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Abstract Background In recent years, proactive strengths-based approaches to improving quality of care have been advocated. The positive deviance approach seeks to identify and learn from those who perform exceptionally well. Central to this approach is the identification of the specific strategies, behaviours, tools and contextual strategies used by those positive deviants to perform exceptionally well. This study aimed to: identify and collate the specific strategies, behaviours, processes and tools used to support the delivery of exceptionally good care in general practice; and to abstract the identified strategies into an existing framework pertaining to excellence in general practice; the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework. Methods This study comprised a secondary analysis of data collected during semi-structured interviews with 33 purposively sampled patients, general practitioners, practice nurses, and practice managers. Discussions explored the key factors and strategies that support the delivery of exceptional care across five levels of the primary care system; the patient, provider, team, practice, and external environment. For analysis, a summative content analysis approach was undertaken whereby data were inductively analysed and summated to identify the key strategies used to achieve the delivery of exceptionally good general practice care, which were subsequently abstracted as a new level of the IDEAL framework. Results In total, 222 individual factors contributing to exceptional care delivery were collated and abstracted into the framework. These included specific behaviours (e.g., patients providing useful feedback and personal history to the provider), structures (e.g., using technology effectively to support care delivery (e.g., electronic referrals & prescriptions)), processes (e.g., being proactive in managing patient flow and investigating consistently delayed wait times), and contextual factors (e.g., valuing and respecting contributions of every team member). Conclusion The addition of concrete and contextual strategies to the IDEAL framework has enhanced its practicality and usefulness for supporting improvement in general practices. Now, a multi-level systems approach is needed to embed these strategies and create an environment where excellence is supported. The refined framework should be developed into a learning tool to support teams in general practice to measure, reflect and improve care within their practice.

Abstract Aim The aim of this study was to: (1) use cognitive task analysis to describe final year nursing students situation awareness in recognising, responding and escalating care of deteriorating patients in ward settings; and (2) make recommendations for training and practice. Design A mixed methods cognitive task analysis with a convergent triangulation design. Method Data collection involved observations of 33 final year nursing students in simulated deteriorating patient scenarios and retrospective cognitive interviews. A process tracing technique was applied to identify the cues to deterioration participants perceived; how cue perception altered as situational demands increased; the extent that participants made connections between perceived cues and reached a situational understanding; and the factors that influenced and constrained participants situation awareness. Qualitative and quantitative findings are woven together and presented using descriptive statistics, illustrative quotations and timeline extractions. Results The median cue perception was 65.4% and 57.6% in the medical and surgical scenarios, respectively. Perception was negatively influenced by incomplete vital sign monitoring as situations escalated; limited physical assessments; passive scanning behaviours; poor task automaticity; and excessive cognitive demands. Incomplete perception, poor cue integration and underdeveloped mental models influenced situational understanding. Escalation calls did not always accurately reflect situations and a reporting mindset was evident. Clinical exposure to deteriorating patients was described as variable and opportunistic. Reporting Method The study is reported in accordance with the Good Reporting of a Mixed Methods Study (GRAMMS) checklist. Patient or Public Contribution Patients and public were not involved in this research.

Abstract Background Upon entering the healthcare system, junior doctors may lack the skills required to care for patients, and feel unprepared for their role, with considerable variation in the level of proficiency in the performance of particular clinical procedures. Objective To compare the performance and proficiency (self-report and observed) of the performance of nine basic clinical procedures. Methods Seventeen interns were observed performing nine clinical procedures in a simulated setting in June 2021 (Assessment 1) and January 2022 (Assessment 2). The observers identified whether each step in the procedure was performed correctly, and provided an overall assessment of proficiency. The participants also rated their own level proficiency. Results At Assessment 1 the number of steps performed correctly ranged from a mean of 41.9–83.5%. At Assessment 2 the number of steps performed correctly ranged from a mean of 41.9–97.8%. The most common median proficiency rating for Assessment 1 was ‘close supervision’, and was ‘indirect supervision’ at Assessment 2. There was a significant and large effect size in the improvement in performance from Assessment 1 to Assessment 2. Low correlations were found between observer and self-reported proficiency in performance of the procedures. Conclusions The large improvement in performance across the two assessments is encouraging. However, there is a need to address the variability in performance on graduation from medical school, and to ensure that any assessment of proficiency is not only reliant on self-report.

Objectives: 1) To introduce to expert colleagues the concept of health sector information quality advocates. 2) To obtain these colleagues opinions on worth of the advocate role and the competencies needed by an advocate. 3) To identify existing courses that matched the needs of the advocacy role. Design: 1) A workshop and pre-workshop survey of participants. 2) An online search of courses targeting a health workforce audience based on key words from the competencies identified by the workshop participants. Setting: The workshop was conducted at the 35th Patient Classification Systems International (PCSI) Conference in Iceland in September 2022. The pre-conference online survey used SurveyMonkey. The online course search used Google Chrome and Google Scholar and the English language. Main outcome measures: 1) Agreement of expert colleagues on the need for an Information quality advocate role. 2) Consensus by the expert colleagues on the important competencies. 3) The identified courses described in terms of mode of course delivery, course cost and duration, the delivering institute and key competencies covered. Each course was assessed and scored on a scale from 0 to 10 based on comprehensiveness and effectiveness. Results: The top five competencies for the information quality advocate in order of importance were data governance principles, quality management, stakeholder engagement, information and system governance, and information culture. The online search results identified many courses for specific technical roles, but most did not have the focus on data validity, reliability and information usefulness that matched the needs of the advocacy role. Conclusions: Focused training is needed to support appropriately skilled information quality advocates for the health sector. The presence of information quality advocates at the point of data collection facilitates the pathway to best practice in data collection.

Introduction Simulation-based training (SBT) has gained significant traction within emergency medicine. The growing body of evidence describes the benefits that SBT can bring. However, identifying barriers and enablers when establishing successful SBT programmes in busy emergency departments (EDs), and ensuring longevity of such programmes, can be difficult.Objective We aim to identify barriers and enablers to SBT in busy EDs.Methods We explored and analysed the thoughts, experience and opinions of professionals involved in SBT and organisational support. 32 participants across 15 international sites were invited to a semistructured interview process. We included participants from a variety of backgrounds, from clinical staff to management staff. Transcribed interview data was classified and coded based on capability, opportunity and motivation behaviour (COM-B) domains and analysed based on theoretical domains framework. Frequency of the most mentioned thematic domain among participants is reported.Results The interview data revealed several common themes, including the following: knowledge and skills (90%), support and leadership (96%), mental barriers (87.5%), local culture (96.6%), dedicated space (65.2%), time constraints (46.8%), social influence (87.5%), education (90.6%), professional development (68.75%), exams (59.3%) and personal goals (93.75%). Management staff was observed to prioritise resource, staffing and flow, while the clinical cohort tended to focus on specialty and personal development when it came to simulation training in the ED.Conclusion Potential barriers and enablers to SBT and in situ simulation for EDs were identified through interviews conducted in this study. The central themes in terms of barriers and enablers were local culture, leadership, individual needs, resources and optimisation. A tailored approach is vital for establishing a successful SBT and in situ simulation programme.

Abstract Background Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future. Methods A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one “ideal” laparoscopic operative report template following international input from the World Society of Emergency Surgery board. Results A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic. Conclusion This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals’ medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC.

Abstract Background Although patients have the potential to provide important information on patient safety, considerably fewer patient-report measures of safety climate (SC) have been applied in the primary care setting as compared to secondary care. Our aim was to examine the application of a patient-report measure of safety climate in an Irish population to understand patient perceptions of safety in general practice and identify potential areas for improvement. Specifically, our research questions were: 1. What are patients’ perceptions of SC in Irish general practice? 2. Do patient risk factors impact perceptions of SC? 3. Do patient responses to an open-ended question about safety enhance our understanding of patient safety beyond that obtained from a quantitative measure of SC? Methods The Patient Perspective of Safety in General Practice (PPS-GP) survey was distributed to primary care patients in Ireland. The survey consisted of both Likert-response items, and free-text entry questions in relation to the safety of care. A series of five separate hierarchical regressions were used to examine the relationship between a range of patient-related variables and each of the survey subscales. A deductive content analysis approach was used to code the free-text responses. Results A total of 584 completed online and paper surveys were received. Respondents generally had positive perceptions of safety across all five SC subscales of the PPS-GP. Regarding patient risk factors, younger age and being of non-Irish nationality were consistently associated with more negative SC perceptions. Analysis of the free-text responses revealed considerably poorer patient perceptions (n = 85, 65.4%) of the safety experience in primary care. Conclusion Our findings indicate that despite being under-utilised, patients’ perceptions are a valuable source of information for measuring SC, with promising implications for safety improvement in general practice. Further consideration should be given to how best to utilise this data in order to improve safety in primary care.

Abstract Background There is much variability in the measurement and monitoring of patient safety across healthcare organizations. With no recognized standardized approach, this study examines how the key components outlined in Vincent et al’s Measuring and Monitoring Safety (MMS) framework can be utilized to critically appraise a healthcare safety surveillance system. The aim of this study is to use the MMS framework to evaluate the Saudi Arabian healthcare safety surveillance system for hospital care. Methods This qualitative study consisted of two distinct phases. The first phase used document analysis to review national-level guidance relevant to measuring and monitoring safety in Saudi Arabia. The second phase consisted of semi-structured interviews with key stakeholders between May and August 2020 via a video conference call and focused on exploring their knowledge of how patient safety is measured and monitored in hospitals. The MMS framework was used to support data analysis. Results Three documents were included for analysis and 21 semi-structured interviews were conducted with key stakeholders working in the Saudi Arabian healthcare system. A total of 39 unique methods of MMS were identified, with one method of MMS addressing two dimensions. Of these MMS methods: 10 (25 %) were concerned with past harm; 14 (35 %) were concerned with the reliability of safety critical processes, 3 (7.5 %) were concerned with sensitivity to operations, 2 (5 %) were concerned with anticipation and preparedness, and 11 (27.5 %) were concerned with integration and learning. Conclusions The document analysis and interviews show an extensive system of MMS is in place in Saudi Arabian hospitals. The assessment of MMS offers a useful framework to help healthcare organizations and researchers to think critically about MMS, and how the data from different methods of MMS can be integrated in individual countries or health systems.

Abstract Background Individuals on the autism spectrum face significant disparities in health and physicians often report difficulties in providing care to autistic patients. In order to improve the quality of care autistic individuals receive, it is important to identify the barriers that physicians experience in providing care so that these may be addressed. This paper reports the initial development and preliminary evaluation of a physician-report ‘Barriers to Providing Healthcare’ measurement tool. Method An established taxonomy of healthcare barriers for autistic individuals informed the initial draft of a 22-item measurement tool. This measurement tool was distributed to physicians working in various healthcare specialties and settings. Exploratory factor analysis (EFA) was conducted to determine the construct validity of the tool; discriminant validity between, and internal consistency of, the resultant factors were assessed. Multiple regressions were used to explore variables potentially associated with barriers endorsed by physicians. Results A total of 203 physicians were included in the analyses. The EFA resulted in a 17-item tool with three distinct factors which explained 37.6% of the variance: 1) Patient-related barriers (Cronbach’s α = 0.83; e.g., the patient’s reactivity to the healthcare environment); 2) Healthcare provider (HCP)/family-related barriers (Cronbach’s α = 0.81; e.g., a lack of providers willing to work with autistic patients); and 3) System-related barriers (Cronbach’s α = 0.84; e.g., there is a lack of support for patients and families). Discriminant validity between the factors was adequate (r

Abstract A 250‐year (1766–2016) archive of reconstructed river flows is presented for 51 catchments across Ireland. By leveraging meteorological data rescue efforts with gridded precipitation and temperature reconstructions, we develop monthly river flow reconstructions using the GR2M hydrological model and an Artificial Neural Network. Uncertainties in reconstructed flows associated with hydrological model structure and parameters are quantified. Reconstructions are evaluated by comparison with those derived from quality assured long‐term precipitation series for the period 1850–2000. Assessment of the reconstruction performance across all 51 catchments using metrics of MAE (9.3 mm/month; 13.3%), RMSE (12.6 mm/month; 18.0%) and mean bias (−1.16 mm/month; −1.7%), indicates good skill. Notable years with highest/lowest annual mean flows across all catchments were 1877/1855. Winter 2015/16 had the highest seasonal mean flows and summer 1826 the lowest, whereas autumn 1933 had notable low flows across most catchments. The reconstructed database will enable assessment of catchment specific responses to varying climatic conditions and extremes on annual, seasonal and monthly timescales.

Abstract Objective Trial registries were set up to improve transparency, remove duplication, improve awareness and avoid waste. Many trials never reach the point of patient enrolment due to a myriad of reasons. The aim of this study was to investigate the reasons for and characteristics of discontinuation of trials. Results A total of 163 discontinued trials were identified and compared to completed trials. A Survey was designed to further explore the nature and conduct of the trial. No differences in registered and categorised information was observed between discontinued and completed trials. Most trials discontinue due to patient or participant recruitment issues, often related to funding. Substantial changes to procedures or the protocol or changes to recruitment strategy were also commonly cited reasons. Survey information was available for 21 discontinued and 28 completed trials and no obvious differences could be identified. Our findings highlight the underlying problem of lack of detail, suboptimal recording, dated information and incomplete reporting of trials within a trial registry which hampers sharing and learning. To date, important progress has been made by the implementation of standards and the requirement of trials to be registered. Our review identifies areas where further improvements can be made.

Background Healthcare complaints are an under utilised source of information for safety improvement, particularly in general practice settings. Within general practice in Ireland, complaints management is dependent on individual practice policies, with little standardisation nationally, impeding their use for safety improvement. There is a need to understand factors that contribute to unlocking the potential of complaints for safety improvement in general practice in Ireland and internationally. Objectives To explore perceptions of healthcare complaints of general practitioners, practice nurses and managers, medico-legal professionals, and policymakers. Methods Participants were recruited using convenience sampling. Interviews were conducted from November 2019–May 2020, based on a semi-structured interview guide. Data were then transcribed and analysed using content analysis. An iterative process was applied to identify emerging themes from the interviews. Results A total of 29 participants (19 female, 10 male) were interviewed. Three themes emerged from the analysis, ‘why patients submit complaints’, ‘management of complaints’, and ‘impact of complaints’. Subthemes included ‘barriers and facilitators to complaining’, ‘practice processes’ for complaints management, and ‘impacts on staff’ of complaints, among others. Conclusion There is a lot to be learned about how individuals experience complaints, however, this study adds to existing knowledge. The findings from this study can be used to tackle challenges facing complaints management in general practice, including the barriers to complaining for patients and the negative impacts of complaints on the staff, and can also help to build on positive aspects of complaints such as the desire for systemic change among interested parties.

Abstract Background Teaching and assessing clinical procedures requires a clear delineation of the individual steps required to successfully complete the procedure. For decades, human reliability analysis (HRA) has been used to identify the steps required to complete technical procedures in higher risk industries. However, the use of HRA is uncommon in healthcare. HRA has great potential supporting simulation-based education (SBE) in two ways: (1) to support training through the identification of the steps required to complete a clinical procedure; and (2) to support assessment by providing a framework for evaluating performance of a clinical procedure. The goal of this study was to use HRA to identify the steps (and the risk associated with each of these steps) required to complete a bronchoscope-assisted percutaneous dilatational tracheostomy (BPDT). BPDT is a potentially high-risk minimally invasive procedure used to facilitate tracheostomy placement at the bedside or in the operating theatre. Methods The subgoals, or steps, required to complete the BPDT procedure were identified using hierarchical task analysis. The Systematic Human Error Reduction and Prediction Approach (SHERPA) was then used to identify potential human errors at each subgoal, the level of risk and how these potential errors could be prevented. Results The BPDT procedure was broken down into 395 subgoals, of which 18% were determined to be of high-risk. The most commonly identified remediation strategies for reducing the risk of the procedure included: checklist implementation and audit, statutory and mandatory training modules, simulation training, consultant involvement in all procedures, and fostering a safety-focused hospital culture. Conclusion This study provides an approach for how to systematically identify the steps required to complete a clinical procedure for both training and assessment. An understanding of these steps is the foundation of SBE. HRA can identify ‘a correct way’ for teaching learners how to complete a technical procedure, and support teachers to give systematic and structured feedback on performance.

Abstract Background Entrustable Professional Activities (EPAs) are units of professional practice that capture essential competencies in which trainees must become proficient before undertaking them independently. EPAs provide supervisors with a solid justification for delegating an activity to trainees. This study aimed to develop and ensure face validity of a set of EPAs for junior doctors in the first year of clinical practice in the Republic of Ireland. Methods An iterative eight stage consensus building process was used to develop the set of EPAs. This process was based on international best practice recommendations for EPA development. A series of surveys and workshops with stakeholders was used to develop a framework of EPAs and associated competencies. An external stakeholder consultation survey was then conducted by the Irish Medical Council. The framework of EPAs was then benchmarked against the 13 core EPAs developed by the Association of American Medical Colleges (AAMC). Results A framework of seven EPAs, and associated competencies resulted from this study. These EPAs address all core activities that junior doctors should be readily entrusted with at the end of the intern year, which is the first year of clinical practice in the Republic of Ireland. Each EPA contains a series of defined competencies. The final EPAs were found to be comparable to the AAMC core EPAs for entering residency. Conclusions A framework of EPAs for interns in Ireland that are appropriate for the intern year has been developed by key stakeholders. The implementation of the EPAs in practice is the next step, and is likely to result in an improved intern training process and increased patient safety.

Abstract Background Improving hand hygiene (HH) compliance is one of the most important, but elusive, goals of infection control. The purpose of this study was to use the capability (C), opportunity (O), motivation (M), and behaviour (B; COM-B) model and the theoretical domains framework (TDF) to gain an understanding of the barriers and enablers of HH behaviours in an intensive care unit (ICU) in order to identify specific interventions to improve HH compliance. Methods A semi-structured interview schedule was developed based upon the COM-B model. This schedule was used to interview a total of 26 ICU staff: 12 ICU nurses, 11 anaesthetic specialist registrars, and three anaesthetic senior house officers. Results Participants were confident in their capabilities to carry out appropriate HH behaviours. The vast majority of participants reported having the necessary knowledge and skills, and believed they were capable of carrying out appropriate HH behaviours. Social influence was regarded as being important in encouraging HH compliance by the interviewees- particularly by nurses. The participants were motivated to carry out HH behaviours, and it was recognised that HH was an important part of their job and is important in preventing infection. It is recommended that staff are provided with targeted HH training, in which individuals receive direct and individualised feedback on actual performance and are provided guidance on how to address deficiencies in HH compliance at the bedside at the time at which the HH behaviour is performed. Modelling of appropriate HH behaviours by senior leaders is also suggested, particularly by senior doctors. Finally, appropriate levels of staffing are a factor that must be considered if HH compliance is to be improved. Conclusions This study has demonstrated that short interviews with ICU staff, founded on appropriate behavioural change frameworks, can provide an understanding of HH behaviour. This understanding can then be applied to design interventions appropriately tailored to the needs of a specific unit, which will have an increased likelihood of improving HH compliance.

Background. Newly graduated medical students often report that they lack the skills required to care for patients, and feel unprepared for clinical practice. However, little is known about when, and if, they acquire these skills in practice. The aim of this study was to assess self-reported level of entrustment in, and frequency of performance of, the seven Entrustable Professional Activities (EPAs) comprising the EPA framework for interns in Ireland. EPAs describe discrete activities that are essential to a particular profession. Methods. Self-report survey data were collected from doctors in the Republic of Ireland during their first year of clinical practice at four different time points during 2020/21. Results. Response rates to the survey varied from 73.3% (126/172) at Time 1 to 25.6% (44/172) at Time 4. After three months, the respondents reported that they could execute all of the EPAs, inclusive of 12 essential procedural skills, with indirect supervision. As the year progressed there was an increase in the proportion of respondents reporting that they performed the EPAs at least once a week. However, the proportion of respondents performing five of the essential procedural skills (e.g. nasogastric tube insertion) remained low across all time points. Conclusion. Consideration should be given as to how to better prepare medical students to execute these EPAs, how the interns can be better supported during the first quarter of internship. The findings from this research are positive. However, there is an urgent need to carry out formal assessments of entrustability, rather than relying on self-report.

During protracted dry spells, there is considerable interest from water managers, media and the public in when and how drought termination (DT) will occur. Robust answers to these questions require better understanding of the hydroclimatic drivers of DT than currently available. Integrated vapour transport (IVT) has been found to drive DT in Western North America, but evidence elsewhere is lacking. To evaluate this association for the British–Irish Isles, event coincidence analysis is applied to 354 catchments in the UK and Ireland over the period 1900–2010 using ERA-20C reanalysis IVT data and 7589 DT events extracted from reconstructed river flow series. Linkages are identified for 53% of all DT events across all catchments. Associations are particularly strong for catchments in western and southern regions and in autumn and winter. In Western Scotland, 80% of autumn DTs are preceded by high IVT, whilst in Southern England more than two thirds of winter DTs follow high IVT episodes. High IVT and DT are most strongly associated in less permeable, wetter upland catchments of Western Britain, reflecting their maritime setting and orographic enhancement of prevailing south-westerly high IVT episodes. Although high IVT remains an important drought-terminating mechanism further east, it less frequently results in DT. Furthermore, the highest rates of DT occur with increasing IVT intensity, and the vast majority of the most abrupt DTs only occur following top decile IVT and under strongly positive North Atlantic Oscillation (NAO) conditions. Since IVT and NAO forecasts may be more skilful than those for rainfall which underpin current forecasting systems, incorporating these findings into such systems has potential to underpin enhanced forecasting of DTs. This could help to mitigate impacts of abrupt recoveries from drought including water quality issues and managing compound drought–flood hazards concurrently.

Abstract Background SAFMEDS (Say-All-Fast-Minute-Every-Day-Shuffled) is a flashcard-type behavioural instructional methodology, involving one-minute learning trials that function both as practice and assessment, used to facilitate the development of fluency in a behaviour. The primary research question was whether SAFMEDS engenders improvement in performance beyond that conferred by usual teaching. A secondary research question was whether SAFMEDS is an effective method of producing fluency in Electrocardiogram (ECG) interpretation. Methods A pilot study was conducted to determine sample size required to power the pragmatic randomised controlled trial (RCT). For the subsequent RCT, participants were randomly assigned to a “usual teaching” control group (n = 14) or the SAFMEDS intervention group (n = 13), with the recognition of 15 cardiac conditions on ECGs (e.g., atrial fibrillation, complete heart block) targeted. Intervention group participants’ performance was tracked over eight weeks as they worked towards achieving the fluency criterion. Percentage accuracy in ECG interpretation was assessed at baseline and post-test for both groups. An ANCOVA was conducted to assess for differences in the performance of the intervention and control group at post-test while controlling for the baseline performance of participants. At post-test, the numbers of participants achieving fluency within the intervention group was examined. Results A large effect size of SAFMEDS (partial η2 = .67) was identified when controlling for the effects of baseline performance. At post-test, the intervention group significantly outperformed (M = 61.5%; SD = 12.1%) the control group (M = 31.6%; SD = 12.5%, p

Abstract Background The design of medical devices impacts upon the performance of healthcare professionals and patient safety. However, multiple devices serving the same function are often available. The purpose of this study was to use simulation as a means of examining the impact of differences in device design on (1) learning of, or attainment of behavioral fluency in, peripheral intravenous cannulation (PIVC); and (2) the generalization, or transfer, of learning on one device to performance of PIVC using an untrained device. Methods A total of 25 final cycle medical students participated in this study which used a randomized two-group design. Participants were randomly assigned to learn PIVC using either a closed PIVC device (a single device which consists of an intravenous cannula with a pre-attached extension tube; n = 14) or an open PIVC device (a two-piece device made up of an intravenous cannula and a separate extension tube which is attached following insertion of the cannula; n = 11). Task analyses were developed for the performance of PIVC using each device. Subsequently, simulation-based fluency training was delivered to both groups using their assigned PIVC device, and continued for each participant until the fluency criterion was achieved. Following achievement of fluency, participants were asked to perform PIVC using the untrained device (i.e., the PIVC device that they had not been trained on). Results All participants in both groups met the fluency criterion, and no significant differences were observed in the number of trials or total training required by groups to achieve fluency. Participants in both groups improved significantly from baseline (M = 11.69) to final training trial (M = 100). However, a significant decrement in performance (M = 81.5) was observed when participants were required to perform PIVC using the untrained device. Conclusions Participants achieved fluency in PIVC regardless of the device used. However, significant decrements in performance were observed when participants were required to perform PIVC using a novel device. This finding supports the need for careful consideration of devices purchased and supplied in the clinical setting, and the need for training prior to the introduction of novel devices or for new staff members.

Abstract Background Low levels of success in performing lumbar puncture have been observed among paediatric trainees. This study assessed the efficacy of simulation-based education with frequency building and precision teaching for training lumbar puncture to behavioural fluency. Methods The intervention group was assessed at baseline, at the final training trial, in the presence of distraction, and a minimum of one month after the cessation of the intervention in order to ascertain whether behavioural fluency in lumbar puncture was obtained. Subsequently, the performance of this intervention group (10 paediatric senior house officers) was compared to the performance of a comparator group of 10 more senior colleagues (paediatric registrars) who had not received the intervention. Retrospective chart audit was utilised to examine performance in the clinical setting. Results Intervention group participants required a mean of 5 trials to achieve fluency. Performance accuracy was significantly higher in the intervention group than the comparator group. Learning was retained at follow-up and persisted during distraction. Retrospective chart audit revealed no significant difference between the performance of the intervention group and a comparator group, comprised of more senior physicians, in the clinical setting, although the interpretation of these analyses are limited by a low number of lumbar punctures performed in the clinical setting. Conclusions The programme of simulation-based education with frequency building and precision teaching delivered produced behavioural fluency in lumbar puncture among paediatric trainees. Following the intervention, the performance of these participants was equivalent to, or greater than, that of senior paediatricians. This study supports the need for further research exploring the effectiveness of simulation-based education with precision teaching to train procedural skills to fluency, and the consideration of how best to explore the impact of these on patient outcomes.

Background: Despite the effectiveness of hand hygiene (HH) for infection control, there is a lack of robust scientific data to guide how HH can be improved in intensive care units (ICUs). The aim of this study is to use the literature, researcher, and stakeholder opinion to explicate potential interventions for improving HH compliance in the ICU, and provide an indication of the suitability of these interventions. Methods: A four-phase co-design study was designed. First, data from a previously completed systematic literature review was used in order to identify unique components of existing interventions to improve HH in ICUs. Second, a workshop was held with a panel of 10 experts to identify additional intervention components. Third, the 91 intervention components resulting from the literature review and workshop were synthesised into a final list of 21 hand hygiene interventions. Finally, the affordability, practicability, effectiveness, acceptability, side-effects/safety, and equity of each intervention was rated by 39 stakeholders (health services researchers, ICU staff, and the public). Results: Ensuring the availability of essential supplies for HH compliance was the intervention that received most approval from stakeholders. Interventions involving role models and peer-to-peer accountability and support were also well regarded by stakeholders. Education/training interventions were commonplace and popular. Punitive interventions were poorly regarded. Conclusions: Hospitals and regulators must make decisions regarding how to improve HH compliance in the absence of scientific consensus on effective methods. Using collective input and a co-design approach, the guidance developed herein may usefully support implementation of HH interventions that are considered to be effective and acceptable by stakeholders.

Background: Despite the effectiveness of hand hygiene (HH) for infection control, there is a lack of robust scientific data to guide how HH can be improved in intensive care units (ICUs). The aim of this study is to use the literature, researcher, and stakeholder opinion to explicate potential interventions for improving HH compliance in the ICU, and provide an indication of the suitability of these interventions. Methods: A four-phase co-design study was designed. First, data from a previously completed systematic literature review was used in order to identify unique components of existing interventions to improve HH in ICUs. Second, a workshop was held with a panel of 10 experts to identify additional intervention components. Third, the 91 intervention components resulting from the literature review and workshop were synthesised into a final list of 21 hand hygiene interventions. Finally, the affordability, practicability, effectiveness, acceptability, side-effects/safety, and equity of each intervention was rated by 39 stakeholders (health services researchers, ICU staff, and the public). Results: Ensuring the availability of essential supplies for HH compliance was the intervention that received most approval from stakeholders. Interventions involving role models and peer-to-peer accountability and support were also well regarded by stakeholders. Education/training interventions were commonplace and popular. Punitive interventions were poorly regarded. Conclusions: Hospitals and regulators must make decisions regarding how to improve HH compliance in the absence of scientific consensus on effective methods. Using collective input and a co-design approach, the guidance developed herein may usefully support implementation of HH interventions that are considered to be effective and acceptable by stakeholders.

Abstract Background Patient safety research is conducted predominantly in hospital settings, with a dearth of insight from primary care, despite suggestions that 2.2% of primary care consultations result in a patient safety incident. This study aimed to assess the feasibility of an intervention intended to improve patient safety in general practice. Methods A randomised controlled feasibility study was conducted with general practices in the Republic of Ireland (N = 9) and Northern Ireland (N = 2), randomly assigned to the intervention (N = 5) or control (N = 6) group. The nine-month intervention consisted of: 1) repeated safety climate (SC) measurement (using GP-SafeQuest questionnaire) and feedback (comparative anonymised practice-level SC data), and 2) patient record reviews using a specialised trigger tool to identify instances of undetected patient harm. For control practices, SC was measured at baseline and study end only. The intervention’s perceived usefulness and feasibility were explored via an end-of-study questionnaire and semi-structured interviews. Results Thirteen practices were invited; 11 participated; 10 completed the study. At baseline, 84.8% of intervention practice staff (39/46) and 77.8% (42/54) of control practice staff completed the SC questionnaire; at the study terminus, 78.3% (36/46) of intervention practice staff and 68.5% (37/54) of control practice staff did so. Changes in SC scores, indicating improvement, were observed among the intervention practices but not in the control group. The trigger tool was applied to 188 patient records; patient safety incidents of varying severity were detected in 19.1% (36/188). Overall, 59% of intervention practice team members completed the end-of-study questionnaire, with the majority in both healthcare systems responding positively about the intervention. Interviews (N = 9) identified the intervention’s usefulness in informing practice management and patient safety issues, time as a barrier to its use, and the value of group discussion of feedback. Conclusion This feasibility study suggests that a definitive randomised controlled trial of the intervention is warranted. Our findings suggest that the intervention is feasible, useful, and sustainable. Practices were willing to be recruited into the study, response and retention rates were acceptable, and there is possible evidence of a positive effect of the intervention. Trial registration The trial registration number is: ISRCTN11426121 (retrospectively registered 12th June 2018).

Abstract Background Recent research has demonstrated that burnout is widespread among physicians, and impacts their wellbeing, and that of patients. Such data have prompted efforts to teach resilience among physicians, but efforts are hampered by a lack of understanding of how physicians experience resilience and stress. This study aimed to contribute to knowledge regarding how physicians define resilience, the challenges posed by workplace stressors, and strategies which enable physicians to cope with these stressors. Methods A qualitative approach was adopted, with 68 semi-structured interviews conducted with Irish physicians. Data were analysed using deductive content-analysis. Results Five themes emerged from the interviews. The first theme, ‘The Nature of Resilience’ captured participants’ understanding of resilience. Many of the participants considered resilience to be “coping”, rather than “thriving” in instances of adversity. The second theme was ‘Challenges of the Profession’, as participants described workplace stressors which threatened their wellbeing, including long shifts, lack of resources, and heavy workloads. The third theme, ‘Job-related Gratification’, captured aspects of the workplace that support resilience, such as gratification from medical efficacy. ‘Resilience Strategies (Protective Practices)’ summarised coping behaviours that participants considered to be beneficial to their wellbeing, including spending time with family and friends, and the final theme, ‘Resilience Strategies (Attitudes)’, captured attitudes which protected against stress and burnout. Conclusions This study emphasised the need for further research the mechanisms of physician coping in the workplace and how we can capitalise on insights into physicians’ experiences of coping with system-level stressors to develop interventions to improve resilience.

Background: There is limited research, and guidance, on how to address safety in general practice proactively. Objectives: This review aimed to synthesize the literature describing the use of patient record review (PRR) to measure and improve patient safety in primary care. The PRR methodologies utilized and the resulting outcomes were examined. Methods: Searches were conducted using Medline, Embase, CINAHL and PsycINFO in February 2017. Reference lists of included studies and existing review papers were also screened. English language, peer-reviewed studies that utilized PRR to identify patient safety incidents (PSIs) occurring in general practice were included. Two researchers independently extracted data from articles and applied the Quality Assessment Tool for Studies with Diverse Designs. Results: A total of 3265 studies were screened, with 15 included. Trigger tools were the most frequent method used for the PRRs (n = 6). The mean number of safety incidents per 100 records was 12.6. Within studies, a mean of 30.6% of incidents were associated with severe harm (range 8.6–50%), and a mean of 55.6% of incidents was considered preventable (range 32.7–93.5%). The most commonly identified types of PSIs related to medication and prescribing, diagnosis, communication and treatment. Three studies reported on improvement actions taken after the PRRs. Conclusion: This review suggests that PRR may be a promising means of proactively identifying patient safety incidents and informing improvements.

Background: Safety climate (SC) measurement is a key component of quality and safety initiatives in primary healthcare. Objectives: To (1) measure perceived SC in Irish primary care; (2) examine whether perceptions of safety varied according to respondent characteristics; and (3) compare responses from our Irish sample to data from England and Scotland. Methods: PC-SafeQuest Survey was administered to all practice staff in Irish general practices between March and May 2016. This survey consists of 30 items across five safety domains (workload, communication, leadership, teamwork, and safety systems). Multiple regression analysis was used to identify predictor variables of perceived safety. The effect size of the difference between the Irish sample’s scores and published English and Scottish data were calculated. Results: A total of 231 questionnaires (38.5%) were returned. Generally, positive perceptions of perceived safety were identified among Irish respondents, but workload had the lowest overall mean score (M = 4.3, SD = 1.2) of the five domains. Comparisons across the Irish, English and Scottish samples identified a medium size effect difference in workload; Scottish respondents perceived workload to have less of a negative impact on safety than Irish or English counterparts (Cohen’s d = 0.602, 0.67 respectively). Analyses indicated that Irish GP principals perceived a more negative impact of workload on safety than administrative staff (β = 0.28, P = 0.03). Conclusion: Irish SC data are largely similar to those of England and Scotland. The perceived potential for workload to negatively impact upon safety emerged within each country. In Ireland, GP principals perceive this as a greater threat than practice administrators do.

Abstract Background Medical students may not be able to identify the essential elements of situational awareness (SA) necessary for clinical reasoning. Recent studies suggest that students have little insight into cognitive processing and SA in clinical scenarios. Objective Structured Clinical Examinations (OSCEs) could be used to assess certain elements of situational awareness. The purpose of this paper is to review the literature with a view to identifying whether levels of SA based on Endsley’s model can be assessed utilising OSCEs during undergraduate medical training. Methods A systematic search was performed pertaining to SA and OSCEs, to identify studies published between January 1975 (first paper describing an OSCE) and February 2017, in peer reviewed international journals published in English. PUBMED, EMBASE, PsycINFO Ovid and SCOPUS were searched for papers that described the assessment of SA using OSCEs among undergraduate medical students. Key search terms included “objective structured clinical examination”, “objective structured clinical assessment” or “OSCE” and “non-technical skills”, “sense-making”, “clinical reasoning”, “perception”, “comprehension”, “projection”, “situation awareness”, “situational awareness” and “situation assessment”. Boolean operators (AND, OR) were used as conjunctions to narrow the search strategy, resulting in the limitation of papers relevant to the research interest. Areas of interest were elements of SA that can be assessed by these examinations. Results The initial search of the literature retrieved 1127 publications. Upon removal of duplicates and papers relating to nursing, paramedical disciplines, pharmacy and veterinary education by title, abstract or full text, 11 articles were eligible for inclusion as related to the assessment of elements of SA in undergraduate medical students. Discussion Review of the literature suggests that whole-task OSCEs enable the evaluation of SA associated with clinical reasoning skills. If they address the levels of SA, these OSCEs can provide supportive feedback and strengthen educational measures associated with higher diagnostic accuracy and reasoning abilities. Conclusion Based on the findings, the early exposure of medical students to SA is recommended, utilising OSCEs to evaluate and facilitate SA in dynamic environments.

Abstract Experimental studies have demonstrated protective effects of NHE‐1 inhibition on cardiac function; however, clinical trials utilizing NHE‐1 antagonists found an increase in overall mortality attributed to thromboembolic strokes. NADPH oxidase‐derived reactive oxygen species (ROS) from microglial cells have been shown to contribute to injury following stroke. We have recently demonstrated that NHE‐1 inhibition enhances ROS in macrophages in a Hv1‐dependent manner. As Hv1 protein is highly expressed in microglia, we hypothesized that “NHE‐1 inhibition may augment neurovascular injury by activating Hv1,” providing a potential mechanism for the deleterious effects of NHE‐1. The goal of this study was to determine whether neurovascular injury and functional outcomes after experimental stroke differed in wild‐type and Hv1 mutant Dahl salt‐sensitive rats treated with an NHE‐1 inhibitor. Stroke was induced using both transient and permanent of middle cerebral artery occlusion (MCAO). Animals received vehicle or NHE‐1 inhibitor KR32568 (2 mg/kg, iv) either 30 min after the start of MCAO or were pretreated (2 mg/kg, iv, day) for 3 days and then subjected to MCAO. Our data indicate that Hv1 deletion confers both neuronal and vascular protection after ischemia. In contrast to our hypothesis, inhibition of NHE‐1 provided further protection from ischemic stroke, and the beneficial effects of both pre‐ and post‐treatment with KR32568 were similar in wild‐type and Hv1−/− rats. These data indicate that Hv1 activation is unlikely to be responsible for the increased incidence of cerebrovascular events observed in the heart disease patients after NHE‐1 inhibition treatment.

Hybridity has long been a contested term, critiqued as elitist and contradictory. This paper begins by arguing that hybridity has been debated too often and applied too seldom. It takes the premise that hybridity is an everyday fact of life and accordingly it should be articulated in academic works as a mode of analysis. In acknowledging works that call for the utilization of hybridity’s analytical potential this work applies hybridity to the analysis of three disparate topics, the modern pilgrimage to Mecca or hajj, the social networking and blogging platform Tumblr, and the Edward Snowden affair. Hybridity is contrasted with Lefebvre’s rhythmanalysis and applied as a conjoined conceptual focus on these issues. In each scenario a variety of hybrid connections are presented and situated in Bauman’s liquid modernity. These representations of hybridity highlight the manifold dimensions of the concept itself, that it can be superficial, political, celebrated, progressive, and mundane. Rather than dismiss the conceptual complexities of hybridity this paper calls for a harnessing of the broad scope of inference that hybridity presents in application. Working with hybridity thus provides a way to link topics and work organically between multiple disciplines.

Autistic individuals report barriers to accessing and receiving healthcare, and experience increased morbidity and mortality. This systematic review synthesizes 31 research studies evaluating interventions implemented to improve the healthcare experiences and/or access of autistic persons. Interventions were most commonly patient-focused (58.1%), focused on supporting the autistic individual to engage with, tolerate, or anticipate medical procedures, care, or settings. Fewer studies were provider-focused (48.4%) or organization-focused (6.5%). Interventions were typically evaluated using measures of reactions (45.2%) or behavior (48.4%), and outcomes were predominantly positive (80.6%). Further research is imperative and should look to how providers and organizations must change. Future research must be inclusive of the autistic community, must measure what matters, and must offer complete detail on interventions implemented.