'You don't see what I see': Co-designing simulation to uncover and address cognitive bias in healthcare.

EDUCATIONAL CHALLENGE: Each year, adverse events are reported in healthcare, of which many relate to healthcare workforce cognitive bias. The active involvement of workforce and consumers in the review and co-design of effective training for the healthcare workforce to recognise, monitor, and manage unconscious bias is required. PROPOSED SOLUTION: We used participatory action research to co-design an innovative, interprofessional simulation based on 'real world' clinical incidents and lived experiences to improve the delivery of safe, high quality, consumer-focused healthcare. Following ethics approval, content analysis of serious adverse patient safety events involving cognitive bias was conducted. These data informed audio-recorded interviews with the healthcare workforce and consumers to explore their experiences of cognitive bias. Following thematic analysis, key themes of communication, stigma, diagnostic overshadowing, and fragmented systems were uncovered. Guided by consumers, these themes were interwoven into a simulation scenario that included real places, stories, and verbatim quotes delivered through mixed media artefacts. This heightened the immersive and experiential learning that aimed to uncover unconscious bias and help learners recognise its impact on clinical decisions and practice. POTENTIAL BENEFITS AND NEXT STEPS: To our knowledge, this is the first interprofessional, co-designed simulation to specifically address cognitive bias in current and future healthcare workforce. Plans to translate this research into a practical framework on how to work with key stakeholders (including consumers) to identify 'real-world' health service risks and co-design targeted simulations to address these gaps are described, including lessons learned.

Fit-Tested N95 Masks Combined With Portable High-Efficiency Particulate Air Filtration Can Protect Against High Aerosolized Viral Loads Over Prolonged Periods at Close Range.

BACKGROUND: Healthcare workers (HCWs) are at risk from aerosol transmission of severe acute respiratory syndrome coronavirus 2. The aims of this study were to (1) quantify the protection provided by masks (surgical, fit-testFAILED N95, fit-testPASSED N95) and personal protective equipment (PPE), and (2) determine if a portable high-efficiency particulate air (HEPA) filter can enhance the benefit of PPE. METHODS: Virus aerosol exposure experiments using bacteriophage PhiX174 were performed. An HCW wearing PPE (mask, gloves, gown, face shield) was exposed to nebulized viruses (108 copies/mL) for 40 minutes in a sealed clinical room. Virus exposure was quantified via skin swabs applied to the face, nostrils, forearms, neck, and forehead. Experiments were repeated with a HEPA filter (13.4 volume-filtrations/hour). RESULTS: Significant virus counts were detected on the face while the participants were wearing either surgical or N95 masks. Only the fit-testPASSED N95 resulted in lower virus counts compared to control (P = .007). Nasal swabs demonstrated high virus exposure, which was not mitigated by the surgical/fit-testFAILED N95 masks, although there was a trend for the fit-testPASSED N95 mask to reduce virus counts (P = .058). HEPA filtration reduced virus to near-zero levels when combined with fit-testPASSED N95 mask, gloves, gown, and face shield. CONCLUSIONS: N95 masks that have passed a quantitative fit-test combined with HEPA filtration protects against high virus aerosol loads at close range and for prolonged periods of time.

Materials matter: Understanding the importance of sociomaterial assemblages for OSCE candidate performance.

INTRODUCTION: The OSCE is a sociomaterial assemblage-a meshing together of human and material components producing multiple effects. Materials matter because they shape candidate performance, with potentially calamitous career consequences if materials influence performance unjustly. Although the OSCE literature refers to materials, few papers study the sociomateriality of OSCEs. Therefore, we explored OSCE stakeholders' talk about sociomaterial assemblages to better understand their importance for candidate performance. METHODS: We conducted 15 focus groups with OSCE candidates (n = 42), examiners (n = 20) and simulated patients (n = 17) after an Australian postgraduate nursing OSCE. Sociomateriality informed our team-based framework analysis of data. RESULTS: Participants identified a multiplicity of OSCE materials (objects, technologies and spaces) thought to matter for candidate performance. Candidates' unfamiliarity with materials and missing or malfunctioning materials were reported to yield numerous negative impacts (eg cognitive overload, negative affect, time-wasting), thereby adversely affecting candidate performance. Both examiners and candidates made micro-adjustments to sociomaterial assemblages during the OSCE in order to make it work (eg candidates saying what they would do rather than doing it). Sometimes, such tinkering extended so far that sociomaterial assemblages were ruptured (eg examiners ignoring rubrics to help pass candidates), potentially influencing OSCE standardisation. DISCUSSION: Our novel empirical study extends previous conceptual work by illustrating wide-ranging sociomaterial assemblages influencing OSCE candidate performance. Further research is now needed employing sociomaterial approaches to further elucidate sociomaterial entanglements in diverse OSCEs. We encourage OSCE stakeholders to become more attuned to the productive nature of materials within all stages of OSCE design and implementation.

Pre-Registration Nursing Students' Perceptions of Digital Health Technology on the Future of Nursing: A Qualitative Exploratory Study.

BACKGROUND: Health informatics competencies, digital health education, and nursing students' perceptions of technology are critical to ensure a future digitally capable health care workforce. PURPOSE: To explore preregistration students' perceptions of digital health technology impact on their role as nurses. METHODS: Using a qualitative exploratory approach, students from 2 Australian universities were purposively sampled. Data were collected through photo-elicitation from 3 focus groups and thematically analyzed. Photo-elicitation provided reference points to encourage more in-depth exploration. RESULTS: Themes included fear of the unknown and who am I? Nursing in a digital world . Human interaction was fundamental to their nursing role and digital health technology could depersonalize care, creating tension around their reason for choosing a nursing career. CONCLUSIONS: Educators should prepare students to redefine their nursing identity by exploring how digital health technology augments their practice and critical thinking skills, while addressing fear of a perceived threat to the future of nursing.

Belonging in high acuity settings: What is needed for newly graduated registered nurses to successfully transition? A qualitative systematic review.

BACKGROUND: A worldwide shortage of nurses providing clinical care, coupled with an increase in severity of illness of hospitalised patients has led to newly graduated Registered Nurses being placed into high acuity settings, such as the emergency department, intensive care unit and operating theatre. The feeling of belonging in these settings impacts on successful transition of newly graduated Registered Nurses, their learning, and may lead to high attrition rates. OBJECTIVE: To comprehensively synthesise qualitative research on newly graduated Registered Nurses' experiences of belonging, while working in high acuity clinical settings. DESIGN: Elements of the Joanna Briggs Institute (JBI) systematic review protocol were utilised. The Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to conduct the review. Data were analysed using thematic analysis. DATA SOURCES: Ovid Emcare, PsychInfo, CINHAL, Proquest and Scopus. METHODS: The PICo (population, interest and context) strategy was used as a guide to develop search terms. Published literature from January 2007 to April 2021 was searched. Screening, selection and data extraction were performed by two authors independently. All discrepancies were resolved through discussion with a third reviewer. RESULTS: A total of 506 studies were identified following the systematic search; after duplicates were removed, 440 were screened by title and abstract and 29 by full text. Six articles were included in this systematic review. Methodological quality was assessed utilising the JBI critical appraisal checklist, and discrepancies ratified through team consensus. The themes; emotional lability, structured program design, preceptors' influence and acceptance were identified. CONCLUSIONS: Newly graduated Registered Nurses in the high acuity setting feel emotionally insecure related mainly to their educational unpreparedness. They have need for a structured program, inclusive of both theory and supported practice. The role of the preceptorship team is vital in enabling a feeling of belonging, as is acceptance by nursing staff of the learning journey.

Practical infection control training for Victoria's aged care workforce at the time of COVID-19 pandemic: a community case study.

The need to improve career development and training for residential aged care workers in Australia to achieve required essential competencies, including infection prevention and control competencies, has been repeatedly highlighted. In Australia long-term care settings for older adults are known as residential aged care facilities (RACFs). The COVID-19 pandemic has brought to light the lack of preparedness of the aged care sector to respond to emergencies, and the urgent need to improve the infection prevention and control training in residential aged care facilities. The government in the Australian State of Victoria allocated funds to support older Australians in RACFs, including funds toward infection prevention and control training of RACF staff. The School of Nursing and Midwifery at Monash University addressed some of these challenges in delivering an education program on effective infection prevention and control practices to the RACF workforce in Victoria, Australia. This was the largest state-funded program delivered to RACF workers to date in the State of Victoria. The aim of this paper is to provide a community case study, where we share our experience of program planning and implementation during early stages of the COVID-19 pandemic and lessons learned.

Impact of art and reflective practice on medical education in the emergency department.

OBJECTIVES: There is heightened intrigue surrounding the application of arts-based pedagogy in medical education. Art encompasses multiple forms of expression and is used to convey specific meaning and emotion, whereas provoking critical reflection. Our aim was to explore the effectiveness of art and reflective practice in medical education, in the context of the ED. METHODS: Longitudinal methodological study design. Prior to the first, and after the final clinical practicum, medical students watched a 3-min film: 'The Art of the ED'. Written reflections focused on changing perceptions towards the film during their medical education programme. Data were thematically analysed. RESULTS: Three themes were collected from 25 written reflections and included: 'professional growth' exploring personal and professional development across the medical programme; seeing 'patients are people'; and the purpose, structure and function of an ED exposed in 'the reality of ED'. Results highlight that arts-based pedagogy can facilitate meaningful and critical reflection in medical students, whereas also fostering professionalism. Reflecting on the film broadened their perspective into a realm of new possibilities, challenging them to identify implicit bias around ED, and promote professional identity formation. CONCLUSIONS: The combination of art and reflection in medical education enhances reflective learning and can lead to transformative change, including the development of core doctoring values of service, empathy and respect for patient. There are clear benefits to medical education incorporating more arts-based pedagogy that promotes reflective exploration and interpretation of the psychosocial context of health and illness, delivery of more holistic models of care and their role as doctors.

Pre-registration nursing students' perceptions of their baseline digital literacy and what it means for education: A prospective COHORT survey study.

BACKGROUND: To build complex digital skills and capability required by digitally-driven work environments, we must first understand nursing students' baseline digital literacy if educators are to develop a fit for purpose curriculum underpinned by digital health technologies. OBJECTIVE: To determine first-year pre-registration nursing students' perceived baseline digital literacy before their first clinical placement. DESIGN: Prospective cohort study. SETTINGS: Two universities in Australia in 2020. PARTICIPANTS: Students enrolled in pre-registration nursing programs at Bachelor's and Master's level. METHODS: Participants (N = 205) completed an online 27-item survey composed of a Likert-type scale, forced-choice items, and open-ended questions. Data were analyzed with descriptive statistics. RESULTS: Participants engaged with digital technology early in life, with 49.75% students using some form of digital technology before ten years of age. Students reported the highest daily use of technology to search the internet for information (92%), online social networking (68.3%) and watching videos (67%). Most students expressed the least confidence in identifying different types of portable storage devices (24.1% Master's students; 41.7% Bachelor's students), describing the advantages of a digital camera (39.3% Master's students; 48.3% Bachelor's students), and totaling numbers in spreadsheets (22.8% Masters students; 48.3% Bachelor's students). No statistical differences were observed between the two universities or the two cohorts in terms of perceived confidence in using technology and software applications to support their learning. Interestingly, 24.7% of participants expressed high confidence in using electronic medical records without prior training, which may reflect positive attitude towards engaging with unknown digital technologies. CONCLUSIONS: Nursing students are frequent internet and social media users. However, despite positive attitudes to digital technology and widespread presence of digital technology in students' lives, deficits in students' confidence in using digital technology and software required for learning persist. Targeted digital literacy education interventions are needed as part of foundational nursing studies to improve nursing students' baseline digital literacy before commencing clinical placement. These should be scaffolded across the program to ensure an effective transition to nursing practice in evolving digitally-driven healthcare environments.

Perceptions of final year nursing students transer of clinical judgement skills from simulation to clinical practice: A qualitative study.

AIM: To explore final year nursing student's ability to transfer clinical judgement skills to the clinical practice setting following immersive simulation. BACKGROUND: Clinical judgement is considered a fundamental skill for nurses to ensure safe, quality care is delivered. In undergraduate nursing education where students have limited clinical experience, simulation-based education is an important educational strategy for introducing and developing these skills. Simulation allows for students to be exposed to repeated experiences and emotional responses to varying clinical situations. Despite this, there is a paucity of literature relating to students' ability to transfer clinical judgement skills from the simulated environment into clinical practice. DESIGN: A naturalistic philosophical approach informed data collection in this qualitative phase of a larger study. METHODS: Data were collected from students and nurse educators using semi-structured interviews as well as from facilitated simulation debriefs. Data were thematically analysed. RESULTS: Four themes were identified which related to student knowledge, self-awareness and the clinical context: Safely collecting the data; Understanding the data to safely make decisions; Emotional intelligence; and Role variation. Students and educators held similar views on many of these elements. CONCLUSIONS: Questioning was identified as a key component of nursing students' clinical judgements. There were challenges in assessing students' ability to link theory to practice in the clinical setting, despite evidence of this occurring in the simulated setting. Simulation prepares students for practice by exposing them to new experiences and stressors and therefore an effective educational technique for developing clinical judgement skills in this cohort.

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.

The efficacy and safety of a chest pain protocol for short stay unit patients: A one year follow-up.

BACKGROUND: The Alfred Emergency Short Stay Unit initiated a chest pain protocol for patients presenting with chest pain to risk stratify for acute coronary syndrome (ACS). A 30-day follow-up of patients discharged with low-or-intermediate risk of ACS demonstrated no deaths or ACS. AIMS: The purpose of this study was to evaluate the long-term safety of the chest pain protocol, a one year follow-up was undertaken. METHODS: A questionnaire was designed for the one-year follow-up and it was administered via a telephone interview by emergency nurses to document adverse cardiac events and health care utilisation. RESULTS: From 297 patients, 224 (75%) were contacted 12 months following discharge. There was one death from stroke (0.4%; 95% confidence interval (CI): 0.01-2.5%) and another from an unknown cause. Five patients had been diagnosed with atrial fibrillation (2.2%; 95% CI: 0.7-5.1%), two patients had an acute myocardial infarction (0.9%; 95% CI: 0.03-2.1%) and four were diagnosed with angina (1.8%; 95% CI: 0.9-3.2%). Nearly half (n=103, 46%; 95% CI: 39.5-52.5%) had returned to the emergency department (ED) for various conditions including 42 patients with further chest pain. Ninety-six patients (43%; 95% CI: 39.3-52.7%) had specialist referrals and 124 investigations were performed. Thirty-four patients had cardiology referrals (15%; 95% CI: 10.7-20.5%) and 25 patients had gastroenterology referrals (11%; 95% CI: 7.3-16.0%). Diagnostic cardiac tests were performed on 38 patients: coronary angiography (n=10), 24-hour Holter monitoring (n=17), 24-hour blood pressure (BP) monitoring (n=4), thallium scans (n=5), exercise stress test (n=1) and CT scan (n=1). CONCLUSION: Patients had a low risk of adverse events 12 months after discharge but substantial continuing health care utilization was observed. Complete assessment by health care professionals prior to discharge may help mitigate representations.