Mutual recognition of qualifications, health workforce migration, and graduate outcomes: a comparative mapping study of undergraduate dental education in Europe.

BACKGROUND: The resource needs of health services are served by the recognition of qualifications across borders which allows professionals to migrate between countries. The movement of dentists across the European Union (EU), especially into the United Kingdom (UK), has provided a valuable boost to workforce supply. Recent changes to policy recognising overseas qualifications have brought attention to the equivalence of qualifications awarded in EU countries. Professional regulators need to be confident that dentists who qualified elsewhere have the appropriate knowledge, skills and experience to practise safely and effectively. The aim of this study was to compare UK and EU dental curricula, identify any differences, and compare the extent of pre-qualification clinical experience. METHODS: This was a mixed methods study comprising a questionnaire and website searches to identify information about curricula, competences, and quality assurance arrangements in each country. The questionnaire was sent to organisations responsible for regulating dental education or dental practice in EU member states. This was supplemented with information obtained from website searches of stakeholder organisations for each country including regulators, professional associations, ministries, and providers of dental education. A map of dental training across the EU was created. RESULTS: National learning outcomes for dental education were identified for seven countries. No national outcomes were identified 13 countries; therefore, learning outcomes were mapped at institution level only. No information about learning outcomes was available for six countries. In one country, there is no basic dental training. Clinical skills and communication were generally well represented. Management and leadership were less represented. Only eight countries referenced a need for graduates to be aware of their own limitations. In most countries, quality assurance of dental education is not undertaken by dental organisations, but by national quality assurance agencies for higher education. In many cases, it was not possible to ascertain the extent of graduates' direct clinical experience with patients. CONCLUSIONS: The findings demonstrate considerable variation in learning outcomes for dental education between countries and institutions in Europe. This presents a challenge to decision-makers responsible for national recognition and accreditation of diverse qualifications across Europe to maintain a safe, capable, international workforce; but one that this comparison of programmes helps to address.

How prepared are newly qualified allied health professionals for practice in the UK? A systematic review.

OBJECTIVES: It is important that allied health professionals (AHPs) are prepared for clinical practice from the very start of their working lives to provide quality care for patients, for their personal well-being and for retention of the workforce. The aim of this study was to understand how well newly qualified AHPs were prepared for practice in the UK. DESIGN: Systematic review. DATA SOURCES: Embase, MEDLINE, CINAHL, ERIC and BEI were searched from 2012 to 2024. Grey literature searching and citation chasing were also conducted. ELIGIBILITY CRITERIA: We included primary studies reporting the preparedness for practice of UK graduates across 15 professions; all study types; participants included graduates who were up to 2 years postgraduation, their supervisors, trainers, practice educators and employers; and all outcome measures. DATA EXTRACTION AND SYNTHESIS: A standardised data extraction form was used. Studies were quality assessed using the Quality Appraisal for Diverse Studies tool. 10% of articles were independently double-screened, extracted and quality assessed; 90% was completed by one researcher. RESULTS: 14 reports were included (9 qualitative, 3 mixed-method and 2 quantitative). Six papers focused on radiographers, three on a mixture of professions, two on paramedics, and one each on physiotherapists, clinical psychologists and orthotists. An important finding of the review is the paucity and low-medium quality of research on the topic. The narrative synthesis tentatively suggests that graduates are adequately prepared for practice with different professions having different strengths and weaknesses. Common areas of underpreparedness across the professions were responsibility and decision-making, leadership and research. Graduates were generally well prepared in terms of their knowledge base. CONCLUSION: High-quality in-depth research is urgently needed across AHPs to elucidate the specific roles, their nuances and the areas of underpreparedness. Further work is also needed to understand the transition into early clinical practice, ongoing learning opportunities through work, and the supervision and support structures in place. PROSPERO REGISTRATION NUMBER: CRD42022382065.

Educating for capability and preparing for practice: Integrating theory and skills.

Capability is the ability to perform clinical skills in ever-changing real world contexts, adapting to challenges and integrating technical and non-technical skills and competencies, for example, cannulating an uncooperative patient at night. Going beyond teaching competency and ensuring capability is imperative, as recommended by the national outcomes for medical graduates. A course on intravenous cannulation was developed with e-learning modules and high-fidelity complex simulation scenarios, aiming to promote capability in practice. The course delivered an intravenous cannulation e-learning package between two practical simulations to 10 final-year medical students. The hybrid simulation design consisted of an actor with a bespoke cannulation part-task trainer strapped to their arm. Each simulation delivered a challenging scenario, requiring the integration of procedural and behavioural skills to succeed. Simulations were video recorded, and participants reviewed their performances before completing semi-structured interviews. Transcribed interviews were thematically analysed. Interview analysis demonstrated two overarching themes: 'Impact on Capability' and 'Preparedness for Practice'. There was consistent recognition of improved capability from the interviews. Simulation exercises were described as the most valuable tool for developing capability. The e-learning helped with structure, facilitating students' adaptation to scenarios. Participants felt that training in medical school was largely competency-based and did not tackle complex interactions. Following e-learning and simulations, students felt more prepared for clinical practice. The course structure has value for medical professionals in developing capability and preparing for clinical practice, helping to reach standards expected of graduates. Plans to assess capability across multiple undergraduate programmes through Entrustable Professional Activities are in progress.

A narrative review of adaptive testing and its application to medical education.

Adaptive testing has a long but largely unrecognized history. The advent of computer-based testing has created new opportunities to incorporate adaptive testing into conventional programmes of study. Relatively recently software has been developed that can automate the delivery of summative assessments that adapt by difficulty or content. Both types of adaptive testing require a large item bank that has been suitably quality assured. Adaptive testing by difficulty enables more reliable evaluation of individual candidate performance, although at the expense of transparency in decision making, and requiring unidirectional navigation. Adaptive testing by content enables reduction in compensation and targeted individual support to enable assurance of performance in all the required outcomes, although at the expense of discovery learning. With both types of adaptive testing, candidates are presented a different set of items to each other, and there is the potential for that to be perceived as unfair. However, when candidates of different abilities receive the same items, they may receive too many they can answer with ease, or too many that are too difficult to answer. Both situations may be considered unfair as neither provides the opportunity to demonstrate what they know. Adapting by difficulty addresses this. Similarly, when everyone is presented with the same items, but answer different items incorrectly, not providing individualized support and opportunity to demonstrate performance in all the required outcomes by revisiting content previously answered incorrectly could also be considered unfair; a point addressed when adapting by content. We review the educational rationale behind the evolution of adaptive testing and consider its inherent strengths and limitations. We explore the continuous pursuit of improvement of examination methodology and how software can facilitate personalized assessment. We highlight how this can serve as a catalyst for learning and refinement of curricula; fostering engagement of learner and educator alike.

How is transition to medical practice shaped by a novel transitional role? A mixed-methods study.

OBJECTIVES: This study considered a novel 'interim' transitional role for new doctors (termed 'FiY1', interim Foundation Year 1), bridging medical school and Foundation Programme (FP). Research questions considered effects on doctors' well-being and perceived preparedness, and influences on their experience of transition. While FiY1 was introduced in response to the COVID-19 pandemic, findings have wider and ongoing relevance. DESIGN: A sequential mixed-methods study involved two questionnaire phases, followed by semi-structured interviews. In phase 1, questionnaires were distributed to doctors in FiY1 posts, and in phase 2, to all new FP doctors, including those who had not undertaken FiY1. SETTING AND PARTICIPANTS: Participants were newly qualified doctors from UK medical schools, working in UK hospitals in 2020. 77% (n=668) of all participants across all phases had undertaken FiY1 before starting FP in August. The remainder started FP in August with varying experience beforehand. OUTCOME MEASURES: Questionnaires measured preparedness for practice, stress, anxiety, depression, burnout, identity, and tolerance of ambiguity. Interviews explored participants' experiences in more depth. RESULTS: Analysis of questionnaires (phase 1 n=441 FiY1s, phase 2 n=477 FiY1s, 196 non-FiY1s) indicated that FiY1s felt more prepared than non-FiY1 colleagues for starting FP in August (ß=2.71, 95% CI=2.21 to 3.22, p<0.0001), which persisted to October (ß=1.85, CI=1.28 to 2.41, p<0.0001). Likelihood of feeling prepared increased with FiY1 duration (OR=1.02, CI=1.00 to 1.03, p=0.0097). Despite challenges to well-being during FiY1, no later detriment was apparent. Thematic analysis of interview data (n=22) identified different ways, structural and interpersonal, in which the FiY1 role enhanced doctors' emerging independence supported by systems and colleagues, providing 'supported autonomy'. CONCLUSIONS: An explicitly transitional role can benefit doctors as they move from medical school to independent practice. We suggest that the features of supported autonomy are those of institutionalised liminality-a structured role 'betwixt and between' education and practice-and this lens may provide a guide to optimising the design of such posts.

Graduates' preparedness for the changing doctor-patient relationship: A qualitative study.

BACKGROUND: A positive doctor-patient relationship is a crucial part of high-quality patient care. There is a general perception that it has been changing in recent years; however, there is a lack of evidence for this. Adapting to the changing doctor-patient relationship has been identified as an important skill doctors of the future must possess. This study explores (1) multiple stakeholder perspectives on how the doctor-patient relationship is changing and (2) in what ways medical graduates are prepared for working in this changing doctor-patient relationship. METHODS: We conducted a national qualitative study involving semi-structured interviews with multiple stakeholders across the United Kingdom. Interviews lasting 45-60 minutes were conducted with 67 stakeholders including doctors in the first 2 years of practice (ECD's), patient representatives, supervisors, deans, medical educators and other health care professionals. The interviews were audiorecorded, transcribed, analysed, coded in NVivo and analysed thematically using a Thematic Framework Analysis approach. RESULTS: The main ways the doctor-patient relationship was perceived to be changing related to increased shared decision making and patients having increasing access to information. Communication, patient-centred care and fostering empowerment, were the skills identified as being crucial for preparedness to work in the changing doctor-patient relationship. Graduates were reported to be typically well-prepared for the preconditions (communication and delivering patient-centred care) of patient empowerment, but that more work is needed to achieve true patient empowerment. CONCLUSION: This study offers a conceptual advance by identifying how the doctor-patient relationship is changing particularly around the 'patient-as-knowledge-source' dimension. On the whole ECD's are well-prepared for working in the changing doctor-patient relationship with the exception of patient empowerment skills. Further research is now needed to provide an in-depth understanding of patient empowerment that is shared among key stakeholders (particularly the patient perspective) and to underpin the design of educational interventions appropriate to career stage.

Progress and challenges in the harmonisation of European undergraduate dental education: A systematic literature review with narrative synthesis.

INTRODUCTION: Harmonising education to support workforce mobility has been a policy objective for the European Union. However, alignment across varied national contexts presents challenges in dental education. METHODS: A systematic literature review with narrative synthesis. Searches of the electronic databases Embase [Ovid]; MEDLINE [Ovid]; Scopus; CINAHL; AMED and PsycINFO were conducted for relevant material published between 2000 and 2019 on undergraduate curricula, quality standards and learning outcomes in dentistry. RESULTS: Seventy-six papers met the inclusion criteria. Fifty-three papers were commentaries or editorials, twenty-one were research studies, and two were literature reviews on specific dental subfields. Eighteen of the research studies reported surveys. The literature contains extensive proposals for undergraduate curricula or learning outcomes, either broadly or for subfields of dentistry. Included papers demonstrated the importance of EU policy and educator-led initiatives as drivers for harmonisation. There is limited evidence on the extent to which proposed pan-European curricula or learning outcomes have been implemented. The nature and extent of dental students' clinical experience with patients is an area of variance across European Union member states. Arrangements for the quality assurance of dental education differ between countries. DISCUSSION: Harmonisation of European dental education has engaged educators, as seen in the publication of proposed curricula and learning outcomes. However, differences remain in key areas such as clinical experience with patients, which has serious implications if graduate dentists migrate to countries where different expectations exist. Mutual recognition of professional qualifications between countries relies on education which meets certain standards, but institutional autonomy makes drawing national comparisons problematic.

A qualitative study using hybrid simulation to explore the impacts of human factors e-learning on behaviour change.

BACKGROUND: There is an international drive to increase human factors training in undergraduate medical curricula through various educational platforms. E-learning can be effective at teaching technical skills but there is limited research exploring the benefits of e-learning in human factors training. This study aimed to utilise hybrid simulation to investigate the impact of a human factors focused e-learning package for intravenous cannulation on safety behaviours. METHODS: Video-reflexive ethnography (VRE) techniques and interviews were used to explore human factor-related behaviour change in hybrid simulation scenarios, before and after e-learning modular training. Ten final-year medical students were recruited for the study. Content analysis of VRE data from hybrid simulation scenarios identified which behaviours had changed; thematic analysis of semi-structured interviews uncovered why. RESULTS: Results demonstrate improvement in safety behaviours in the domains of physical-, cognitive- and macro-ergonomics, suggesting safer cannulation practice following training. Online videos with interactive activities were reported as the major pedagogical driver for change. The impact of the e-learning was identified across four themes: environment, person, policy-related tasks, and preparedness for practise. Reported intention to change practise and altered behaviour in the workplace supports the conclusion that this training prepares students for practise by facilitating them to incorporate human factors principles in their clinical work. CONCLUSION: E-learning is a valuable and effective method for supporting medical student learning about human factors. Hybrid simulation and VRE combine well together to evaluate behaviour change following educational interventions.

Evaluating the recruitment process into UK anaesthesia core training: a national data linkage study of doctors' performance at selection and subsequent postgraduate training.

PURPOSE OF THE STUDY: To explore which factors increase the likelihood of being deemed appointable to core anaesthesia training in the UK and whether those factors subsequently predict performance in postgraduate training. STUDY DESIGN: Observational study linking UK medical specialty recruitment data with postgraduate educational performance, as measured by Annual Review of Competence Progression (ARCP) outcomes. Data were available for 2782 trainee doctors recruited to anaesthesia core training from 2012 to 2016 with at least one subsequent ARCP outcome. RESULTS: Both higher interview and shortlisting scores were independent and statistically significant (p≤0.001) predictors of more satisfactory ARCP outcomes, even after controlling for the influence of postgraduate exam failure. It was noted that a number of background variables (eg, age at application) were independently associated with the odds of being deemed appointable at recruitment. Of these, increasing age and experience were also negative predictors of subsequent ARCP rating. These influences became statistically non-significant once ARCP outcomes associated with exam failure were excluded. CONCLUSIONS: The predictors of 'appointability' largely also predict subsequent performance in postgraduate training, as indicated by ARCP ratings. This provides evidence for the validity of the selection process. Our results also suggest that greater weight could be applied to shortlisting scores within the overall process of ranking applicants for posts.

Sociodemographic and educational characteristics of doctors applying for psychiatry training in the UK: secondary analysis of data from the UK Medical Education Database project.

Aims and methodWorkforce shortages in psychiatry are common worldwide. The international literature provides insights into factors influencing decisions to train in psychiatry but is predominately survey based. This national cohort study aimed to identify the characteristics of doctors who were most likely to apply to psychiatry training programmes. The sample comprised doctors who entered UK medical schools in 2007/8 and who made first-time specialty training applications in 2015. The association between application to psychiatry and doctors' sociodemographic and educational characteristics was examined using multivariable logistic regression. RESULTS: Those most likely to apply were White, privately educated older doctors with below average performance at medical school.Clinical implicationsTo reduce workforce shortages, psychiatry must make itself more attractive to all doctors, especially those from underrepresented groups such as state-educated Black and minority ethnic individuals. Otherwise, national policies to widen participation in the study of medicine by such groups may exacerbate the current recruitment crisis.Declaration of interestNone.

Frameworks and quality measures used for debriefing in team-based simulation: a systematic review.

Objectives: The skill of the debriefer is known to be the strongest independent predictor of the quality of simulation encounters yet educators feel underprepared for this role. The aim of this review was to identify frameworks used for debriefing team-based simulations and measures used to assess debriefing quality. Methods: We systematically searched PubMed, CINAHL, MedLine and Embase databases for simulation studies that evaluated a debriefing framework. Two reviewers evaluated study quality and retrieved information regarding study methods, debriefing framework, outcome measures and debriefing quality. Results: A total of 676 papers published between January 2003 and December 2017 were identified using the search protocol. Following screening of abstracts, 37 full-text articles were assessed for eligibility, 26 studies met inclusion criteria for quality appraisal and 18 achieved a sufficiently high-quality score for inclusion in the evidence synthesis. A debriefing framework was used in all studies, mostly tailored to the study. Impact of the debrief was measured using satisfaction surveys (n=11) and/or participant performance (n=18). Three themes emerged from the data synthesis: selection and training of facilitators, debrief model and debrief assessment. There was little commonality across studies in terms of participants, experience of faculty and measures used. Conclusions: A range of debriefing frameworks were used in these studies. Some key aspects of debrief for team-based simulation, such as facilitator training, the inclusion of a reaction phase and the impact of learner characteristics on debrief outcomes, have no or limited evidence and provide opportunities for future research particularly with interprofessional groups.

Factors associated with junior doctors' decisions to apply for general practice training programmes in the UK: secondary analysis of data from the UKMED project.

BACKGROUND: The UK, like many high-income countries, is experiencing a worsening shortfall of general practitioners (GPs) alongside an increasing demand for their services. At the same time, factors influencing junior doctors' decisions to apply for GP training are only partially understood and research in this area has been hampered by the difficulties in connecting the datasets that map the journey from student to qualified GP. The UK Medical Education Database (UKMED) has been established to ameliorate this problem by linking institutional data across the spectrum of medical education from school to specialty training. Our study aimed to use UKMED to investigate which demographic and educational factors are associated with junior doctors' decisions to apply for GP training. METHODS: Study data, provided by the UKMED Development Group and accessed remotely, contained longitudinal educational and sociodemographic information on all doctors who entered UK medical schools in the 2007/2008 academic year and who made first-time specialty training applications in 2015. We used multivariable logistic regression models to investigate two binary outcomes, namely (1) application to GP training, possibly alongside applications to other specialties, and (2) application solely to GP training. RESULTS: Of 7634 doctors in the sample, 43% applied to GP training possibly alongside other specialities and 26% applied solely to GP training. The odds of applying to GP training were associated with particular demographic factors (being female, non-white or secondary educated in the UK increased the odds of application) and educational factors (non-graduate entry, intercalation and above-median academic performance during medical school all decreased the odds of application). After adjusting for these factors, both the medical school and the foundation school attended were independently associated with the odds of applying to GP training. CONCLUSIONS: Our findings suggest that the supply and demand imbalance in UK primary care might be improved by (1) efforts to attract greater numbers of female, non-white and UK secondary-educated students into medical schools, and (2) targeting resources at medical and foundation schools that deliver doctors likely to fill significant gaps in the workforce. Further research is required to better understand inter-school differences and to develop strategies to improve recruitment of GP trainees.

Identifying applicants suitable to a career in nursing: a value-based approach to undergraduate selection.

AIMS: The aim of this study was to complement existing evidence on the suitability of Multiple Mini Interviews as a potential tool for the selection of nursing candidates on to a BSc (Hons) nursing programme. BACKGROUND: This study aimed to trial the Multiple Mini Interview approach to recruitment with a group of first year nursing students (already selected using traditional interviews). DESIGN: Cross-sectional validation study. This paper reports on the evaluation of the participants' detailed scores from the Multiple Mini Interview stations; their original interview scores and their end of year results. METHODS: This study took place in March 2015. Scores from the seven Multiple Mini Interview stations were analysed to show the internal structure, reliability and generalizability of the stations. Original selection scores from interviews and in-course assessment were correlated with the MMI scores and variation by students' age, gender and disability status was explored. RESULTS: Reliability of the Multiple Mini Interview score was moderate (G = 0·52). The Multiple Mini Interview score provided better differentiation between more able students than did the original interview score but neither score was correlated with the module results. Multiple Mini Interview scores were positively associated with students' age but not their gender or disability status. CONCLUSION: The Multiple Mini Interview reported in this study offers a selection process that is based on the values and personal attributes regarded as desirable for a career in nursing and does not necessarily predict academic success. Its moderate reliability indicates the need for further improvement but it is capable of discriminating between candidates and shows little evidence of bias.

Making progression and award decisions.

This article was migrated. The article was marked as recommended. It is incumbent on medical schools to show, both to regulatory bodies and to the public at large, that their graduating students are "fit for purpose" as doctors. Since students graduate by virtue of passing assessments, it is vital that schools quality assure their assessment procedures, standards and outcomes. An important part of this quality assurance process is how progression and award decisions are made. This begins with developing clear evidence-based policies and processes that ensure assessments are effective, relevant, fair, robust and secure. Assessment is a series of processes primarily designed to enable judgements to be made as to whether a student has, or has not, met the standard required for the outcomes at that stage. This article will provide a clear rationale and guidance for establishing robust processes for making progression and award decisions.

Health Worker Focused Distributed Simulation for Improving Capability of Health Systems in Liberia.

INTRODUCTION: The main goal of this study was to produce an adaptable learning platform using virtual learning and distributed simulation, which can be used to train health care workers, across a wide geographical area, key safety messages regarding infection prevention control (IPC). METHODS: A situationally responsive agile methodology, Scrum, was used to develop a distributed simulation module using short 1-week iterations and continuous synchronous plus asynchronous communication including end users and IPC experts. The module contained content related to standard IPC precautions (including handwashing techniques) and was structured into 3 distinct sections related to donning, doffing, and hazard perception training. OUTCOME: Using Scrum methodology, we were able to link concepts applied to best practices in simulation-based medical education (deliberate practice, continuous feedback, self-assessment, and exposure to uncommon events), pedagogic principles related to adult learning (clear goals, contextual awareness, motivational features), and key learning outcomes regarding IPC, as a rapid response initiative to the Ebola outbreak in West Africa. Gamification approach has been used to map learning mechanics to enhance user engagement. CONCLUSIONS: The developed IPC module demonstrates how high-frequency, low-fidelity simulations can be rapidly designed using scrum-based agile methodology. Analytics incorporated into the tool can help demonstrate improved confidence and competence of health care workers who are treating patients within an Ebola virus disease outbreak region. These concepts could be used in a range of evolving disasters where rapid development and communication of key learning messages are required.

A study to assess the influence of interprofessional point of care simulation training on safety culture in the operating theatre environment of a university teaching hospital.

Interprofessional point of care or in situ simulation is used as a training tool in our operating theatre directorate with the aim of improving crisis behaviours. This study aimed to assess the impact of interprofessional point of care simulation on the safety culture of operating theatres. A validated Safety Attitude Questionnaire was administered to staff members before each simulation scenario and then re-administered to the same staff members after 6-12 months. Pre- and post-training Safety Attitude Questionnaire-Operating Room (SAQ-OR) scores were compared using paired sample t-tests. Analysis revealed a statistically significant perceived improvement in both safety (p < 0.001) and teamwork (p = 0.013) climate scores (components of safety culture) 6-12 months after interprofessional simulation training. A growing body of literature suggests that a positive safety culture is associated with improved patient outcomes. Our study supports the implementation of point of care simulation as a useful intervention to improve safety culture in theatres.

Rising to the challenge: acute stress appraisals and selection centre performance in applicants to postgraduate specialty training in anaesthesia.

The ability to work under pressure is a vital non-technical skill for doctors working in acute medical specialties. Individuals who evaluate potentially stressful situations as challenging rather than threatening may perform better under pressure and be more resilient to stress and burnout. Training programme recruitment processes provide an important opportunity to examine applicants' reactions to acute stress. In the context of multi-station selection centres for recruitment to anaesthesia training programmes, we investigated the factors influencing candidates' pre-station challenge/threat evaluations and the extent to which their evaluations predicted subsequent station performance. Candidates evaluated the perceived stress of upcoming stations using a measure of challenge/threat evaluation-the cognitive appraisal ratio (CAR)-and consented to release their demographic details and station scores. Using regression analyses we determined which candidate and station factors predicted variation in the CAR and whether, after accounting for these factors, the CAR predicted candidate performance in the station. The CAR was affected by the nature of the station and candidate gender, but not age, ethnicity, country of training or clinical experience. Candidates perceived stations involving work related tasks as more threatening. After controlling for candidates' demographic and professional profiles, the CAR significantly predicted station performance: 'challenge' evaluations were associated with better performance, though the effect was weak. Our selection centre model can help recruit prospective anaesthetists who are able to rise to the challenge of performing in stressful situations but results do not support the direct use of challenge/threat data for recruitment decisions.

Experience of Using Simulation Technology and Analytics During the Ebola Crisis to Empower Frontline Health Workers and Improve the Integrity of Public Health Systems.

The Ebola outbreak highlighted the challenge of health security and particularly of how best to give frontline workers the knowledge, confidence and competence to respond effectively. The goal was to develop a tool to improve infection prevention and control through local capacity building within the context of an emergency response. The research showed that digital technology could be a powerful 'force multiplier' allowing much greater access to high fidelity training during an outbreak and keeping it current as protocols evolved or new safety critical steps were identified. Tailoring training to the local context was crucial to its relevance and accessibility. This initiative used a novel approach to the development of the training tool - ebuddi. It used agile development to co-create the tool with active participation of local communities. A further pilot showed how it could be extended to meet the longer term needs of triage training and ensure better quality assurance. In the longer term it may have the potential to improve compliance with International Health Regulations, be adapted for future emergencies, and contribute to global health security.

Dilemma of dilemmas: how collective and individual perspectives can clarify the size dilemma in voluntary linear public goods dilemmas.

Empirical findings on public goods dilemmas indicate an unresolved dilemma: that increasing size-the number of people in the dilemma-sometimes increases, decreases, or does not influence cooperation. We clarify this dilemma by first classifying public goods dilemma properties that specify individual outcomes as individual properties (e.g., Marginal Per Capita Return) and group outcomes as group properties (e.g., public good multiplier), mathematically showing how only one set of properties can remain constant as the dilemma size increases. Underpinning decision-making regarding individual and group properties, we propose that individuals are motivated by both individual and group preferences based on a theory of collective rationality. We use Van Lange's integrated model of social value orientations to operationalize these preferences as an amalgamation of outcomes for self, outcomes for others, and equality of outcomes. Based on this model, we then predict how the public good's benefit and size, combined with controlling individual versus group properties, produce different levels of cooperation in public goods dilemmas. A two (low vs. high benefit) by three (2-person baseline vs. 5-person holding constant individual properties vs. 5-person holding constant group properties) factorial experiment (group n = 99; participant n = 390) confirms our hypotheses. The results indicate that when holding constant group properties, size decreases cooperation. Yet when holding constant individual properties, size increases cooperation when benefit is low and does not affect cooperation when benefit is high. Using agent-based simulations of individual and group preferences vis-à-vis the integrative model, we fit a weighted simulation model to the empirical data. This fitted model is sufficient to reproduce the empirical results, but only when both individual (self-interest) and group (other-interest and equality) preference are included. Our research contributes to understanding how people's motivations and behaviors within public goods dilemmas interact with the properties of the dilemma to lead to collective outcomes.

Combined femoral and sciatic nerve block vs combined femoral and periarticular infiltration in total knee arthroplasty: a randomized controlled trial.

This study tests the null hypothesis that there is no difference between sciatic nerve block (SNB) and periarticular anesthetic infiltration (PI) as adjuncts to femoral nerve blockade (FNB) in total knee arthroplasty in terms of postoperative opioid requirements. Fifty-two patients undergoing total knee arthroplasty were randomized to receive either (a) combined FNB-SNB or (b) combined FNB-PI. Average morphine consumption in the first 24 (20 vs 23 mg) and 48 hours (26 vs 33 mg) showed no significant difference. Visual Analogue Scale scores, knee flexion (60° vs 67.5°) and extension lag (0° vs 5°) were comparable. Anesthetic time, surgical time, and length of hospital stay (5.5 vs 6 days) were similar. This study showed no significant difference between the 2 groups. The PI offers a practical and potentially safer alternative to SNB.