Exploring the use of high and low demand simulation for human performance assessment during multiorgan retrieval with the joint scrub practitioner.

Introduction: The National Organ Retrieval Service (NORS) 2015 review recommended a Joint Scrub Practitioner for abdominal and cardiac teams during combined organ retrieval. To evaluate the feasibility of this role, and to understand the functional implications, this study explores the use of simulation and provides a novel and comprehensive approach to assess individual and team performance in simulated multiorgan retrievals. Methods: Two high-fidelity simulations were conducted in an operating theatre with porcine organs, en bloc, placed in a mannequin. For donation after brainstem death (DBD) simulation, an anaesthetic machine provided simulated physiological output. Retrievals following donation after circulatory death (DCD) began with rapid arrival in theatre of the mannequin. Cardiothoracic (lead surgeon) and abdominal (lead and assistant surgeons; joint scrub practitioner, n=9) teams combined for the retrievals. Data collected before, during and after simulations used self-report and expert observers to assess: attitudinal expectations, mental readiness, mental effort, non-technical skills, teamwork, task workload and social validation perceptions. Results: Attitudinal changes regarding feasibility of a joint scrub practitioner for DBD and DCD are displayed in the main body. There were no significant differences in mental readiness prior to simulations nor in mental effort indicated afterwards; however, variance was noted between simulations for individual team members. Non-technical skills were slightly lower in DCD than in DBD. Global ratings of teamwork were significantly (p<0.05) lower in DCD than in DBD. Measures of attitude indicated less support for the proposed joint scrub practitioner role for DCD than for DBD. Discussion: The paper posits that the joint scrub practitioner role in DCD multiorgan retrieval may bring serious and unanticipated challenges. Further work to determine the feasibility of the NORS recommendation is required. Measures of team performance and individual psychological response can inform organ retrieval feasibility considerations nationally and internationally.

The Vanguard Study: Human Performance Evaluation of UK National Organ Retrieval Service Teams Utilizing a Single Scrub Practitioner in Multiorgan Retrieval.

BACKGROUND: The National Organ Retrieval Service (NORS) 2015 review recommended a single scrub practitioner provide support simultaneously to abdominal and cardiothoracic teams in UK multiorgan retrieval. Previously, this model had been used only by the combined abdominal and cardiac team in Scotland. This study reports the impact on performance as part of the Vanguard project, which utilized the single scrub practitioner role with 5 NORS teams, to determine applicability United Kingdom wide. METHODS: Participants comprised members of abdominal (n = 56) and cardiothoracic (n = 54) teams attending UK thoraco-abdominal retrievals. Data were collected by validated psychometric scales to assess individual workload, anxiety, confidence, demands/coping resources, and teamwork. Additional data were collected through open comments and quantitative data describing context and outcome of retrieval. RESULTS: Abdominal and cardiothoracic teams showed different responses when using single (Vanguard) or dual scrub practitioners (Standard). Vanguard configuration was associated with significantly higher anxiety for abdominal but not cardiothoracic teams. Perceived workload increased for abdominal teams during Vanguard but decreased for cardiothoracic teams. Scrub practitioners reported elevated anxiety and decreased confidence in retrievals using Vanguard configuration. CONCLUSIONS: This is the first large study examining human performance during organ retrieval in the United Kingdom. Despite previous regional success, this study showed a significant negative impact of the single scrub practitioner when extrapolated widely to UK teams. As a result of this study, NORS declined to implement the single scrub model. These data support the use of human performance analysis as an essential part of successful development in organ retrieval practice.

The illusion of competency versus the desirability of expertise: seeking a common standard for support professions in sport.

In this paper we examine and challenge the competency-based models which currently dominate accreditation and development systems in sport support disciplines, largely the sciences and coaching. Through consideration of exemplar shortcomings, the limitations of competency-based systems are presented as failing to cater for the complexity of decision making and the need for proactive experimentation essential to effective practice. To provide a better fit with the challenges of the various disciplines in their work with performers, an alternative approach is presented which focuses on the promotion, evaluation and elaboration of expertise. Such an approach resonates with important characteristics of professions, whilst also providing for the essential 'shades of grey' inherent in work with human participants. Key differences between the approaches are considered through exemplars of evaluation processes. The expertise-focused method, although inherently more complex, is seen as offering a less ambiguous and more positive route, both through more accurate representation of essential professional competence and through facilitation of future growth in proficiency and evolution of expertise in practice. Examples from the literature are also presented, offering further support for the practicalities of this approach.

Evidence-based development and initial validation of the pain assessment checklist for seniors with limited ability to communicate-II (PACSLAC-II).

OBJECTIVES: Our goal was to develop and validate, based on theoretical and empirical knowledge, the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC-II), a shorter tool that would improve on the PACSLAC, while addressing limitations of the original version. METHODS: The PACSLAC was revised based on the relevant clinical and theoretical literature. Psychometric properties and clinical utility of the resulting 31-item PACSLAC-II were examined. Specifically, the PACSLAC-II was used to assess pain based on video footage of long-term care (LTC) residents with dementia undergoing painful procedures as part of routine care. Its ability to discriminate pain from non-pain-related states was compared with that of preexisting pain assessment tools using archival data. A second phase involved the use of the PACSLAC and PACSLAC-II by LTC staff to solicit feedback from health care providers. Mixed-methods analysis of this feedback was conducted. RESULTS: The PACSLAC-II demonstrated satisfactory reliability, excellent validity, and ability to differentiate between pain and nonpain states. The PACSLAC-II also accounted for unique variance in differentiating between pain and nonpain states, even after controlling for the preexisting tools combined, including the PACSLAC. The PACSLAC-II was also preferred by many LTC nurses and care aides, because of its length and condensed nature, which was thought to facilitate documentation and greater efficiency in pain management. DISCUSSION: Findings indicate that the empirical and theoretically driven revisions to the PACSLAC led to improved ability to differentiate between pain and nonpain states, while retaining its clinical utility.

Parameterising expertise in coaching: past, present and future.

Research into expertise is increasing across a number of domains pertinent to sport. Whilst this increase is particularly apparent in coaching, a key question is how to identify an expert coach? Accordingly, this paper draws upon existing studies into expert coaches to address this issue; in particular, the criteria used to select expert coaches for research purposes and the methods used in expert coach research. Based on these data, we contend that the elements of expertise are not fully reflected within currently accepted criteria which, in turn, results in expert coaching research not necessarily identifying the appropriate individuals to study. The paper concludes with recommendations for more rigorous criteria for selecting expert coaches and highlights the associated implications for the future training and development of expert coaches.

A comparative investigation of observational pain assessment tools for older adults with dementia.

OBJECTIVES: Pain assessment in patients with dementia and severe limitations in ability to communicate can be challenging. The American Geriatrics Society (AGS) encourages the incorporation of 6 behavioral domains (ie, facial expressions, verbalizations/vocalizations, body movements, changes in interpersonal interactions, changes in activity patterns/routines and mental status changes) when conducting pain assessments among seniors with dementia. We investigated 6 observational pain assessment measures (differing with respect to the extent that they cover the AGS-recommended domains) under 2 different pain conditions (ie, influenza vaccination and movement-exacerbated pain) in a sample of long-term care residents with cognitive impairments. Given that a criticism of pain assessment scales is that many of the pain behaviors assessed are highly overlapping with symptoms of delirium, we also investigated the impact of the elimination of delirium-related items. RESULTS: Consistent with expectations, all measures were able to differentiate between pain and baseline conditions. Reliability and validity varied across measures. Most measures continued to differentiate between pain and baseline states after items that overlap with delirium were eliminated. DISCUSSION: Our results provide much needed psychometric information regarding newly developed pain assessments measures for seniors with dementia. The measures differed with respect to ability to differentiate pain-related from non-pain-related states. Moreover, our findings support the utility of comprehensive coverage of the AGS-recommended pain assessment domains.

A psychophysical investigation of the facial action coding system as an index of pain variability among older adults with and without Alzheimer's disease.

OBJECTIVE: Reflexive responses to pain such as facial reactions become increasingly important for pain assessment among patients with Alzheimer's disease (AD) because self-report capabilities diminish as cognitive abilities decline. Our goal was to study facial expressions of pain in patients with and without AD. DESIGN: We employed a quasi-experimental design and used the Facial Action Coding System (FACS) to assess reflexive facial responses to noxious stimuli of varied intensity. Two different modalities of stimulation (mechanical and electrical) were employed. RESULTS: The FACS identified differences in facial expression as a function of level of discomforting stimulation. As expected, there were no significant differences based on disease status (AD vs control group). CONCLUSIONS: This is the first study to discriminate among FACS measures collected during innocuous and graded levels of precisely measured painful stimuli in seniors with (mild) dementia and in healthy control group participants. We conclude that, as hypothesized, FACS can be used for the assessment of evoked pain, regardless of the presence of AD.