A systematic scoping review on the evidence behind debriefing practices for the wellbeing/emotional outcomes of healthcare workers

Introduction

Debriefings give healthcare workers voice through the opportunity to discuss unanticipated or difficult events and recommend changes. The typical goal of routine debriefings has been to improve clinical outcomes by learning through discussion and reflection of events and then transferring that learning into clinical practice. However, little research has investigated the effects of debriefings on the emotional experiences and well-being of healthcare workers. There is some evidence that debriefings are a multi-faceted and cost-effective intervention for minimising negative health outcomes, but their use is inconsistent and they are infrequently adopted with the specific intention of giving healthcare workers a voice. The purpose of this systematic scoping review is therefore to assess the scope of existing evidence on debriefing practices for the well-being and emotional outcomes of healthcare workers.

Methods

Following screening, 184 papers were synthesised through keyword mapping and exploratory trend identification.

Results

The body of evidence reviewed were clustered geographically, but diverse on many other criteria of interest including the types of evidence produced, debriefing models and practices, and outcomes captured.

Discussion

The current review provides a clear map of our existing understanding and highlights the need for more systematic, collaborative and rigorous bodies of evidence to determine the potential of debriefing to support the emotional outcomes of those working within healthcare.

Systematic Review Registration

https://osf.io/za6rj.

Optimizing land management strategies for maximum improvements in lake dissolved oxygen concentrations

Eutrophication and anoxia are unresolved issues in many large waterbodies. Globally, management success has been inconsistent, highlighting the need to identify approaches which reliably improve water quality. We used a process-based model chain to quantify effectiveness of terrestrial nutrient control measures on in-lake nitrogen, phosphorus, chlorophyll and dissolved oxygen (DO) concentrations in Lake Simcoe, Canada. Across a baseline period of 2010-2016 hydrochemical outputs from catchment models INCA-N and INCA-P were used to drive the lake model PROTECH, which simulated water quality in the three main basins of the lake. Five terrestrial nutrient control strategies were evaluated. Effectiveness differed between catchments, and water quality responses to nutrient load reductions varied between deep and shallow lake basins. Nutrient load reductions were a significant driver of increased DO concentrations, however strategies which reduced tributary inflow had a greater impact on lake restoration, associated with changes in water temperature and chemistry. Importantly, when multiple strategies were implemented simultaneously, resultant large flow reductions induced warming throughout the water column. Negative impacts of lake warming on DO overwhelmed the positive effects of nutrient reduction, and limited the effectiveness of lake restoration strategies. This study indicates that rates of lake recovery may be accelerated through a coordinated management approach, which considers strategy interactions, and the potential for temperature change-induced physical and biological feedbacks. Identified impacts of flow and temperature on rates of lake recovery have implications for management sustainability under a changing climate.

Bridging the gap between terrestrial, riverine and limnological research: Application of a model chain to a mesotrophic lake in North America

Models remain our best available tool for managing low lake dissolved oxygen concentrations, which pose a serious ecological risk. This study investigated whether process-based catchment models (INCA-N and INCA-P) could accurately drive a lake model (PROTECH), to bridge a gap between terrestrial, riverine and limnological research. INCA was calibrated over all 20 catchments of the Simcoe watershed, Canada. Daily outputs (flow, nitrogen and phosphorus concentrations) over the period 2010-2016 were selected for a common "baseline" period, and used as inputs to PROTECH, which was calibrated across the three major basins of lake Simcoe; Kempenfelt (K42), Cooks (C9), and the main basin (E51). Results showed that at catchment outflows INCA models achieved an average flow R² of 0.8; a load R² of 0.7 (both for TP and N-NO3), a concentration R² of 0.4 and 0.5 (for TP and N-NO3 respectively), and an SiO₂ R²>0.8. In each basin PROTECH achieved an R² for both temperature and dissolved oxygen (DO) concentrations of >0.9. Performance of N-NO₃, TP and Chlorophyll-a concentrations were good (R² values of up to 0.98, 0.92 and 0.53 respectively). Multi-stressor analyses established that most occurrences when DO dropped below the desired 7mg/l threshold (DO7) were attributable to combinations of high temperatures and low tributary inflows. The importance of additional drivers was depth dependent, with photosynthesis being particularly important in shallower C9 and E51 basins during summer, when algae contributed sufficient O₂ to the water column to inhibit DO7 events. Conversely in the deeper more strongly stratified K42 basin, greater algal growth boosted the biochemical oxygen demand, enhancing declines in DO. Lake physics explained a significant number of DO7 events in all three basins. Integrated catchment-lake modelling approaches are important in understanding lake physical and ecological processes, and the impacts of land management and future climate change.

Assessing the impacts of climate change and socio-economic changes on flow and phosphorus flux in the Ganga river system

Anthropogenic climate change has impacted and will continue to impact the natural environment and people around the world. Increasing temperatures and altered rainfall patterns combined with socio-economic factors such as population changes, land use changes and water transfers will affect flows and nutrient fluxes in river systems. The Ganga river, one of the largest river systems in the world, supports approximately 10% global population and more than 700 cities. Changes in the Ganga river system are likely to have a significant impact on water availability, water quality, aquatic habitats and people. In order to investigate these potential changes on the flow and water quality of the Ganga river, a multi-branch version of INCA Phosphorus (INCA-P) model has been applied to the entire river system. The model is used to quantify the impacts from a changing climate, population growth, additional agricultural land, pollution control and water transfers for 2041-2060 and 2080-2099. The results provide valuable information about potential effects of different management strategies on catchment water quality.

Rainfall runoff modelling of the Upper Ganga and Brahmaputra basins using PERSiST

There are ongoing discussions about the appropriate level of complexity and sources of uncertainty in rainfall runoff models. Simulations for operational hydrology, flood forecasting or nutrient transport all warrant different levels of complexity in the modelling approach. More complex model structures are appropriate for simulations of land-cover dependent nutrient transport while more parsimonious model structures may be adequate for runoff simulation. The appropriate level of complexity is also dependent on data availability. Here, we use PERSiST; a simple, semi-distributed dynamic rainfall-runoff modelling toolkit to simulate flows in the Upper Ganges and Brahmaputra rivers. We present two sets of simulations driven by single time series of daily precipitation and temperature using simple (A) and complex (B) model structures based on uniform and hydrochemically relevant land covers respectively. Models were compared based on ensembles of Bayesian Information Criterion (BIC) statistics. Equifinality was observed for parameters but not for model structures. Model performance was better for the more complex (B) structural representations than for parsimonious model structures. The results show that structural uncertainty is more important than parameter uncertainty. The ensembles of BIC statistics suggested that neither structural representation was preferable in a statistical sense. Simulations presented here confirm that relatively simple models with limited data requirements can be used to credibly simulate flows and water balance components needed for nutrient flux modelling in large, data-poor basins.

Distributed and dynamic modelling of hydrology, phosphorus and ecology in the Hampshire Avon and Blashford Lakes: evaluating alternative strategies to meet WFD standards

The issues of diffuse and point source phosphorus (P) pollution in the Hampshire Avon and Blashford Lakes are explored using a catchment model of the river system. A multibranch, process based, dynamic water quality model (INCA-P) has been applied to the whole river system to simulate water fluxes, total phosphorus (TP) and soluble reactive phosphorus (SRP) concentrations and ecology. The model has been used to assess impacts of both agricultural runoff and point sources from waste water treatment plants (WWTPs) on water quality. The results show that agriculture contributes approximately 40% of the phosphorus load and point sources the other 60% of the load in this catchment. A set of scenarios have been investigated to assess the impacts of alternative phosphorus reduction strategies and it is shown that a combined strategy of agricultural phosphorus reduction through either fertiliser reductions or better phosphorus management together with improved treatment at WWTPs would reduce the SRP concentrations in the river to acceptable levels to meet the EU Water Framework Directive (WFD) requirements. A seasonal strategy for WWTP phosphorus reductions would achieve significant benefits at reduced cost.

Uncertainty assessments and hydrological implications of climate change in two adjacent agricultural catchments of a rapidly urbanizing watershed

Lake Simcoe is the most important inland lake in Southern Ontario. The watershed is predominantly agricultural and under increasing pressure from urbanization, leading to changing runoff patterns in rivers draining to the lake. Uncertainties in rainfall-runoff modeling in tributary catchments of the Lake Simcoe Watershed (LSW) can be an order of magnitude larger than pristine watersheds, hampering water quality predictions and export calculations. Here we conduct a robust assessment to constrain the uncertainty in hydrological simulations and projections in the LSW using two representative adjacent agricultural catchments. Downscaled CGCM 3 projections using A1B and A2 emission scenarios projected increases of 4°C in air temperature and a 26% longer growing season. The fraction of precipitation falling as snow will decrease. Spring runoff is an important event in LSW but individual HBV best calibrated parameter sets under-predicted peak flows by up to 32%. Using an ensemble of behavioral parameter sets achieved credible representations of present day hydrology and constrained uncertainties in future projections. Parameter uncertainty analysis showed that the catchments differ in terms of their snow accumulation/melt and groundwater dynamics. Human activities exacerbate the differences in hydrological response. Model parameterization in one catchment could not generate credible hydrological simulations in the other. We cautioned against extrapolating results from monitored to ungauged catchments in managed watersheds like the LSW.

A cost-effectiveness analysis of water security and water quality: impacts of climate and land-use change on the River Thames system

The catchment of the River Thames, the principal river system in southern England, provides the main water supply for London but is highly vulnerable to changes in climate, land use and population. The river is eutrophic with significant algal blooms with phosphorus assumed to be the primary chemical indicator of ecosystem health. In the Thames Basin, phosphorus is available from point sources such as wastewater treatment plants and from diffuse sources such as agriculture. In order to predict vulnerability to future change, the integrated catchments model for phosphorus (INCA-P) has been applied to the river basin and used to assess the cost-effectiveness of a range of mitigation and adaptation strategies. It is shown that scenarios of future climate and land-use change will exacerbate the water quality problems, but a range of mitigation measures can improve the situation. A cost-effectiveness study has been undertaken to compare the economic benefits of each mitigation measure and to assess the phosphorus reductions achieved. The most effective strategy is to reduce fertilizer use by 20% together with the treatment of effluent to a high standard. Such measures will reduce the instream phosphorus concentrations to close to the EU Water Framework Directive target for the Thames.

The interactive responses of water quality and hydrology to changes in multiple stressors, and implications for the long-term effective management of phosphorus

Soluble reactive phosphorus (SRP) plays a key role in eutrophication, a global problem decreasing habitat quality and in-stream biodiversity. Mitigation strategies are required to prevent SRP fluxes from exceeding critical levels, and must be robust in the face of potential changes in climate, land use and a myriad of other influences. To establish the longevity of these strategies it is therefore crucial to consider the sensitivity of catchments to multiple future stressors. This study evaluates how the water quality and hydrology of a major river system in the UK (the River Thames) respond to alterations in climate, land use and water resource allocations, and investigates how these changes impact the relative performance of management strategies over an 80-year period. In the River Thames, the relative contributions of SRP from diffuse and point sources vary seasonally. Diffuse sources of SRP from agriculture dominate during periods of high runoff, and point sources during low flow periods. SRP concentrations rose under any future scenario which either increased a) surface runoff or b) the area of cultivated land. Under these conditions, SRP was sourced from agriculture, and the most effective single mitigation measures were those which addressed diffuse SRP sources. Conversely, where future scenarios reduced flow e.g. during winters of reservoir construction, the significance of point source inputs increased, and mitigation measures addressing these issues became more effective. In catchments with multiple point and diffuse sources of SRP, an all-encompassing effective mitigation approach is difficult to achieve with a single strategy. In order to attain maximum efficiency, multiple strategies might therefore be employed at different times and locations, to target the variable nature of dominant SRP sources and pathways.

Macronutrient cycles and climate change: key science areas and an international perspective

Human activities have doubled global cycles of Nitrogen (N) and Phosphorus (P) and elevated N and P have compromised ecosystem services through the degradation of natural resources of soils, freshwaters and marine waters with a subsequent loss of biodiversity. Elevated Carbon (C) levels in the atmosphere have been linked to global warming, with positive feedback mechanisms accelerating the warming process. In order to initiate nutrient control, both national and international mitigation measures have been implemented. However, many of these initiatives focus upon a single nutrient without considering cycle interactions. A sound understanding of processes and transformations involved in the interactions of macronutrient cycles is required to avoid inadvertently enhancing effects of one nutrient, during mitigation for impacts of another. Emerging research initiatives are addressing these research gaps, with programmes in the US (USGCRP) and the UK (Macronutrient Cycles) advocating integration between scientists and stakeholders, in order to deliver results directly to policy makers. Through these programmes the scales of nitrogen and phosphorus fluxes will be quantified, and a determination made of the nature of nutrient transformations in catchments under a changing climate and perturbed carbon cycle. The consideration of connectivity between multiple macronutrient cycles will help to minimise the threats to biodiversity, ecosystem dynamics, public water supplies and human health by improved management and better focused policy.

A multidisciplinary team approach to skull base chordomas

OBJECT

A multidisciplinary team devised a protocol for long-term care of patients with skull base chordomas. In this study they describe their approach.

METHODS

Forty-two patients presented between 1986 and 1998 and were treated by maximum surgical cytoreduction and photon radiation therapy. Tumor volume-doubling time determined on the basis of magnetic resonance imaging, immunostaining, and cell proliferation (Ki67 labeling index [LI]) studies indicated growth rates of individual chordomas. The best outlook was associated with the greatest extent of tumor removal achieved during the first operation. There were no deaths associated with patients who underwent first-time surgery, but there was a 7.1% mortality rate associated with those who underwent subsequent operations. Cerebrospinal fluid leaks, additional cranial nerve palsies, and pharyngeal wound problems were the most difficult management problems encountered after second and subsequent surgeries. The time interval between operations was usually between 2 years and 3 years after the first surgery; very few patients required a second surgery, with a quiescent period in excess of 5 years. Life-table 5- and 10-year survival rates were 77% and 69%, respectively.

CONCLUSIONS

The authors believe that this series of skull base chordomas provides new insights into the management of these lesions, particularly with regard to techniques that increase survival times and studies that aid in formulating prognoses.

A multidisciplinary team approach to skull base chondrosarcomas

OBJECT

The authors review their experience with treating skull base chondrosarcomas, which are much rarer than skull base chordomas and differ from them in prognosis and treatment.

METHODS

Seventeen patients (12 male and five female patients) with histologically verified chondrosarcomas were followed up prospectively over a 12-year period. The mean age at presentation was 35.9 years. Most patients presented with cranial nerve palsies. Seven had undergone surgery prior to referral to the authors' unit. All underwent maximum surgical cytoreduction by the most direct surgical approach; only the two patients harboring the mesenchymal variant underwent radiotherapy.

CONCLUSIONS

One patient died of a pulmonary embolus; the patients harboring mesenchymal chondrosarcomas died at 20 and 36 months, respectively, after treatment. Of the remaining patients, 93% were alive 5 years postsurgery and had a projected 10-year survival rate of 84% (mean survival time 9.3 years). These data emphasize the very slow progression of this tumor compared with skull base chordoma.

The Glasgow Coma Score: reliable evidence?

The Glasgow Coma Score (GCS) is an important factor in the management and prognosis of a patient with neurosurgical pathology. We have found that there is often a disparity between the quoted and actual GCS of patients referred to this unit. We performed a prospective observational study to determine the proportion of patients referred with a correct GCS. Forty-two (51%) out of a total of 82 patients had a correct GCS on referral. The proportion of patients referred with a correct GCS did not vary with either the grade or speciality of the referring doctor.

Psychological rehabilitation from sports injuries

Medical professionals realise the importance of incorporating psychological strategies into rehabilitation from athletic injury, but often feel they lack the knowledge to do so. This paper explores the role which psychology can play when injured athletes are rehabilitating. Rehabilitation from sport injury involves not only physical, but psychological considerations. Topics include: the post-injury emotional and cognitive reactions of athletes, the importance of social support, the athlete's attitude toward recovery, the therapist's, physician's and coach's roles during rehabilitation, strategies to increase adherence, and effective communication between client and medical professionals. Considerations for returning to practice and competition are also discussed.

Validation of an MRI/PET landmark registration method using 3D simulated PET images and point simulations

Three-dimensional (3D) simulated PET images generated from MRI were used to validate a multimodality registration technique based on the identification of internal anatomical landmarks. In addition, point-based simulations were compared with registration datasets acquired over 3 yr of routine use of the technique. Registration errors were found to range from 1.0 mm at the brain centre to 2.8 mm in each dimension at the brain surface.

Effects of a cognitive intervention package on the free-throw performance of varsity basketball players during practice and competition

To examine the effects of a cognitive intervention package on the free-throw shooting performance of basketball players, with 3 Canadian male university caliber basketball players ages 20, 22, and 24 years, during practice and in competition single-subject multiple-baseline design was implemented. Each subject was introduced to the imagery-rehearsal intervention at different times during the 14-week competitive basketball season. Free-throw data were collected during 50 practice sessions and 32 games. Data from both practice and competitive situations were examined using a comparison of graphed means. In the practice condition an increase in free-throw performance for all three subjects occurred during the posttreatment intervention. In the game condition, Subjects A and B showed posttreatment improvement. The cognitive intervention package consisting of visualization and relaxation can be an effective strategy for improving free-throw performance of some basketball players. Further research should involve control-group examination using a larger sample across a variety of tasks.

Modifiable cardiac risk factors of smoking, elevated serum cholesterol and hypertension: a community survey

This descriptive study assessed the prevalence, perceptions and practices of community residents concerning three risk factors most commonly associated with coronary heart disease: smoking behaviour, hypertension and elevated blood cholesterol/dietary factors. One thousand questionnaires were randomly mailed to residents with a response rate of 48.1%. Results indicated that residents identify smoking and dietary factors as major risks for the development of heart disease. Although the prevalence of hypertension and the frequency of blood pressure screening was similar to other provincial and community surveys that investigated cardiac behaviours, differences were found with the prevalence of smoking behaviour, the frequency of blood cholesterol screening, and knowledge and practices of dietary behaviour. As a result of the study, target groups have been identified and programs have been recommended to meet community needs.

Modifiable cardiac risk factors of obesity, inactivity, and stress: a community survey

In this descriptive study the perceptions and practices of community residents concerning three risk factors associated with coronary heart disease (obesity, inactivity, and stress) and their prevalence were assessed. One thousand questionnaires were randomly mailed to residents of Thunder Bay, Ontario, Canada with a response rate of 48.1%. The results suggest that all three risk factors under study could be contributing to the significantly higher mortality rates in Thunder Bay due to coronary heart disease (when compared to provincial norms). Programs should be developed in the community under study to promote awareness of cardiac risk factors and strategies developed to reduce these risk factors.

Motivations of professionals for involvement in the delivery of a heart disease education and support program

This paper describes the motivations of individuals (N = 101) assisting in the delivery of a program of information and support for heart attack and heart surgery patients and their partners. The majority of those surveyed were recruited through association with charitable foundations or through a professional colleague and are motivated by the personal satisfaction derived from providing education and support to those recovering from heart disease.

A community survey of cardiac emergency skills: symptom recognition and CPR

This descriptive study assessed recognition of symptoms of myocardial infarction (MI) by community members and their ability to respond to emergency situations with cardiopulmonary resuscitation (CPR) skills. One thousand questionnaires were randomly mailed to residents with a response rate of 48.1%. Results indicated that residents have limited awareness of symptoms of MI other than demonstrated chest pain and that 20.6% of the respondents had taken a CPR course. CPR courses were taken by 9.6% of respondents who had one or more relatives diagnosed with heart disease. The lack of awareness of symptoms of MI and limited ability to perform CPR skills in emergency situations by community residents may contribute to the high mortality rates due to heart disease. Results of the study suggest that educational campaigns be instituted in the community under study to promote recognition of and response to cardiac emergencies.

Musical reinforcement of practice behaviors among competitive swimmers

This study determined whether music could be used as a reinforcer for increasing productive and decreasing nonproductive behavior of 6 competitive swimmers during the dry-land portion of practice session. The swimmers were randomly assigned to either the contingent reinforcement group, who received music for productive behavior, or the noncontingent group, who received music regardless of their training productivity. An ABAB design showed that a large and immediate increase in productive practice behavior and decrease in nonproductive practice behavior occurred during the contingent phase compared to the baseline phase. Subjects rated the musical reinforcement favorably and elected to have the procedure continued.

Cardiac risk factors of smoking, hypertension, obesity and family history: a review of the literature

This review of the literature focuses on risk factors of smoking, hypertension, obesity, and family history that are associated with the development of coronary heart disease. The prevalence of these cardiac risk factors are incorporated from several Canadian health surveys. Health professionals in cardiovascular settings can use the information to develop cardiac teaching programs to promote awareness and healthy cardiac practices in the Canadian population.

Perceptions of athletic injuries by athletes, coaches, and medical professionals

35 athletes, their coaches, and medical professionals independently assessed the disruption, seriousness, and short-term effects of the athletes' athletic injuries. Athletes underestimated the disruption and short-term effects of the injury when compared to medical professionals. 25 lower level athletes and those with no previous serious athletic injury overestimated the short-term effects of their injuries. Coaches overestimated the disrupting effects of the injury for 10 higher level athletes and 25 athletes with no previous injury.

Differences in perceptions of seriousness and disrupting effects of athletic injury as viewed by athletes and their trainer

Discrepancies between athletes' ratings of the seriousness and disruptive impact of an athletic injury and ratings by one experienced Sports Medicine Trainer were examined for 30 male and 13 female athletes undergoing treatment at a Sports Medicine Clinic. Overestimation of the seriousness or disruptive impact of the injury was significantly correlated with reports of more pain, higher state anxiety, and greater feelings of anger, apathy, loneliness, and inadequacy, and was more common among athletes competing at lower levels. These findings indicate need for psychological support for those athletes who overreact to injury.