What and when to debrief: a scoping review examining interprofessional clinical debriefing

INTRODUCTION

Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts.

METHODS

Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches.

RESULTS

Forty-six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD.

CONCLUSIONS

The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Coleadership in Maternity Teams, a Randomized, Counterbalanced, Crossover Trial in Simulation

OBJECTIVE

This study aimed to measure the effect of a coleadership model on team performance compared with singular leadership model in simulated maternity emergencies.

METHODS

A randomized, counterbalanced, crossover trial was performed at 2 tertiary maternity hospitals. Teams of obstetric physicians and nurse/midwives responded to 2 simulated maternity emergencies in either a singular or coleadership model. The primary outcome measure was teamwork rated with the Auckland Team Behavior tool. Secondary outcome measures included clinical performance (completion of critical tasks, time to critical intervention, documentation), self-rated teamwork (TEAM tool) and workload. Participants also answered a survey assessing their views on the coleadership model. Paired t tests and mixed-effects linear regression considering team as a random effect were used to estimate the unadjusted and adjusted associations between leadership model and the outcomes of interest.

RESULTS

There was no difference between leadership models for the primary outcome of teamwork (5.3 vs. 5.3, P = 0.91). Clinical outcome measures and self-rated teamwork scores were also similar. Team leaders reported higher workload than other team members, but these were not different between the leadership models. Participants viewed coleadership positively despite no measured objective evidence of benefit.

CONCLUSIONS

A coleadership model did not lead to a difference in team performance within simulated maternity emergencies. Despite this, participants viewed coleadership positively.

Heterogeneity in biological assemblages and exposure in chemical risk assessment: Exploring capabilities and challenges in methodology with two landscape-scale case studies

Chemical exposure concentrations and the composition of ecological receptors (e.g., species) vary in space and time, resulting in landscape-scale (e.g. catchment) heterogeneity. Current regulatory, prospective chemical risk assessment frameworks do not directly address this heterogeneity because they assume that reasonably worst-case chemical exposure concentrations co-occur (spatially and temporally) with biological species that are the most sensitive to the chemical's toxicity. Whilst current approaches may parameterise fate models with site-specific data and aim to be protective, a more precise understanding of when and where chemical exposure and species sensitivity co-occur enables risk assessments to be better tailored and applied mitigation more efficient. We use two aquatic case studies covering different spatial and temporal resolution to explore how geo-referenced data and spatial tools might be used to account for landscape heterogeneity of chemical exposure and ecological assemblages in prospective risk assessment. Each case study followed a stepwise approach: i) estimate and establish spatial chemical exposure distributions using local environmental information and environmental fate models; ii) derive toxicity thresholds for different taxonomic groups and determine geo-referenced distributions of exposure-toxicity ratios (i.e., potential risk); iii) overlay risk data with the ecological status of biomonitoring sites to determine if relationships exist. We focus on demonstrating whether the integration of relevant data and potential approaches is feasible rather than making comprehensive and refined risk assessments of specific chemicals. The case studies indicate that geo-referenced predicted environmental concentration estimations can be achieved with available data, models and tools but establishing the distribution of species assemblages is reliant on the availability of a few sources of biomonitoring data and tools. Linking large sets of geo-referenced exposure and biomonitoring data is feasible but assessment of risk will often be limited by the availability of ecotoxicity data. The studies highlight the important influence that choices for aggregating data and for the selection of statistical metrics have on assessing and interpreting risk at different spatial scales and patterns of distribution within the landscape. Finally, we discuss approaches and development needs that could help to address environmental heterogeneity in chemical risk assessment.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Clinicians' attitudes towards a co-leadership structure for maternity emergency teams: An interview study

Shared leadership improves team performance in many domains and is present in some interprofessional healthcare teams. Despite the dominant paradigm of a singular obstetrician leader in maternity emergencies, co-leadership, a specific form of shared leadership, has been identified as a potentially beneficial to clinical care. This qualitative interview study addresses the gaps in knowledge regarding clinician attitudes toward co-leadership and how a co-leadership structure might be implemented within a maternity care setting. Twenty-five clinicians (midwives, obstetricians and anaesthetists) working in the birthing units of two tertiary maternity units were interviewed and a conventional content analysis conducted. Clinicians viewed co-leadership as potentially beneficial to patient care through improved leadership performance and co-leader back up behavior. Implementation of co-leadership was thought to require a supportive organizational culture, agreed patient management protocols and the participation in simulation training. Enacting co-leadership required adaptable leadership sharing practices, effective communication, and high levels of trust between the co-leaders. These findings inform the future implementation strategies for co-leadership in interprofessional healthcare teams.

Shared Leadership in Healthcare Action Teams: A Systematic Review

OBJECTIVES

The aims of this review were to consolidate the reported literature describing shared leadership in healthcare action teams (HCATs) and to review the reported outcomes related to leadership sharing in healthcare emergencies.

METHODS

A systematic search of the English language literature before November 2017 was performed using PsycINFO, MEDLINE, PubMed, CINAHL, and EMBASE. Articles describing sharing of leadership functions in HCATs were included. Healthcare teams performing routine work were excluded. Studies were reviewed for type of leadership sharing and sharing-related outcomes.

RESULTS

Thirty-three articles met the inclusion criteria. A variety of shared leadership models were described across the following three categories: spontaneous collaboration, intuitive working relations, and institutionalized practices. While leadership sharing has the potential for both positive and negative influences on team performance, only six articles reported outcomes potentially attributable to shared leadership.

CONCLUSIONS

Despite strong evidence for a positive relationship between shared leadership and team performance in other domains, there is limited literature describing shared leadership models in HCATs. The association between shared leadership and team performance in HCATs is a rich area for further investigation.

The use of ecological models to assess the effects of a plant protection product on ecosystem services provided by an orchard

The objective of this case study was to explore the feasibility of using ecological models for applying an ecosystem services-based approach to environmental risk assessment using currently available data and methodologies. For this we used a 5 step approach: 1) selection of environmental scenario, 2) ecosystem service selection, 3) development of logic chains, 4) selection and application of ecological models and 5) detailed ecosystem service assessment. The study system is a European apple orchard managed according to integrated pest management principles. An organophosphate insecticide was used as the case study chemical. Four ecosystem services are included in this case study: soil quality regulation, pest control, pollination and recreation. Logic chains were developed for each ecosystem service and describe the link between toxicant effects on service providing units and ecosystem services delivery. For the soil quality regulation ecosystem service, springtails and earthworms were the service providing units, for the pest control ecosystem service it was ladybirds, for the pollination ecosystem service it was honeybees and for the recreation ecosystem service it was the meadow brown butterfly. All the ecological models addressed the spatio-temporal magnitude of the direct effects of the insecticide on the service providing units and ecological production functions were used to extrapolate these outcomes to the delivery of ecosystem services. For all ecosystem services a decision on the acceptability of the modelled and extrapolated effects on the service providing units could be made using the protection goals as set by the European Food Safety Authority (EFSA). Developing quantitative ecological production functions for extrapolation of ecosystem services delivery from population endpoints remains one of the major challenges. We feel that the use of ecological models can greatly add to this development, although the further development of existing ecological models, and of new models, is needed for this.

The power of feeling seen: perspectives of individuals with eating disorders on receiving validation

BACKGROUND

A common complaint of individuals suffering from mental health conditions is feeling invalidated or misunderstood by care providers. This is notable, given that non-collaborative care has been linked to poor engagement, low motivation and treatment non-adherence. This study examined how receiving validation from care providers is experienced by individuals who have an eating disorder (ED) and the impact of receiving validation on the recovery journey.

METHODS

Eighteen individuals who had an eating disorder for an average duration of 19.1 years (two identifying as male, 16 identifying as female), participated in semi-structured interviews on barriers and facilitators to self-compassion. Seven were fully recovered, and 11 were currently participating in recovery-focused residential treatment. Thematic analysis focused on the meaning and impact of receiving validation to participants.

RESULTS

Five care provider actions were identified: (i) making time and space for me, (ii) offering a compassionate perspective, (iii) understanding and recognizing my treatment needs, (iv) showing me I can do this, and (v) walking the runway. These were associated with four key experiences (feeling trust, cared for, empowered, and inspired), that participants described as supportive of their recovery.

CONCLUSIONS

This research provides insight into patient perspectives of validation and strategies care providers can use, such as compassionate reframing of difficult life experiences, matching interventions to patient readiness, and modeling vulnerability.

Early infestations by arthropod pests induce unique changes in plant compositional traits and leaf reflectance

BACKGROUND

With steadily growing interest in the use of remote-sensing technologies to detect and diagnose pest infestations in crops, it is important to investigate and characterize possible associations between crop leaf reflectance and unique pest-induced changes in plant compositional traits. Accordingly, we compiled plant compositional traits from chrysanthemum and gerbera plants in four treatments: non-infested, or infested with mites, thrips or whiteflies, and we acquired hyperspectral leaf reflectance data from the same plants over time (0-14 days).

RESULTS

Plant compositional traits changed significantly in response to arthropod infestations, and individual chrysanthemum and gerbera plants were classified with 78% and 80% accuracy, respectively. Based on leaf reflectance, individual plants from the four treatments were classified with moderate accuracy levels of 76% (gerbera) and 73% (chrysanthemum) but with a clear distinction between non-infested and infested plants. Accurate and consistent diagnosis of biotic stressors was not achieved.

CONCLUSION

To our knowledge, this is the first study in which infestations by multiple economically important arthropod pests are directly compared and associated with leaf reflectance responses and changes in plant compositional traits. It is important to highlight that imposed stress levels were low, period of infestation was short, and hyperspectral remote-sensing data were acquired at four time points with analyses based on large data sets (3826 leaf reflectance profiles for chrysanthemum and 4041 for gerbera). This study provides novel insight into crop responses to different biotic stressors and into possible associations between plant compositional traits and hyperspectral leaf reflectance data acquired from crop leaves.

Assessing chemical risk within an ecosystem services framework: Implementation and added value

An ecosystem services (ES) approach to chemical risk assessment has many potential advantages, but there are also substantial challenges regarding its implementation. We report the findings of a multi-stakeholder workshop that evaluated the feasibility of adopting an ES approach to chemical risk assessment using currently available tools and data. Also evaluated is the added value such an approach would bring to environmental decision making. The aim was to build consensus across disparate stakeholders and to co-produce a common understanding of the regulatory benefits and feasibility of implementing an ES approach in European chemicals regulation. Workshop discussions were informed by proof of concept studies and resulted in the development of a novel tiered framework for assessing chemical risk to ES delivery. There was consensus on the substantial added value of adopting an ES-based approach for regulatory decision making. Ecosystem services provide a common currency and a 'unifying approach' across environmental compartments, stressors and regulatory frameworks. The ES approach informs prioritisation of risk and remedial action and aids risk communication and risk management. It facilitates a more holistic assessment, enables ES trade-offs to be compared across alternative interventions, and supports comparative risk assessments and a socio-economic analysis of management options and decisions. Key to realising this added value is a shift away from using a single threshold value to categorise risk, towards a consideration of the exposure-effect distribution for individual ES of interest. Also required is the development of an integrated systems-level approach across regulatory frameworks and agreement on specific protection goals and scenarios for framing environmental risk assessments. The need to further develop tools for extrapolating toxicity data to service providers and ES delivery, including logic chains and ecological production functions, was highlighted. Also agreed was the need for methods and metrics for ES valuation to be used in assessing trade-offs.

Identifying ecological production functions for use in ecosystem services-based environmental risk assessment of chemicals

There is increasing research interest in the application of the ecosystem services (ES) concept in the environmental risk assessment of chemicals to support formulating and operationalising regulatory environmental protection goals and making environmental risk assessment more policy- and value-relevant. This requires connecting ecosystem structure and processes to ecosystem function and henceforth to provision of ecosystem goods and services and their economic valuation. Ecological production functions (EPFs) may help to quantify these connections in a transparent manner and to predict ES provision based on function-related descriptors for service providing species, communities, ecosystems or habitats. We review scientific literature for EPFs to evaluate availability across provisioning and regulation and maintenance services (CICES v5.1 classification). We found quantitative production functions for nearly all ES, often complemented with economic valuation of physical or monetary flows. We studied the service providing units in these EPFs to evaluate the potential for extrapolation of toxicity data for test species obtained from standardised testing to ES provision. A broad taxonomic representation of service providers was established, but quantitative models directly linking standard test species to ES provision were extremely scarce. A pragmatic way to deal with this data gap would be the use of proxies for related taxa and stepwise functional extrapolation to ES provision and valuation, which we conclude possible for most ES. We suggest that EPFs may be used in defining specific protection goals (SPGs), and illustrate, using pollination as an example, the availability of information for the ecological entity and attribute dimensions of SPGs. Twenty-five pollination EPFs were compiled from the literature for biological entities ranging from 'colony' to 'habitat', with 75% referring to 'functional group'. With about equal representation of the attributes 'function', 'abundance' and 'diversity', SPGs for pollination therefore would seem best substantiated by EPFs at the level of functional group.

Assessing the feasibility and value of employing an ecosystem services approach in chemical environmental risk assessment under the Water Framework Directive

The feasibility and added value of an ecosystem services approach in retrospective environmental risk assessment were evaluated using a site-specific case study in a lowland UK river. The studied water body failed to achieve good ecological status temporarily in 2018, due in part to the exceedance of the environmental quality standard (annual average EQS) for zinc. Potential ecosystem service delivery was quantified for locally prioritised ecosystem services: regulation of chemical condition; maintaining nursery populations and habitats; recreational fishing; nature watching. Quantification was based on observed and expected taxa or functional groups within WFD biological quality elements, including macrophytes, benthic macroinvertebrates and fish, and on published functional trait data for constituent taxa. Benthic macroinvertebrate taxa were identified and enumerated before, during and after zinc EQS exceedance, enabling a generic retrospective risk assessment for this biological quality element, which was found to have good ecosystem service potential. An additional targeted risk assessment for zinc was based on laboratory-based species sensitivity distributions normalised using biotic-ligand modelling to account for site-specific, bioavailability-corrected zinc exposure. Risk to ecosystem services for diatoms (microalgae) was found to be high, while risks for benthic macroinvertebrates and fish were found to be low. The status of potential ecosystem service delivery (ESD) by fish was equivalent to high ecological status defined under the WFD, while ESD was higher for benthic macroinvertebrates than defined by WFD methods. The illustrated ecosystem services approach uses readily available data and adds significantly to the taxonomic approach currently used under the WFD by using functional traits to evaluate services that are prioritised as being important in water bodies. The main shortcomings of the illustrated approach were lack of: representation of bacteria and fungi; WFD predicted species lists for diatoms and macrophytes; site-specific functional trait data required for defining actual (rather than potential) ecosystem service delivery.

Child Fluoride Varnish Programs Implementation: A Consensus Workshop and Actions to Increase Scale-Up in Australia

This paper presents the findings of the National Fluoride Varnish Workshop in 2018 along with subsequent actions to scale-up the use of fluoride varnish nationally in Australia. The use of fluoride varnish programs to prevent dental caries in high-risk child populations is an evidence-based population health approach used internationally. Such programs have not been implemented at scale nationally in Australia. A National Fluoride Varnish Consensus Workshop was held in Sydney in November 2018 with an aim of sharing the current work in this area being undertaken by various Australian jurisdictions and seeking consensus on key actions to improve the scale-up nationally. Forty-four people attended the Workshop with oral health representatives from all Australian state and territory health departments, as well as the Australian Dental Association (ADA) at both NSW branch and Federal levels. There was strong support for further scale-up of fluoride varnish programs nationally and to see the wider use of having non-dental professionals apply the varnish. This case study identifies key actions required to ensure scale-up of systematic fluoride varnish programs as part of a strategic population oral health approach to preventing dental caries among high-risk children who may not routinely access dental care.

P–416 Radiotherapy inflicts long-term damage upon the uterus, causing uterine artery endothelial dysfunction and pregnancy loss in mice

Study question

Does the uterus sustain direct and long-term damage following radiotherapy, independent of ovarian damage?

Summary answer

Radiotherapy causes direct and long-term uterine damage. Ovariectomised and hormonally supplemented mice experience uterine artery endothelial dysfunction and pregnancy loss following transfer of healthy blastocysts.

What is known already

The detrimental off-target impacts of cancer therapies on the ovary are well established, with some fertility preservation techniques available to ensure patients maintain their fertility following gonadotoxic treatment. Low doses of radiotherapy kill the majority of primordial follicle oocytes in the ovary, reducing the ovarian reserve and fertile lifespan. Patients who have received radiotherapy experience higher rates of pregnancy complications including preterm birth, low birth weight, and stillbirth. However, no studies have investigated if radiation inflicts direct, fertility compromising damage to the uterus.

Study design, size, duration

Adolescent female mice were untreated or exposed to whole body y-irradiation (7Gy), then ovariectomised. Immediate damage was assessed up to 24 hours post-irradiation (n = 4/group). Four weeks following treatment, mice were hormone primed to induce endometrial receptivity (n = 7/group), artificial decidualisation (n = 7–8/group), or receive embryo transfers from healthy, unexposed donor mice to assess embryo implantation (n = 11–13/group), and mid-gestation development (n = 8–10/group).

Participants/materials, setting, methods

Four week old C57BL6/CBA (F1) female mice were used for this study. Immunofluorescence and in situ hybridisation were utilised to localise markers of immediate DNA damage and cell death following irradiation, and markers of receptivity in hormone primed uteri. Measurements of uterine artery blood flow were recorded using Doppler ultrasonography, and indices of pulsatility and resistance calculated. Uterine artery wire myography was performed to assess competency of endothelial and smooth muscle compartments following irradiation.

Main results and the role of chance

Within 24 hours of irradiation, DNA damage (yH2AX) and apoptosis (Puma/TUNEL) were elevated in uteri, compared to control. Irradiated mice that received embryo transfers from untreated donors had similar numbers of implantation sites 3-days post-transfer versus controls, however uteri were pale and atrophic suggesting impaired vascularisation. By 10-days post-transfer, implantation sites in irradiated mice were resorbing (p < 0.001), although uterine artery Doppler ultrasound measurements demonstrated no change in pulsatility or resistance indices. When the brain was shielded from irradiation to protect the hypothalamic-pituitary-gonadal axis, resorption still occurred (p < 0.001), suggesting direct uterine damage is the likely cause of pregnancy loss. To investigate uterine damage in the absence of an embryo, endometrial receptivity was induced artificially. Uteri from irradiated animals were lighter compared to control (p < 0.05), however localisation of receptivity markers (E-cadherin, Mucin1, Ki67) was normal. When decidualisation was artificially induced irradiated uteri were also lighter (p < 0.01) indicating impaired decidualisation and reduced capacity to adapt to pregnancy. Wire myography performed on uterine arteries demonstrated endothelial dysfunction in irradiated mice (p < 0.0001).

Limitations, reasons for caution

Here, only a single age and dose of radiotherapy exposure are modelled. Patients of all ages can receive many doses of radiotherapy in combination with various chemotherapies. Our highly manipulable model enables any treatment variation to be modelled and the effect on the uterus and pregnancy examined.

Wider implications of the findings: Reproductive aged cancer patients need to be appropriately counselled regarding the risks to their long-term fertility following treatment. Until now, potential permanent impacts to the uterus following cancer treatment have not been considered. It is clear radiotherapy can impose long-term damage to the uterus and influence pregnancy success and fertility.

Trial registration number

NA

Improving pain management for children having dental extractions under general anaesthesia

Children provided with general anaesthesia for dental extractions at East Surrey Hospital were audited to determine the percentage of children who were prescribed adequate pain management in accordance with guidance published by the Association of Paediatric Anaesthetists of Great Britain and Ireland. Three audit cycles were completed. Data were collected retrospectively through case note review. The results from the first cycle showed that only 47% of children were prescribed with a recommended analgesic regimen. Implementation of change included the development of a protocol for analgesic delivery, which was disseminated to the anaesthetic and dental teams. Full compliance with the audit standards was then demonstrated in the second and third cycles. This audit demonstrates the importance of multidisciplinary collaboration in order to provide high standards of care for children undergoing dental extractions under general anaesthesia. The protocol developed could be applied to other surgical day case procedures for children to improve the patient experience.

Fine-scale acoustic telemetry in a riverine environment: movement and habitat use of the endangered Mary River cod Maccullochella mariensis

Understanding movement and habitat requirements of endangered species is critical to conservation management. We evaluate fine-scale acoustic telemetry to study breeding-related movement and habitat use of the endangered Mary River cod Maccullochella mariensis in a riverine environment and, in relation to key environmental variables, to inform management. Movement activity varied significantly in relation to water temperature and diel period, and spatial occupancy and habitat selection varied substantially in relation to the nesting behaviour of Mary River cod. Important nesting habitat included a large hollow log mid-channel and well-shaded logs and log jams adjacent to the river bank. Extrapolating this information to the general population was inhibited by relatively small sample sizes, due in part to the restricted spatial scale of the hydrophone arrays and longitudinal movements of tagged fish beyond the acoustic range of our array. Notwithstanding this, our results demonstrate that (1) fine-scale acoustic telemetry can quantify complex biological behaviours in riverine environments; (2) Mary River cod require specific environmental stimuli and habitat to support the reproductive cycle; and (3) changing environmental conditions may influence Mary River cod behaviour, and understanding this response is necessary for sustainable management. Findings from this study can inform future applications of this methodology in riverine environments and contribute to the development of management strategies and habitat restoration activities supporting the recovery of Mary River cod populations.

Preliminary report of a simulation community of practice needs analysis

Aim

To understand the current needs related to education and training, and other investment priorities, in simulated learning environments in Australia following a significant period of government funding for simulation-based learning.

Methods

A mixed methods study, comprising qualitative focus groups and individual interviews, followed by a quantitative cross-sectional survey informed by themes emerging from the qualitative data.

Findings

Two focus groups and 22 individual interviews were conducted. Participants included simulation educators, technical users and new adopters. Survey data were collected from 152 responses. Barriers at the introduction and maintenance stages of simulated learning included irregular staff training resulting in inconsistent practice, and lack of onsite technical support. Educators lacked skills in some simulation and debriefing techniques, and basic education and research skills were limited, while technicians raised concerns regarding the maintenance of equipment and managing budgets.

Discussion and conclusion

Despite its effectiveness as an education tool, barriers remain at the introduction and maintenance stages of simulated learning environments. Efforts to improve the integrity and sustainability of simulation training should be informed by a comprehensive needs analysis. The resulting data should be used to address barriers in a way that maximises the limited resources and funding available for this important learning tool.

Midwifery leadership in maternity emergencies: a video analysis

Maternity emergencies require effective leadership due to their time-critical high stakes nature, and like many emergency teams are recommended to have a singular leader. Midwives possess many of the skills required for leadership, but the extent to which they contribute to leadership in emergencies is unknown. In this video analysis study of 16 interprofessional teams responding to a simulated post-partum hemorrhage, a functional view of leadership was applied to determine midwifery contribution to leadership. The number and type of leadership utterances by team members during an emergency response was assessed, and midwifery and doctor leadership utterances compared. Midwives contributed just over 40% of all leadership utterances, indicating the occurrence of interprofessional shared leadership, despite the recommendation for a singular leadership. While the number of leadership utterances per scenario was similar for midwives and doctors, midwives contributed less to utterances of a clinical nature compared to doctors but a similar amount of non-clinical leadership. Further exploration of the factors which influence midwifery leadership in emergencies and the impact it may have on patient care is warranted.

A systematic approach to map the adolescent human papillomavirus vaccine decision and identify intervention strategies to address vaccine hesitancy

OBJECTIVES

Unsubstantiated safety concerns with human papillomavirus (HPV) vaccines continue to linger. This study sought to identify factors that influence the adolescent HPV vaccine decision and systematically identify intervention functions and strategies likely to be effective in reducing vaccine hesitancy.

STUDY DESIGN

This is a qualitative focus group study.

METHODS

Focus groups were conducted with female adolescents (aged 14-16 years) in Cork and Kerry. During focus groups, the trained facilitator used a semistructured, Theoretical Domains Framework (TDF)-based topic guide to prompt discussion. Transcripts were thematically analysed using the TDF and Behaviour Change Wheel. Behaviour Change Technique Taxonomy version 1 was used to suggest intervention functions and strategies for addressing HPV vaccine hesitancy.

RESULTS

A total of 50 adolescents (96% vaccinated), participated in 10 focus groups. The key themes were presented by means of the relevant TDF domains. Seven domains were selected as the most relevant: knowledge, social influences, beliefs about capabilities, optimism, beliefs about consequences, emotion and environmental context and resources. Five intervention functions were identified, education, persuasion, enablement, modelling and environmental restructuring, and linked to 11 relevant Behaviour Change Technique (BCTs). Potential intervention strategies were developed.

CONCLUSIONS

This study provided a detailed insight into behavioural factors influencing the vaccine decision-making process. It was identified that awareness and knowledge about HPV and its health sequelae was low. Lack of information is a well-recognised determinant of vaccine hesitancy. Therefore, education was recommended as a key area to address in future intervention studies.

Closing Editorial: Conversations in healthcare education

This article was migrated. The article was marked as recommended. The theme coincided with the 8 thInternational Clinical Skills Conference held in Prato Italy, May 2019. The conference focused on putting the spotlight on conversations in healthcare and we were highly successful in achieving this aim by generating much discussion, debate and dialogue amongst our conference delegates. The conference is known for its informality, friendliness and ability to bring people together as a community of practice and this year was no exception. The conversations on twitter alone was unprecedented with over three million impressions over the period of the conference. This is a truly remarkable number given that the conference is limited to only 250 delegates because of the size of the venue. Whilst the conference did not generate as many paper submissions to MedEdPublish as we would have liked, the five papers submitted were noteworthy and included practical tips to use for teaching intrinsic skills to physicians ( LaFleur et al., 2019), implementing a collaborative social media platform in obstetrics and gynaecology ( O'sullivan, Janssens and Warhurst, 2019), and developing consultation skills for medical students ( Andersson et al., 2019). Nevertheless, we believe this is the first experiment in true 360-degree scientific peer review. A system where manuscripts published on the journal's website before a conference can be explained in conference presentations, questions asked, discussed on social media and finally reviews published alongside the paper on the website. Such a model must surely be beneficial for disseminating new research and ensuring it is of the highest standard. Conversations in healthcare today continue to be of great importance to the future of clinical education and for developing health professionals with the skills needed for person-centred care and we look forward to continuing this work into the future.

Opening Editorial: Conversations in health care education

This article was migrated. The article was marked as recommended. Clinical education happens predominantly via conversations. Conversations between the educator and learner, among learners, between those giving and receiving health care and even among educators striving to improve in their teaching. Sometimes these conversations may be difficult, with troublesome feedback and hard lessons to learn, sometimes they are unstructured and messy. Almost always, more dialogue is needed. This theme coincides with the 8 th International Clinical Skills Conference in Prato, Italy. The conference has a history of starting conversations among researchers, educators and clinicians and the theme for the conference coincides with the theme for this issue. This pairing of a conference with a post publication peer review journal has not to our knowledge been previously attempted. This format gives a unique opportunity to provide a deeper learning from the peer review process. High-quality submissions will be published on the site and presented at the conference. Readers and conference attendees alike will be able to comment on the papers presented. In this way, discussions in person, online and via the traditional publishing route can be brought together to improve the publishing and research process. Indeed, the theme of 'conversations' could not be more apt than in these 'metaconversations' about educational research. We believe that the conversations within the walls and courtyard of the Palazzo Vaj that have influenced so many educational researchers in the past will have a chance to reach a wider audience than just the conference attendees. Some of the types of conversations in clinical skills we will discuss have great importance in the future of clinical education and for developing health professionals with the skills needed for person-centre care. We especially wish to promote articles that highlight work undertaken in Low-Middle Income Countries (LMICs) as these align with the values of the charity that underpins the conference, the International Clinical Skills Foundation (Inc.).

Priorities and opportunities in the application of the ecosystem services concept in risk assessment for chemicals in the environment

The ecosystem services approach has gained broad interest in regulatory and policy circles for use in ecological risk assessment. Whilst identifying several challenges, scientific experts from European regulatory authorities, the chemical industry and academia considered the approach applicable to all chemical sectors and potentially contributing to greater ecological relevance for setting and assessing environmental protection goals compared to current European regulatory frameworks for chemicals. These challenges were addressed in workshops to develop a common understanding across stakeholders on how the ecosystem services concept might be used in chemical risk assessment and what would need to be done to implement it. This paper describes the consensus outcome of those discussions. Knowledge gaps and research needs were identified and prioritised, exploring the use of novel approaches from ecology, ecotoxicology and ecological modelling. Where applicable, distinction is made between prospective and retrospective ecological risk assessment. For prospective risk assessment the development of environmental scenarios accounting for chemical exposure and ecological conditions was designated as a top priority. For retrospective risk assessment the top priority research need was development of reference conditions for key ecosystem services and guidance for their derivation. Both prospective and retrospective risk assessment would benefit from guidance on the taxa and measurement endpoints relevant to specific ecosystem services and from improved understanding of the relationships between measurement endpoints from standard toxicity tests and the ecosystem services of interest (i.e. assessment endpoints). The development of mechanistic models, which could serve as ecological production functions, was identified as a priority. A conceptual framework for future chemical risk assessment based on an ecosystem services approach is presented.

Leadership sharing in maternity emergency teams: a retrospective cohort study in simulation

Background

Shared leadership is associated with improved team performance in many domains, but little is understood about how leadership is shared spontaneously in maternity emergency teams, and if it is associated with improved team performance.

Methods

A video analysis study of multidisciplinary teams attending a maternity emergency management course was performed at a simulation centre colocated with a tertiary maternity hospital. Sixteen teams responding to a simulated postpartum haemorrhage were analysed between November 2016 and November 2017. Videos were transcribed, and utterances coded for leadership type using a coding system developed a priori. Distribution of leadership utterances between team members was calculated using the Gini coefficient. Teamwork was assessed using validated tools and clinical performance was assessed by time to perform a critical intervention and a checklist of required tasks.

Results

There was a significant sharing of leadership functions across the team despite the traditional recommendation for a singular leader, with the dominant leader only accounting for 58% of leadership utterances. There was no significant difference in Auckland Team Assessment Tool scores between high and low leadership sharing teams (5.02 vs 4.96, p=0.574). Time to critical intervention was shorter in low leadership sharing teams (193 s vs 312 s, p=0.018) but checklist completion did not differ significantly. Teams with better clinical performance had fewer leadership utterances beyond the dominant two leaders compared with poorer performing teams.

Conclusions

Leadership is spontaneously shared in maternity emergency teams despite the recommendation for singular leadership. Spontaneous leadership emerging from multiple team members does not appear to be associated with the improvements in team performance seen in other domains.

Toward sustainable environmental quality: Priority research questions for Europe

The United Nations' Sustainable Development Goals have been established to end poverty, protect the planet, and ensure prosperity for all. Delivery of the Sustainable Development Goals will require a healthy and productive environment. An understanding of the impacts of chemicals which can negatively impact environmental health is therefore essential to the delivery of the Sustainable Development Goals. However, current research on and regulation of chemicals in the environment tend to take a simplistic view and do not account for the complexity of the real world, which inhibits the way we manage chemicals. There is therefore an urgent need for a step change in the way we study and communicate the impacts and control of chemicals in the natural environment. To do this requires the major research questions to be identified so that resources are focused on questions that really matter. We present the findings of a horizon-scanning exercise to identify research priorities of the European environmental science community around chemicals in the environment. Using the key questions approach, we identified 22 questions of priority. These questions covered overarching questions about which chemicals we should be most concerned about and where, impacts of global megatrends, protection goals, and sustainability of chemicals; the development and parameterization of assessment and management frameworks; and mechanisms to maximize the impact of the research. The research questions identified provide a first-step in the path forward for the research, regulatory, and business communities to better assess and manage chemicals in the natural environment. Environ Toxicol Chem 2018;37:2281-2295. © 2018 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals, Inc. on behalf of SETAC.

Human factors enablers and barriers for successful airway management - an in-depth interview study

Human factors are the individual, team, environmental and organisational aspects of the anaesthetic environment that affect performance and decision-making of anaesthesia teams. This study aimed to identify which human factors were enablers and/or barriers to anaesthesia teams during airway management challenges. Sixteen interviews were conducted with experienced anaesthetists and anaesthetic nurses using an in-depth interview technique (the Critical Decision Method) to identify human factors enablers and/or barriers during successful management of a significant airway challenge. Thematic analysis identified three overarching enablers: equipment location and storage; experience and learning; teamwork and communication. Five overarching barriers were also identified: time and resource limitations; teamwork and communication; equipment location and storage; experience and learning; insufficient back-up planning; and equipment preparation. This study showed that a variety of human factors issues affect the handling of airway challenges, ranging from individual and team to organisational and environmental aspects. Recommendations for the design of airway management decision support tools that relate to equipment standardisation, decision support complexity, inclusive mutual learning and teamwork are discussed.

Advantages and challenges associated with implementing an ecosystem services approach to ecological risk assessment for chemicals

The ecosystem services (ES) approach is gaining broad interest in regulatory and policy arenas for use in landscape management and ecological risk assessment. It has the potential to bring greater ecological relevance to the setting of environmental protection goals and to the assessment of the ecological risk posed by chemicals. A workshop, organised under the auspices of the Society of Environmental Toxicology and Chemistry Europe, brought together scientific experts from European regulatory authorities, the chemical industry and academia to discuss and evaluate the challenges associated with implementing an ES approach to chemical ecological risk assessment (ERA). Clear advantages of using an ES approach in prospective and retrospective ERA were identified, including: making ERA spatially explicit and of relevance to management decisions (i.e. indicating what ES to protect and where); improving transparency in communicating risks and trade-offs; integrating across multiple stressors, scales, habitats and policies. A number of challenges were also identified including: the potential for increased complexity in assessments; greater data requirements; limitations in linking endpoints derived from current ecotoxicity tests to impacts on ES. In principle, the approach was applicable to all chemical sectors, but the scale of the challenge of applying an ES approach to general chemicals with widespread and dispersive uses leading to broad environmental exposure, was highlighted. There was agreement that ES-based risk assessment should be based on the magnitude of impact rather than on toxicity thresholds. The need for more bioassays/tests with functional endpoints was recognized, as was the role of modelling and the need for ecological production functions to link measurement endpoints to assessment endpoints. Finally, the value of developing environmental scenarios that can be combined with spatial information on exposure, ES delivery and service provider vulnerability was recognized.

The Driver Behaviour Questionnaire for older drivers: Do errors, violations and lapses change over time?

The aim of the current study was to examine how self-reported aberrant driving behaviours change across a three time-points in a group of older drivers. Two hundred and twenty-seven older drivers (males = 69.6%) from the Candrive/Ozcandrive longitudinal study completed the Driving Behaviour Questionnaire (DBQ) each yearacross three time-points (i.e., Year 1, Year 2, Year 3). At the third time-point, older drivers ranged in age from 77 to 96 years (M = 81.74 years; SD = 3.44 years). A longitudinal confirmatory factor analysis showed that a modified 21-item, 3-factor (errors, lapses and violations) DBQ was invariant across the time period, suggesting that the structure of the questionnaire was stable across each time-point. Further, multiple domain latent growth analysis on the resultant factors for errors, lapses and violations showed that the frequency of errors remained similar across the three-year period, while violations and lapses showed very marginal decreases in frequency. These changes were independent of the absolute number of these behaviours; Drivers with higher violations or lapses in Year one, showed similar decreases in frequency as those who self-reported lower frequencies of the behaviours. These results suggest that the DBQ is a reliable tool to measure older drivers' self-reported aberrant driving behaviours, and that these behaviours do not show much change across time. Future research should validate the self-reported responses from the DBQ with more objective measures such as those collected through naturalistic driving study (NDS) methodology or on-road driving tasks.

Prospective mixture risk assessment and management prioritizations for river catchments with diverse land uses

Ecological risk assessment increasingly focuses on risks from chemical mixtures and multiple stressors because ecosystems are commonly exposed to a plethora of contaminants and nonchemical stressors. To simplify the task of assessing potential mixture effects, we explored 3 land use-related chemical emission scenarios. We applied a tiered methodology to judge the implications of the emissions of chemicals from agricultural practices, domestic discharges, and urban runoff in a quantitative model. The results showed land use-dependent mixture exposures, clearly discriminating downstream effects of land uses, with unique chemical "signatures" regarding composition, concentration, and temporal patterns. Associated risks were characterized in relation to the land-use scenarios. Comparisons to measured environmental concentrations and predicted impacts showed relatively good similarity. The results suggest that the land uses imply exceedances of regulatory protective environmental quality standards, varying over time in relation to rain events and associated flow and dilution variation. Higher-tier analyses using ecotoxicological effect criteria confirmed that species assemblages may be affected by exposures exceeding no-effect levels and that mixture exposure could be associated with predicted species loss under certain situations. The model outcomes can inform various types of prioritization to support risk management, including a ranking across land uses as a whole, a ranking on characteristics of exposure times and frequencies, and various rankings of the relative role of individual chemicals. Though all results are based on in silico assessments, the prospective land use-based approach applied in the present study yields useful insights for simplifying and assessing potential ecological risks of chemical mixtures and can therefore be useful for catchment-management decisions. Environ Toxicol Chem 2018;37:715-728. © 2017 The Authors. Environmental Toxicology Chemistry Published by Wiley Periodicals, Inc.