/neuter surgical laboratory taking place in the second year of the curriculum. Eight students were classified as high-performing, and 10 students were classified as low-performing. A quantitative evaluation of the scores and a qualitative assessment of written comments were completed. Proctors assigned higher scores to high-performing students compared to low-performing students, but no difference was observed overall in self-assessment scores assigned by students. When only anesthesia students were evaluated, we found a difference in self-assessment scores for high- versus low-performers, but this was not true for surgery students. Differences between proctor and student assessment scores diminished over time for all students and for anesthesia students, but not for surgery students. High-performing student anesthetists self-assessed and received proctor assessments with higher scores in technical skills. Comments from high-performing students tended to be less reflective and more positive. Low-performing students were more defensive and more likely to use I-statements in their comments. Overall, quantitative analysis did not reveal a difference in self-assessment between high-performers and low-performers; however, specific differences existed in qualitative characteristics, surgery versus anesthesia students, and proctor assessments. The differences in self-assessment between high- and low-performing students suggest areas of further investigation for the use of reflection in education.

Psychological Science in the Wake of COVID-19: Social, Methodological, and Metascientific Considerations

The COVID-19 pandemic has extensively changed the state of psychological science from what research questions psychologists can ask to which methodologies psychologists can use to investigate them. In this article, we offer a perspective on how to optimize new research in the pandemic's wake. Because this pandemic is inherently a social phenomenon-an event that hinges on human-to-human contact-we focus on socially relevant subfields of psychology. We highlight specific psychological phenomena that have likely shifted as a result of the pandemic and discuss theoretical, methodological, and practical considerations of conducting research on these phenomena. After this discussion, we evaluate metascientific issues that have been amplified by the pandemic. We aim to demonstrate how theoretically grounded views on the COVID-19 pandemic can help make psychological science stronger-not weaker-in its wake.

Translation and Validation of the Spanish Version of the Spiritual Care Competence Questionnaire (SCCQ)

We aimed to validate the Spanish version of the Spiritual Care Competence Questionnaire (SCCQ) in a sample of 791 health care professionals from Spanish speaking countries coming principally from Argentina, Colombia, Mexico and Spain. Exploratory factor analysis pointed to six factors with good internal consistency (Cronbach's alpha ranging from 0.71 to 0.90), which are in line with the factors of the primary version of the SCCQ. Conversation competences and Perception of spiritual needs competences scored highest, and Documentation competences and Team spirit the lowest, Empowerment competences and Spiritual self-awareness competences in-between. The Spanish Version of the SCCQ can be used for assessment of spiritual care competencies, planning of educational activities and for comparisons as well as monitoring/follow-up after implementation of improvement strategies.

Actual and Perceived Level of Scientific English across Italian Physiotherapy Courses: A Cross-Sectional Study

The knowledge of the English language is fundamental for the application of evidence-based practice. Hence, this study explores, through an online survey, the (1) perceived and (2) actual level of Scientific English among Italian undergraduate (UGs) and postgraduate (PGs) physiotherapists. As for (1), the participants expressed their agreement with 10 statements regarding the attitude towards Scientific English through a 1–4 Likert-type scale, with consensus set at ≥70%. As for (2), an ad-hoc 10-point questionnaire was developed through a Delphi procedure, with a pass score set at ≥60%. The survey was completed by 421 participants (UG: 47%; PG: 53%). As for (1), consensus was achieved in both groups in 4 out of 10 statements, specifically the ones addressing the capability to fully understand a scientific paper and physiotherapy-specific language in English. As for (2), the mean score reached by both groups was below 60%. The participants who had studied or were studying at a university in southern Italy presented 2.56 [1.54; 4.24] times higher odds to fail the test. New strategies to bridge the gap in the knowledge of Scientific English in Italy should be developed, through the creation of a unique syllabus tailored to the needs of future physiotherapists.

Professional codes of conduct: A scoping review

BACKGROUND

Professional ethical codes are an important part of healthcare. They are part of the professionalisation of an occupation, are used for regulation of the professions and are intended to guide ethical behaviour in healthcare. However, so far, little is known about the practical use of professional codes in healthcare, particularly in paramedicine.

OBJECTIVE

The aim of this scoping review was to determine what is known in the existing literature about health professionals' knowledge, awareness and use of their professional codes.

METHOD

A scoping review was performed based on a six-stage framework as described by Levac et al. Six databases were searched: OVID Medline, EMBASE, EMCARE, CINAHL, ProQuest and Scopus, in September 2020. Google Scholar, Trove and Google using .gov and .org websites were also searched for grey literature. Two reviewers independently assessed study eligibility.

RESULTS

The search yielded 1162 results after duplicate removal. Thirty-nine studies remained after title and abstract review. Twenty-five articles were included after full-text review. Sixteen examined nursing, eight examined medicine and one examined both nursing and medicine. No studies were identified that examined paramedicine. Twenty-one studies were of a cross-sectional design and four studies were of a qualitative design.

CONCLUSION

Most health professionals know the codes exist, but do not think they know the content. Despite valuing professional codes highly, healthcare professionals do not use them regularly in clinical practice. Further research is needed, and professional codes should be made useful for practice and consideration given to how codes can be written, communicated and implemented to increase their actualisation in healthcare. Research should also begin in paramedicine to identify clinician's knowledge and use of codes in this profession.

REVIEW REGISTRATION

Open Science Framework - doi:10.17605/OSF.IO/NKBY4.

ETHICS STATEMENT

This article does not contain any studies involving human participants performed by any of the authors. The review followed good scientific conduct.

Reflections of pharmacy students on experiential education in providing health services to people with history of substance use disorders in Malaysia

Introduction: Accreditation standards for pharmacy students’ education include the requirement for experiential education (EE) and acknowledge, in building life-long learning skills, the need to develop students’ skills in analysing their practice-based performance. The goal of this qualitative study was to assess students’ ability to reflect on their experience providing face-to-face care to patients with a history of substance use disorders (PHSUDs). Materials and methods: Interviews were conducted with undergraduate pharmacy students who provided care to PHSUDs in an EE programme. An interview guide was used to explore students’ experiences and their perceptions regarding the challenges they encountered, changes in their attitude towards PHSUDs and ways to improve their ability to care for PHSUDs. Data relevant to the study was extracted from interview transcripts, manually sorted and coded using Microsoft Excel and subjected to thematic analysis.  Results: The themes identified were 1) Increased self-confidence in face-to-face interactions with PHSUDs 2) Increased empathy towards PHSUDS 3) Reduction in stigmatised attitudes towards PHSUDs 4) Positive nature of the interactions with PHSUDs 5) Appreciation for the opportunity to apply knowledge in practice 6) Recognition of the need for improved communication skill training 7) Recognition of the need to improve training for dealing with unexpected questions and situations. Conclusion: Pharmacy students demonstrated reflective skills in identifying multiple positive learning outcomes stemming from a one-day EE programme involving PHSUDs. In addition, they provided insights useful to faculty in curriculum planning.

Emergency department registered nurses overestimate their disaster competency: A cross-sectional study

BACKGROUND

Major incidents continue to pose a threat to health care systems by overwhelming them with a sudden surge of patients. A major factor impacting a hospital's surge capacity is the skills, abilities, and knowledge of emergency department (ED) registered nurses (RN). The level of disaster nursing competency they possess affects patient safety and outcome. ED RNs' ability to accurately assess their competency and knowledge is imperative for mitigating the effect of major incidents. ED RN's perception of overall disaster preparedness has not been thoroughly addressed. The aim of this study was to assess emergency department registered nurses' self-perceived disaster preparedness.

METHOD

The study was a cross-sectional study per the STROBE checklist. A self-assessment questionnaire based on the results of a study identifying specific disaster nursing competencies for ED RNs was distributed to all ED RNs at six participating hospitals between January 10th to February 19th of 2019. A five-point Likert-type scale was used to assess competency.

RESULTS

ED RNs' disaster preparedness according to the Total Disaster Competency mean was low. Furthermore, the results indicate that ED RNs' significantly overestimate their disaster nursing competency when compared to the Total Disaster Competency mean. Additionally, this study identified factors such as experience and education were positively associated with disaster preparedness and self-assessment ability.

CONCLUSION

ED RNs' overestimate their disaster preparedness. However, ED RNs with experience and education may be better prepared. ED RNs with formal disaster education appeared to have better insight concerning their preparedness. Clinical experience, advanced levels of education, and training were positively associated with preparedness. Overestimating disaster competencies may negatively impact patient outcomes during a major incident.

Self-face and emotional faces-are they alike?

The image of one’s own face is a particularly distinctive feature of the self. The self-face differs from other faces not only in respect of its familiarity but also in respect of its subjective emotional significance and saliency. The current study aimed at elucidating similarities/dissimilarities between processing of one’s own face and emotional faces: happy faces (based on the self-positive bias) and fearful faces (because of their high perceptual saliency, a feature shared with self-face). Electroencephalogram data were collected in the group of 30 participants who performed a simple detection task. Event-related potential analyses indicated significantly increased P3 and late positive potential amplitudes to the self-face in comparison to all other faces: fearful, happy and neutral. Permutation tests confirmed the differences between the self-face and all three types of other faces for numerous electrode sites and in broad time windows. Representational similarity analysis, in turn, revealed distinct processing of the self-face and did not provide any evidence in favour of similarities between the self-face and emotional (either negative or positive) faces. These findings strongly suggest that the self-face processing do not resemble those of emotional faces, thus implying that prioritized self-referential processing is driven by the subjective relevance of one’s own face.

PUT DO MRAČNE STRANE POSLA:

Nepoželjna organizacijska ponašanja (NOP) štetna su ponašanja koja donose milijunske gubitke organizacijama, a ujedno škode psihološkoj dobrobiti i produktivnosti zaposlenika. Ličnost je jedna od glavnih determinanti NOP-a, no istraživanja odnosa ličnosti i NOP-a uglavnom su se fokusirala na svjesni aspekt ličnosti, tzv. eksplicitnu ličnosti i tek su u manjem broju razmatrala psihološke mehanizme putem kojih ličnost djeluje na NOP. Ovaj rad uključuje pregled istraživanja odnosa ličnosti i NOP-a pri čemu, u odnosu na ranije preglede, razmatra i kako nesvjesni aspekti ličnosti (tzv. implicitna ličnost) mogu pomoći u objašnjavanju NOP-a. U radu se fokusiram se na dvije metode koje pokazuju najveći potencijal za predviđanje radnog ponašanja – Test uvjetovanog rezoniranja i Test implicitnih asocijacija. Nakon toga, razmatram psihološke mehanizme putem kojih eksplicitna i implicitna ličnost djeluju na NOP, koristeći stavove prema poslu i organizaciji i emocije na radnom mjestu kao varijable koje objašnjavaju odnos ličnosti i NOP-a. Konačno, na temelju pregleda istraživanja odnosa ličnosti, stavova, emocija i NOP-a, razvijam teoretski model odnosa ove četiri varijable, koji olakšava razumijevanje složenih psiholoških mehanizama putem kojih implicitna i eksplicitna ličnost dovode do NOP-a.

Relationships Between Cognitive and Driving Self-awareness in Older Drivers

OBJECTIVES

Many older drivers incorrectly estimate their driving ability. The present study aimed to determine whether, and if so, to what extent unawareness of cognitive abilities affects self-awareness of driving ability.

METHOD

Two successive studies were conducted in older drivers. A cohort study investigated cognitive self-awareness and an experimental study examined driving self-awareness. In each one, self-awareness was assessed by cross-analyzing objective (respectively Trail-Making Tests A and B and the Digit Symbol Substitution Test and driving performance of on-road assessment) and subjective data (responses about everyday cognitive skills and driving ability). Older drivers were then classified as being over-, correct, or underestimators. The 3 cognitive and driving self-awareness profiles were then cross-analyzed.

RESULTS

In the cohort study, 1,190 drivers aged 70 years or older were included. The results showed that 42.7% of older drivers overestimated their cognitive ability, 42.2% estimated it correctly, and 15.1% underestimated it. The experimental study included 145 participants from the cohort. The results showed that 34% of participants overestimated, 45% correctly estimated, and 21% underestimated their driving ability. There was a significant relationship between cognitive and driving self-awareness profiles (p = .02). This overlap was more marked in overestimators.

DISCUSSION

Significant overlap between cognitive and driving self-awareness provides useful and new knowledge about driving in the aging population. Misestimation of cognitive ability could hamper self-awareness of driving ability, and consequently self-regulation of driving. It is now crucial to develop measures that promote self-awareness of ability.

Benevolent Conformity: The Influence of Perceived Motives on Judgments of Conformity

Although people often disapprove of conformity, they also dislike when others deviate from group norms. What explains this ambivalence? We hypothesized that judgments of conformity would be affected by whether people view it as motivated by self-interested or benevolent motives. Four studies (N = 808), using both hypothetical and real-life instances of conformity, support this prediction. We find that people judge those who conform to gain social approval (self-interested conformity) as weak-willed, but those who conform out of concern for their group (benevolent conformity) as competent and possessing strong character. In addition, we predict and find that people view self-interested conformity as "fake" but benevolent conformity as revealing one's true self. Finally, we show that differences in perceived intentions explain how people sustain positive self-regard while succumbing to group pressures and why people judge their own conformity more favorably than others' conformity. We discuss implications for encouraging and discouraging conformity.

Development and validation of film stimuli to assess empathy in the work context

A growing body of research suggests that empathy predicts important work outcomes, yet limitations in existing measures to assess empathy have been noted. Extending past work on the assessment of empathy, this study introduces a newly developed set of emotion-eliciting film clips that can be used to assess both cognitive (emotion perception) and affective (emotional congruence and sympathy) facets of empathy in vivo. Using the relived emotions paradigm, film protagonists were instructed to think aloud about an autobiographical, emotional event from working life and relive their emotions while being videotaped. Subsequently, protagonists were asked to provide self-reports of the intensity of their emotions during retelling their event. In a first study with 128 employees, who watched the film clips and rated their own as well as the protagonists’ emotions, we found that the film clips are effective in eliciting moderate levels of emotions as well as sympathy in the test taker and can be used to calculate reliable convergence scores of emotion perception and emotional congruence. Using a selected subset of six film clips, a second two-wave study with 99 employees revealed that all facet-specific measures of empathy had moderate-to-high internal consistencies and test–retest reliabilities, and correlated in expected ways with other self-report and test-based empathy tests, cognition, and demographic variables. With these films, we expand the choice of testing materials for empathy in organizational research to cover a larger array of research questions.

Goals of care discussions: perceptions of radiation and medical oncologists

BACKGROUND

Goals of care discussions (GOCD) are essential when counseling patients with cancer. Respective roles of radiation oncologists (RO) and medical oncologists (MO) in GOCD can be unclear. This study aims to clarify the dynamics and barriers to GOCD.

METHODS

Five hundred and fifty-four ROs and 1604 MOs at NCI-designated comprehensive cancer centers were sent an anonymous electronic survey regarding demographics, opinions, training in GOCD, GOCD frequency, and three vignettes. Response formats were Yes/No, Likert-type, and free response. Chi-square and Wilcoxon rank-sum tests were performed. Likert-type scores were reported as median [interquartile range].

RESULTS

There were 76 (13.7%) RO and 153 (9.5%) MO who completed surveys. Sixty-three percent of RO and 66% of MO reported GOCD with > 50% of patients (p = 0.90). GOCD were initiated for declining performance status (74%) and poor life expectancy (69%). More MO (42%) received formal GOCD training compared to RO (18%) (p < 0.01). MO were more comfortable conducting GOCD than RO (p < 0.01). RO-conducted GOCD were rated to be less important by MO compared to RO (p < 0.05). Thirty-six percent of MO reported being "not at all" or "somewhat" comfortable with RO-conducted GOCD. RO-initiated GOCD with new patients were rated less appropriate by RO compared to MO perceptions of RO-initiated GOCD (p < 0.01).

CONCLUSIONS

While MO and RO conduct GOCD with similar frequency, MO are more comfortable conducting GOCD and are more likely to have formal training. MO rate importance of RO involvement lower than RO. Further research is needed to understand interdisciplinary dynamics that may impact GOCD and subsequent patient care outcomes.

Performance of Residents During Laparoscopic Cholecystectomy: Is Self-assessment Reliable?

BACKGROUND

To compare the self-assessment of surgical residents and observers (faculty members and nurses) during laparoscopic cholecystectomy (LC).

MATERIALS AND METHODS

A prospective observational study was conducted between February 2020 and July 2020 at a medical school hospital. Seventy-four LC surgeries were performed by surgical residents in the presence of faculty members. A self-assessment of the technical and nontechnical performance of the residents was requested. The self-assessment of residents was compared with observer evaluations using the Kruskal-Wallis test. Gwet AC2 fit coefficient was used to determine the consistency between the observers' and residents' assessments. Bland-Altman plots were generated with 95% limits of agreement to describe the agreement between the total scores of the observers.

RESULTS

The self-assessment of residents had a statistically significant higher score when compared with observers (faculty and nurses) (P<0.001). However, no significant difference was observed between the total scores given by the observers (faculty members and nurses) (P>0.05). There was a moderate agreement between the resident versus faculty members [0.503; 95% confidence interval (CI), 0.430-0.576] and resident versus nurse (0.518; 95% CI, 0.432-0.605) when evaluating technical skills. However, there was substantial agreement between faculty members and nurses (0.736; 95% CI, 0.684-0.789). Postoperative pain was significantly correlated with resident self-assessment (P=0.022).

CONCLUSION

The self-assessment scores of surgical residents in LC operations were overestimated compared with observer assessments.

Data management and sharing: Practices and perceptions of psychology researchers

Research data is increasingly viewed as an important scholarly output. While a growing body of studies have investigated researcher practices and perceptions related to data sharing, information about data-related practices throughout the research process (including data collection and analysis) remains largely anecdotal. Building on our previous study of data practices in neuroimaging research, we conducted a survey of data management practices in the field of psychology. Our survey included questions about the type(s) of data collected, the tools used for data analysis, practices related to data organization, maintaining documentation, backup procedures, and long-term archiving of research materials. Our results demonstrate the complexity of managing and sharing data in psychology. Data is collected in multifarious forms from human participants, analyzed using a range of software tools, and archived in formats that may become obsolete. As individuals, our participants demonstrated relatively good data management practices, however they also indicated that there was little standardization within their research group. Participants generally indicated that they were willing to change their current practices in light of new technologies, opportunities, or requirements.

Can general surgery interns accurately measure their own technical skills? Analysis of cognitive bias in surgical residents' self-assessments

BACKGROUND

Accurate self-assessment of knowledge and technical skills is key to self-directed education required in surgical training. We aimed to investigate the presence and magnitude of cognitive bias in self-assessment among a cohort of surgical interns.

METHODS

First-year general surgery residents self-assessed performance on a battery of technical skill tasks (knot tying, suturing, vascular anastomosis, Fundamentals of Laparoscopic Skills peg transfer and intracorporeal suturing) at the beginning of residency. Each self-assessment was compared to actual performance. Bias and deviation were defined as arithmetic and absolute difference between actual and estimated scores. Spearman correlation assessed covariation between actual and estimated scores. Improvement in participant performance was analyzed after an end-of-year assessment.

RESULTS

Participants (N = 34) completed assessments from 2017 to 2019. Actual and self-assessment scores were positively correlated (0.55, P < .001). Residents generally underestimated performance (bias -4.7 + 8.1). Participants who performed above cohort average tended to assess themselves more negatively (bias -7.3 vs -2.3) and had a larger discrepancy between self and actual scores than below average performers (deviation index 9.7 + 8.2 vs 3.8 + 3.1, P < .05). End-of-year total scores improved in 31 (91.2%) participants by an average of 11 points (90 possible). Least accurate residents in initial self-assessments (deviation indices >75th percentile) improved less than more accurate residents (median 5 vs 16 points, P < .05). All residents with a deviation index >75 percentile underestimated their performance.

CONCLUSION

Cognitive bias in technical surgical skills is apparent in first-year surgical residents, particularly in those who are higher performers. Inaccuracy in self-assessment may influence improvement and should be addressed in surgical training.

Behavioral Economics in Information Systems Research: Critical Analysis and Research Strategies

Theories of decision-making have long been important foundations for information systems (IS) research and much of IS is concerned with information processing for decision making. The discipline of behavioral economics (BE) provides the dominant contemporary approach for understanding human decision-making. Therefore, it is logical that IS research that involves decision making should consider BE as foundation or reference theory. Surprisingly, and despite calls for greater use of BE in IS research, it seems that IS has been slow to adopt contemporary BE as reference theory. This paper reports a critical analysis of BE in all fields of IS based on an intensive investigation of quality IS research using bibliometric content analysis. The analysis shows that IS researchers have a general understanding of BE, but their use of the theories has an ad hoc feel where only a narrow range of BE concepts and theories tend to form the foundation of IS research. The factors constraining the adoption of BE theories in IS are discussed and strategies for the use of this influential foundation theory are proposed. Guidance is provided on how BE could be used in various aspects of IS. The paper concludes with the view that BE reference theory has the potential to transform significant areas of IS research.

Is Applied Ethics Morally Problematic?

This paper argues that applied ethics can itself be morally problematic. As illustrated by the case of Peter Singer’s criticism of social practice, morally loaded communication by applied ethicists can lead to protests, backlashes, and aggression. By reviewing the psychological literature on self-image, collective identity, and motivated reasoning three categories of morally problematic consequences of ethical criticism by applied ethicists are identified: serious psychological discomfort, moral backfiring, and hostile conflict. The most worrisome is moral backfiring: psychological research suggests that ethical criticism of people’s central moral convictions can reinforce exactly those attitudes. Therefore, applied ethicists unintentionally can contribute to a consolidation of precisely those social circumstances that they condemn to be unethical. Furthermore, I argue that the normative concerns raised in this paper are not dependent on the commitment to one specific paradigm in moral philosophy. Utilitarianism, Aristotelian virtue ethics, and Rawlsian contractarianism all provide sound reasons to take morally problematic consequences of ethical criticism seriously. Only the case of deontological ethics is less clear-cut. Finally, I point out that the issues raised in this paper provide an excellent opportunity for further interdisciplinary collaboration between applied ethics and social sciences. I also propose strategies for communicating ethics effectively.

Leading and Working From Home in Times of COVID-19: On the Perceived Changes in Leadership Behaviors

Due to the COVID-19 crisis, managers and employees in many organizations suddenly are forced to work from home. Although working from home (WFH) is not a new phenomenon, it is new in its current scale and scope because of COVID-19. Against this background, we investigate the effect of WFH during the COVID-19 crisis on changes in leadership behaviors, and associated changes in perceived manager quality and productivity, at different hierarchical levels in organizations. Based on the literature, we develop two predictions in opposite directions. On the one hand, implementing WFH may force managers to show less direction and control and especially more delegation. On the other hand, research into the effects of exogenous shocks such as COVID-19, suggests that managers may become more controlling and delegate less. Consistent with the first prediction, we find that managers perceive they execute significantly less control and delegate more. Employees also perceive a significant decrease in control, however they perceive on average no change in delegation. Furthermore, and in line with the second prediction, employees of lower-level managers even report a significant decrease in delegation. Finally, our results show that increased delegation is associated with increased perceived productivity and higher manager quality. Together, these results suggest that in the context of the COVID-19 crisis, the effectiveness of WFH might be hampered by the fact that required changes in leadership behaviors, in particular in delegation, are difficult to realize in times of crisis.

Psychosocial factors associated with the self-reported frequency of cell phone use while driving in Iran

Cell phone use while driving is a common contributing factor in thousands of road traffic injuries every year globally. Despite extensive research investigating the risks associated with cell phone use while driving, social media campaigns to raise public awareness and a number of laws banning phone use while driving, this behaviour remains prevalent throughout the world. The current study was conducted in Iran, where road traffic injuries are the leading causes of death and disability, and where drivers continue to use their cell phones, despite legislative bans restricting this behaviour. A total of 255 drivers in the city of Mashhad (male = 66.3%; mean age = 30.73 years; SD = 9.89) completed either an online or a paper-based survey assessing the self-reported frequency of using a cell phone while driving. Psychosocial factors contributing to cell phone use while driving and support for legislation restricting this behaviour, as well as the Big Five personality traits, were also measured. Overall, the results showed that almost 93% of drivers use their cell phones while driving at least once a week, with 32.5% reporting they always use their cell phones while driving. Ordinal logistic regression revealed that the presence of a child passenger, age, perceived benefits and risks of using cell phones while driving, as well as the perceived ability to drive safely while using a cell phone, were strongly associated with the frequency of cell phone use while driving. As for personality traits-extraversion, agreeableness and conscientiousness significantly predicted the frequency of cell phone use in this sample of Iranian drivers.

Cardiac auscultation skills in final year veterinary students and recent veterinary graduates, referral hospital veterinary surgeons and veterinary cardiologists or cardiology residents

BACKGROUND

Cardiac auscultation is an important part of the physical examination. This study evaluated cardiac auscultation skills in veterinary students and compared their abilities to recent veterinary graduates, referral hospital veterinary surgeons and veterinary cardiologists or cardiology residents. In addition it compared their self-predicted quiz scores to their actual scores, evaluating if they could accurately predict their own performance level.

METHODS

A digital recording device was used to record auscultation sounds from 12 different patients with a diagnosis confirmed by a board-certified veterinary cardiologist. The sound files and associated phonocardiograms were uploaded to a video sharing website. A cloud-based online multiple-choice quiz was generated and shared with final year veterinary students, recent veterinary graduates, referral hospital veterinary surgeons and veterinary cardiologists or cardiology residents.

RESULTS

There were 128 participants: 51 final year veterinary students, 62 recent veterinary graduates, and 10 referral hospital veterinary surgeons and five veterinary cardiologists or cardiology residents. No difference was found between the cardiac auscultation skills of recent veterinary graduates and final year veterinary students. Veterinary students' self-predicted scores were lower than actual scores.

CONCLUSIONS

Recent veterinary graduates did not perform better than final year veterinary students in this study, suggesting that auscultation skills do not continue to improve in the first few years after graduation. Efforts should be made to maximise students' learning in cardiac auscultation skills. Veterinary students show a lack of confidence in cardiac auscultation skills.

Use of patient assessment skills in advanced pharmacy practice experiences

INTRODUCTION

Pharmacy programs are required to teach patient assessment (PA) skills. However, pharmacist workforce survey data indicates that limited opportunities exist for students to practice PA skills in real-world settings. The study objectives were to (1) assess how often PA skills are utilized by fourth-year pharmacy (P4) students on advanced pharmacy practice experiences (APPEs), (2) determine perceived competence in performing PA skills, and (3) examine relationships between grade-point average or post-graduation plans and the number of skills performed and between skill use frequency and self-reported competency.

METHODS

P4 students completed a questionnaire assessing 13 PA skills. Respondents performing a skill indicated frequency of use and rated their competence using a 5-point scale. Descriptive and bivariate statistics were reported.

RESULTS

The response rate was 81%. Measuring blood pressure (BP) (76%) and evaluating metered-dose inhaler (MDI) technique (74%) were most commonly performed. Peak-flow meter evaluation (6%) and lymph node examination (2%) were least commonly performed. Measuring BP and evaluating MDI technique had the highest competency ratings (4.6 + 0.7 for both). Lung (3.4 + 0.7) and heart (2.8 + 1) auscultation had the lowest competency ratings. Positive correlations were found between the frequency of skill use and self-reported competence for assessing MDI technique, peripheral pulses, and peripheral edema. No other findings were significant.

CONCLUSIONS

P4 students reported high perceived competency for PA skills performed frequently during APPEs. Preceptor education, requiring skill use, and encouraging students to proactively identify situations to use skills could increase opportunities for use of PA skills.

Improving Metacognition in the Classroom

Abstract. Students are often overconfident in educational settings and struggle to differentiate between well-learned and poorly-learned concepts. The present article reviews current research on strategies that help students assess their understanding, with a focus on research using authentic educational tasks and materials. We propose a framework for these strategies that we refer to as wait-generate-validate. The wait-generate-validate strategies can give students a more objective measure of their learning from lectures, understanding of course concepts, text comprehension, problem-solving ability, and test preparedness. These strategies have been shown to lead to more effective study decisions and greater learning. Lastly, we translate the reviewed research into practical tips for students and teachers and conclude with recommendations for future research regarding how students judge their learning in diverse educational contexts.

Paediatric dentist's ability to detect and diagnose dental trauma using 2D versus 3D imaging

BACKGROUND

Visualisation of the third dimension has been reported to increase effectiveness of correctly diagnosing traumatic dental injuries.

AIM

To assess the ability of paediatric dentists to detect and diagnose Traumatic Dental Injuries (TDI) using two different imaging modalities, intraoral radiographs (2D) and CBCT scans (3D). In addition, observer's confidence regarding the obtained diagnosis, using either technique, was assessed.

MATERIAL AND METHODS

Both 2D and 3D images of 20 dental trauma cases in children were presented in random order to a panel of thirteen paediatric dentists. Observers received instructions for the screening of the images for radiographic findings related to dental trauma, using structured scoring sheets for 2D and 3D images. Observed data were compared to those recorded by two experienced benchmark observers. A ten-point scale was used for assessing observer's confidence regarding their final diagnosis using 2D versus 3D images.

RESULTS

Performance of individual observers showed wide variation. Statistical significance was reached for correctly detected and correctly diagnosed findings (p = 0.02), in favor of 3D. Most of the observers reported comparable confidence using 2D and 3D, two observers were more confident using 3D and one observer was more confident using 2D.

CONCLUSIONS

Paediatric dentist's ability to detect and diagnose findings in patients with TDI was higher on 3D images. Most observers showed a similar confidence score of their diagnostic performance both on 2D and on 3D.

Temporal and social comparative self-assessments of physical health in young, middle-aged, and young-old adults in the MIDUS study

This study examined temporal and social comparisons of physical health status. Participants in two waves of the MIDUS cohort ranging in age from young adult to young-old (N = 2,408) rated current, past, and future physical health, as well as peer health. Past health was generally rated as better than current health (particularly among young adults). Young adults expected better future health; young-old adults expected declining health. All groups recalled their health as better than they reported a decade earlier. Middle-aged and young-old respondents expected more decline than they reported ten years later; young adults' ratings were consistent. The two older groups believed they were healthier than same-age peers, whereas younger respondents believed they were less healthy (though as healthy as the other age groups). The nature and trajectories of temporal and social comparisons of physical health across the lifespan suggest the need to examine their consequences for health behaviors.

A rational model of the Dunning-Kruger effect supports insensitivity to evidence in low performers

Evaluating one's own performance on a task, typically known as 'self-assessment', is perceived as a fundamental skill, but people appear poorly calibrated to their abilities. Studies seem to show poorer calibration for low performers than for high performers, which could indicate worse metacognitive ability among low performers relative to others (the Dunning-Kruger effect). By developing a rational model of self-assessment, we show that such an effect could be produced by two psychological mechanisms, in either isolation or conjunction: influence of prior beliefs about ability or a relation between performance and skill at determining correctness on each problem. To disentangle these explanations, we conducted a large-scale replication of a seminal paper with approximately 4,000 participants in each of two studies. Comparing the predictions of two variants of our rational model provides support for low performers being less able to estimate whether they are correct in the domains of grammar and logical reasoning.

Health-Oriented Leadership and Mental Health From Supervisor and Employee Perspectives: A Multilevel and Multisource Approach

The link between leadership and mental health at the workplace is well established by prior research. However, most of the studies have addressed this relationship from a single-source perspective. The aim of this study was to examine how supervisor and employee ratings of health-oriented leadership correspond to each other and which sources are predictive for employee mental health. We assessed data within 99 teams (headed by 99 supervisors) containing 713 employees in 11 different companies in Southern Germany. Supervisors and their staff completed questionnaires on the supervisors' health-oriented staff-care dimensions awareness, value of health and health behavior (Health-Oriented Leadership Scale, HoL) and current mental distress (Hospital Anxiety and Depression Scale, HADS). Hierarchical linear models revealed that supervisors' self-ratings were significantly related to their employees' ratings (at the team level) only on the health behavior dimension, but not on the health awareness and value of health dimensions. Also, supervisors rated themselves significantly higher on HoL compared to their employees. Employee ratings of HoL significantly predicted their own level of mental distress (direct within-level effect), whereas supervisor ratings of HoL did not predict employees' mental distress at the team level (direct cross-level effect). Supervisors' self-ratings of HoL did not influence the relationship between employee ratings of HoL and their mental distress on an individual level (cross-level interaction). These results highlight the complex relationship between multisource assessments of HoL and employee mental health, emphasizing the importance of subjective perception for mental health. Future studies should investigate under which conditions supervisor and employee ratings correspond to each other and are predictive for mental health at the workplace.

The Influence of Regulatory Focus on Media Choice in Interpersonal Conflicts

People’s choices of (electronic) communication channels are central to the quality of communication—and sometimes detrimental to their actual communication goals. However, while factors influencing media choice are abundant, potential means to intentionally influence these choices are scarce within computer-mediated communication research. We explore the role of regulatory focus as one possible factor to understand and influence media choice in interpersonal conflicts. Regulatory focus theory proposes two motivational systems, promotion (i.e., needs for nurturance and growth) and prevention (i.e., needs for safety and security), that account for differences in preferred strategies for goal-pursuit. In a vignette-based study, we manipulated the situational regulatory focus (promotion or prevention) and surveyed participants’ preferred media choice for a hypothetical conflict scenario. Our results show that the induction of a dominant prevention focus (vs. promotion focus) leads to a shift in preference towards leaner communication media and channels that establish a higher subjective buffer between sender and receiver (e.g., text-messaging over calling). We elaborate on how these findings contribute to the understanding of media choice in interpersonal conflicts and point out potential ways to influence behavior through the design of communication technologies. Limitations of the present study and future research opportunities are discussed.

Incorporating telehealth into health service psychology training: A mixed-method study of student perspectives

OBJECTIVE

Telehealth is increasingly recognized as an avenue for enhancing psychologists' capacities to meet the mental health needs of a diverse and underserved (due to barriers e.g., distance, transportation) public. The present study sought to inform training in telepsychology (i.e., telehealth delivery of psychological services) by using both quantitative and qualitative methods to explore the perspectives of doctoral students who have already been involved in such training.

METHOD

A total of 19 predoctoral students from two universities, with at least some experience in telepsychology training, provided their perspectives on two complementary research questions: (1) How do students perceive their level of competence in various domains of telepsychology?; and (2) What are students' perspectives on the process of telepsychology competency development during their doctoral training?

RESULTS

The results of our study provide early evidence that doctoral trainees are able to develop telepsychology competencies and suggest that a supportive, training-oriented environment and fit between telepsychology and existing programmatic areas of emphasis are likely key to success.

CONCLUSIONS

Continued efforts to enhance training in providing telepsychology services should focus on how to best define, measure, and promote competency development in this emerging specialty area.

An 8-year retrospective survey of assessment in postgraduate dental training in complicated tooth extraction competency

BACKGROUND/PURPOSE

Direct observation of procedural skills (DOPS) has been increasingly used in health education in recent years. This study evaluated the effect of education and trainees' perception of assessment on the clinical skills of postgraduate dental trainees in complicated tooth extraction.

MATERIALS AND METHODS

This study was conducted as a retrospective survey among postgraduate dental trainees learning complicated tooth extraction in Taipei and Linkou Chang Gung Memorial Hospital from 2012 to 2019. Practical skills were assessed using DOPS by trainees and faculty members. Each clinical case included a complicated extraction of a permanent tooth.

RESULTS

A total of 69 participants (26 men and 43 women, average age = 26.49 years, range = 24-34 years) were included in this study. Within the survey cohort, faculty assessments scored significantly higher than did trainees' self-assessments in each complicated tooth extraction procedure, with no difference between both sexes. The higher-performing trainees tended to underrate their performance much more than did the lower-performing trainees. More than 40% of the trainees evaluated themselves as having "poor capability" in some invasive surgical procedures, even though their actual performance was not lower than that of those who evaluated themselves as having adequate or good capability.

CONCLUSION

Self-assessment skills should be developed with more practice and experience. We hope that these findings can guide the planning of faculty development programs for clinical instructors, particularly the new cohort of faculty who will succeed the rapidly retiring boomer generation in the next 10 years.

Irrational beliefs differentially predict adherence to guidelines and pseudoscientific practices during the COVID-19 pandemic

In the coronavirus "infodemic," people are exposed to official recommendations but also to potentially dangerous pseudoscientific advice claimed to protect against COVID-19. We examined whether irrational beliefs predict adherence to COVID-19 guidelines as well as susceptibility to such misinformation. Irrational beliefs were indexed by belief in COVID-19 conspiracy theories, COVID-19 knowledge overestimation, type I error cognitive biases, and cognitive intuition. Participants (N = 407) reported (1) how often they followed guidelines (e.g., handwashing, physical distancing), (2) how often they engaged in pseudoscientific practices (e.g., consuming garlic, colloidal silver), and (3) their intention to receive a COVID-19 vaccine. Conspiratorial beliefs predicted all three outcomes in line with our expectations. Cognitive intuition and knowledge overestimation predicted lesser adherence to guidelines, while cognitive biases predicted greater adherence, but also greater use of pseudoscientific practices. Our results suggest an important relation between irrational beliefs and health behaviors, with conspiracy theories being the most detrimental.

The reliability of resident self-evaluation of operative performance

BACKGROUND

Self-assessment is critical to professional self-regulation yet many trainees may not reliably self-evaluate. We examine the gap between resident and faculty perceptions of trainee operative performance and contributing factors.

METHODS

Surgery resident and faculty evaluations of trainee performance were collected from 14 academic institutions using smartphone-based performance assessments. Differences in resident/faculty ratings evaluating the same procedure were analyzed using descriptive statistics and Bayesian mixed models.

RESULTS

Of 7382 evaluations, 46% trainees and faculty performance ratings were discrepant (r = 0.47), with 80% residents rating themselves lower than faculty in those cases. This gap existed regardless of case complexity and widened as trainees gained experience. Trainees who overrated themselves had the lowest mean performance scores from faculty.

CONCLUSION

Half of residents perceived their performance differently from faculty, and this difference widened for senior residents. Future focus should be to provide opportunity for trainees to improve skills to reliably assess themselves before graduation.

Faculty Perspectives Regarding Day One-Ready Examination Items

The objective of this mixed-methods, cross-sectional study was to evaluate faculty perspectives regarding Day One-Ready (DOR) content on examination questions given to students at a veterinary medical college and to elucidate whether differing viewpoints on what information constitutes DOR knowledge exist among different veterinary disciplines. Twelve faculty members at a veterinary medical college from three different disciplines (small animal internal medicine, surgery, and primary care) reviewed examination questions given to veterinary students, answered the questions, and stated whether they tested DOR information. After elimination of items not answered by all respondents and after reviewing for question quality, 103 questions remained for analysis. An evaluator from each discipline participated in a discussion about DOR content. Of the questions, 30% were unanimously considered to assess DOR information. No association was found between type of question (medicine, surgery, uncategorized) and whether it was considered DOR. Primary care doctors assessed more questions as testing DOR information than either type of specialist. Questions answered correctly were more likely to be assessed as DOR. During discussion, themes identified with DOR information included common conditions, practical diagnostics, critical knowledge, and discriminating between differential diagnoses. Specialists and primary care doctors differed in their assessment of DOR questions. Veterinary faculty should carefully consider whether examination questions contain DOR information and are appropriate for testing knowledge of the entry-level veterinarian.

An Integrative Review of Hygiene Practice Studies in the Food Service Sector

ABSTRACT

This article reviews the recent literature on studies relevant to hygiene practices of food service workers. A total of 32 articles were chosen for evaluation from a systematic search of the published literature from 2014 to 2019. For the assessment of hygiene practices, hand washing as a measurement item and observation as a method were most frequently used. Factors influencing hygiene practices were categorized as internal and external variables. Internal variables included knowledge; psychological factors, such as attitude, risk perception, self-efficacy, and optimistic bias; and food handlers' sociodemographic characteristics, such as work experience and exposure to hygiene training. External variables included characteristics of food premises, such as the size of the operation and number of people served, and organizational factors, such as training. Regarding the recent training literature, attempts to bring in new methodologies and new technologies were found, such as multimedia case studies, cognitive word association, behavior-focused training, wearable technology, and simulation games. Among the theories utilized, knowledge, attitude, and practices were applied most frequently to explain hygiene practices. In particular, this review highlights the important fact that internal and external factors that affect hygiene practices should be considered to maintain good hygiene practices.

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