Encouraging Digital Patient Portal Use in Ambulatory Surgery: A Mixed Method Research of Patients and Health Care Professionals Experiences and Perceptions.

PURPOSE: As more complex surgery is performed in 1-day admissions there is a growing demand for appropriate postoperative follow-up. A digital patient portal (DPP) is a promising tool to support this and increase patients' quality of recovery. However, both patients and health care professionals have not fully embraced this eHealth technology. This study investigates the extent to which a patient portal is used in a tertiary ambulatory surgical care unit and assesses usability, applicability and user-friendliness both for the patient and health care worker. DESIGN: Mixed method research design combining qualitative and quantitative methods. METHODS: Four hundred and fifteen patients undergoing knee arthroscopic surgery or endonasal sinus surgery were included. Quantitative log data from the patient platform, clinical outcome measures and a patient questionnaire were used. Additionally, qualitative data was collected through interviews (with patients, n = 13; involved caregivers and physicians, n = 7) and observations (first introduction to patient with platform and team meetings, n = 15). FINDINGS: Forty percent of the included patients effectively used the patient platform (≥1 login). The patients mainly used the platform for gathering information; 62% of the active patients on the platform registered questionnaires initiated from the surgery center (eg, preoperative questionnaire) or diaries (e.g, daily follow-up using the Quality of Recovery Scale). Different barriers and facilitators toward DPP implementation were noted. Attention should be paid to the intrinsic and extrinsic motivation for using the portal and to the added value of the portal for the patient and health care professionals. CONCLUSIONS: Patients' perceptions of the DPP were positive and an increase in DPP use was observed during the study due to adjustments (eg, technical adjustments). However, a decline over time was noticed. The role of intrinsic and extrinsic motivation of all included parties needs to be further corroborated.

Postoperative innovative technology for ambulatory anesthesia and surgery.

PURPOSE OF REVIEW: To give an overview of the impact of different forms of telehealth that are currently used in ambulatory anesthesia and surgery. Telehealth is applicable during the early recovery and intermediate recovery period (e.g. monitoring of quality of recovery), and as a tool for postoperative check-up during the late recovery phase. RECENT FINDINGS: Postoperative follow-up after ambulatory surgery is still crucial to maintain quality of care as pain and postoperative nausea and vomiting remain common adverse events. There is a surge of telehealth applications from procedure-specific commercial smartphone apps (mHealth) to complete digital patient platforms instituted by the government. However, patient and healthcare provider engagement is not universal. Usability of these applications is mandatory as well as identifying and overcoming the barriers to its use. SUMMARY: Telehealth gives many opportunities for postoperative follow-up of ambulatory surgery patients. Clear evidence on the benefits of telehealth in ambulatory surgery is however still sparse. Future research should focus on telehealth for improving quality and safety of postoperative recovery, convincing policymakers for reimbursement encouraging healthcare providers and patients to engage in telehealth.

Personal and Interpersonal Drivers that Contribute to the Intention to Use Gerontechnologies.

BACKGROUND: Over the past few years, various new types of technologies have been introduced, which have been tailored to meet the specific needs of older adults by incorporating gerontological design principles (i.e., "gerontechnologies"). However, it has been difficult to motivate older adults to adopt and use these new technologies. Therefore, it is crucial to better understand not only the role of personal drivers but also the family influences on older adults. OBJECTIVE: This research goes beyond traditional technology acceptance theories by investigating the role of personal (e.g., inherent novelty seeking) and interpersonal drivers (e.g., influence of family) in stimulating older adults to use gerontechnologies. Nine hypotheses, building on traditional and new technology acceptance theories, were developed and tested. METHODS: This research applies a cross-sectional study design. Therefore, a face-to-face survey instrument was developed building on a qualitative pilot study and validated scales. Three hundred and four older adults (minimum age = 70 years) were willing to participate as well as one of their family members. Structural equation modeling was applied to analyze the hypothesized conceptual model. RESULTS: Our results extend the seminal technology acceptance theories by adding personal (i.e., inherent novelty seeking p = 0.017) and interpersonal drivers. More specifically, it was found that the attitude toward gerontechnologies was influenced by family tech savviness (i.e., people who often use technology), as this relationship is fully mediated through the social norms of older adults (p = 0.014). The same was found for older adults' trust in the family member's technology knowledge (p ≤ 0.001). Here, the relationship with older adults' attitude toward gerontechnologies was partially mediated by the older adults' trust in technology. CONCLUSION: This study identified important personal and interpersonal drivers that influence attitudes toward and intentions to use gerontechnologies. To foster technology acceptance among older adults, it was found that it is important to strengthen the trust in and the attitude toward gerontechnologies. Furthermore, family members' knowledge and beliefs in technology were the keys to promoting the actual use of gerontechnologies among older adults. Furthermore, the families' trust in gerontechnologies and the provision of access to technology can improve their attitudes toward technology and usage intentions for the older relative.

The boundary-spanning behavior of nurses: The role of support and affective organizational commitment.

AIM: The aim of this study was to examine the relationship between organizational, supervisor, and coworker support, as perceived by registered nurses and their boundary-spanning behaviors. Furthermore, this article examines the mediating role of the affective organizational commitment of nurses in these relationships. BACKGROUND: Registered nurses play a key role in hospitals, as they have an important impact on the quality of the services delivered. For nurses to perform at their best, they need organizational, leader, and coworker support. To date, few studies have explored the link between nurses' perceived support, affective organizational commitment, and boundary-spanning behaviors. METHODS: This cross-sectional research used a questionnaire survey to explore the hypothesized relationships in a sample of 273 nurses from a hospital in Belgium. Structural equation modeling was used for statistical analysis of the mediation model. RESULTS: One hundred forty-seven (53.5%) nurses responded to the survey. Perceived support from the organization, supervisors, and coworkers positively influences nurses' boundary-spanning behaviors. Affective organizational commitment was found to mediate the positive relationship between perceived organization support, perceived coworker support, and boundary-spanning behaviors. Perceived supervisor support and boundary-spanning behaviors showed a direct relationship not mediated by affective organizational commitment. CONCLUSIONS: Perceived support has an important influence on the boundary-spanning behavior of nurses. This study emphasizes the importance on how support exerts an influence on boundary-spanning behavior and underscores the importance of affective organizational commitment. Health care organizations, supervisors, and coworkers are essential in fostering boundary-spanning behaviors of nurses, both directly and through the development of affective organizational commitment. These actors should therefore be aware of the way they behave and the implications their behavior may have.

Analysis of failed discharge after ambulatory surgery: unanticipated admission.

BACKGROUND: Advantages of ambulatory surgery are lost when patients need an unplanned admission. This retrospective cohort study investigated reasons for failed discharge and unanticipated admission of adult patients after day surgery. METHODS: Ambulatory patients (n = 145) requiring unanticipated admission were compared to patients (n = 4980) not requiring admission and timely discharged from a total of 5156 ambulatory surgical procedures. Demographic data, organisational data, reason for admission, type of anesthesia, surgical discipline, length of procedure, ASA classification, surgical completion time and severity of illness score were collected from both groups. Reason for admission was classified according to four subtypes. Logistic regression analysis was used. RESULTS: Incidence of unanticipated admission following day care surgery was 2.89%. The reasons for admission were mainly organisational issues (45.52%), time of completion surgery in the afternoon between 12 pm and 3 pm (OR 1.73; 95% CI 1.05-2.86) and surgery that ends after 3 pm (OR 6.52; 95% CI 4.11-10.34). Surgical factors associated with unanticipated admission (38.62%) were length of surgery of one to three hours (OR 2.05; 95% CI 1.27-3.29), length of surgery more than three hours (OR 8.31; 95% CI 3.56-19.40). Additionally, anaesthetic (10.34%) and medical (5.52%) reasons were found, e.g. ASA class II (OR 1.61; 95% CI 1.06-2.44), ASA class III (OR 2.19; 95% CI 1.10-4.34); moderate severity of illness score (OR 1.72; 95% CI 1.03-2.88) and major of severity of illness score (OR 7.85; 95% CI 2.31-26.62). CONCLUSIONS: Unanticipated admissions following day surgery occur mainly due to social/organisational and surgical reasons. However, medical and anaesthetic reasons also explain 15.86% of the unanticipated admissions.

Varying viewpoints of Belgian stakeholders on models of interhospital collaboration.

BACKGROUND: Hospitals are increasingly parts of larger care collaborations, rather than individual entities. Organizing and operating these collaborations is challenging; a significant number do not succeed, as it is difficult to align the goals of the partners. However, little research has focused on stakeholders' views regarding hospital collaboration models or on whether these views are aligned with those of hospital management. This study explores Belgian hospital stakeholders' views on the factors affecting hospital collaborations and their perspectives on different models for Belgian interhospital collaboration. METHODS: Qualitative focus group study on the viewpoints, barriers, and facilitators associated with hospital collaboration models (health system, network, joint venture). RESULTS: A total of 55 hospital stakeholders (hospital managers, chairs of medical councils, chair of hospital boards and special interest groups) participated in seven focus group sessions. Collaboration in health care is challenging, as the goals of the different stakeholder groups are partly parallel but also sometimes conflicting. Hospital managers and special interest groups favored health systems as the most integrated form. Hospital board members also opted for this model, but believed a coordinated network to be the most pragmatic and feasible model at the moment. Members of physicians' organizations preferred the joint venture, as it creates more flexibility for physicians. Successful collaboration requires trust and commitment. Legislation must provide a supporting framework and governance models. CONCLUSIONS: Involvement of all stakeholder groups in the process of decision-making within the collaboration is perceived as a necessity, which confirms the importance of the stakeholders' theory. The health system is the collaboration structure best suited to enhancing task distribution and improving patient quality. However, the existence of networks and joint ventures is considered necessary in the process of transformation towards more solid hospital collaborations such as health systems.

The role of hospitals in bridging the care continuum: a systematic review of coordination of care and follow-up for adults with chronic conditions.

BACKGROUND: Multiple studies have investigated the outcome of integrated care programs for chronically ill patients. However, few studies have addressed the specific role hospitals can play in the downstream collaboration for chronic disease management. Our objective here is to provide a comprehensive overview of the role of the hospitals by synthesizing the advantages and disadvantages of hospital interference in the chronic discourse for chronically ill patients found in published empirical studies. METHOD: Systematic literature review. Two reviewers independently investigated relevant studies using a standardized search strategy. RESULTS: Thirty-two articles were included in the systematic review. Overall, the quality of the included studies is high. Four important themes were identified: the impact of transitional care interventions initiated from the hospital's side, the role of specialized care settings, the comparison of inpatient and outpatient care, and the effect of chronic care coordination on the experience of patients. CONCLUSION: Our results show that hospitals can play an important role in transitional care interventions and the coordination of chronic care with better outcomes for the patients by taking a leading role in integrated care programs. Above that, the patient experiences are positively influenced by the coordinating role of a specialist. Specialized care settings, as components of the hospital, facilitate the coordination of the care processes. In the future, specialized care centers and primary care could play a more extensive role in care for chronic patients by collaborating.

Barriers and Enablers of Second-Order Problem-Solving Behavior: How Nurses Can Break Away From the Workaround Culture.

BACKGROUND AND OBJECTIVES: Nurses are challenged by numerous day-to-day unexpected problems due to poorly performing work systems that hinder patient care. These operational failures persist in hospitals, partly because nurses tend to prefer quick fixes or workarounds over real improvements that prevent recurrence. The aim of this review is to shed light on the barriers to and enablers of nurses' second-order problem-solving behavior and their consequences, so that hospitals can learn from failure and improve organizational outcomes. METHODS: We conducted a systematic review, with quantitative, qualitative, and mixed-method articles, searching 6 databases (PubMed, Embase, Web of Science, CINAHL, and Google Scholar) following the Preferred Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Quality assessment for inclusion was performed by 2 independent authors using the Mixed Methods Appraisal Tool (MMAT). A descriptive synthesis was used for analysis. RESULTS: This study reveals the barriers and enablers for second-order problem-solving behavior, and synthesizes improvement proposals within 3 perspectives, namely the "empowerment" perspective, the "process improvement" perspective, and the "time" perspective. Furthermore, we found that limited attention is given to the patient's perspective, and the existence of a no-action behavior. CONCLUSION: Although operational failures have several important consequences for hospital staff and organizations, there has been hardly any research into the barriers and enablers that initiate second-order problem-solving behavior; stemming this nursing behavior has thus rarely appeared as a suggestion for improvement.

Exploring non-physician care professionals' roles in cancer multidisciplinary team meetings: A qualitative study.

The growing complexity of cancer care necessitates collaboration among different professionals. This interprofessional collaboration improves cancer care delivery and outcomes. Treatment decision-making within the context of a multidisciplinaire team meeting (MDTMs) may be seen as a particular form of interprofessional collaboration. Various studies on cancer MDTMs highlight a pattern of suboptimal information sharing between attendants. To overcome the lack of non-medical, patient-based information, it might be recommended that non-physician care professionals play a key patient advocacy role within cancer MDTMs. This study aims to explore non-physician care professionals' current and aspired role within cancer MDTMs. Additionally, the perceived hindering factors for these non-physician care professionals to fulfil their specific role are identified. The analysis focuses on nurses, specialist nurses, head nurses, psychologists, social workers, a head of social workers and data managers. The results show that non-physician care professionals play a limited role during case discussions in MDTMs. Neither do they actively participate in the decision-making process. Barriers perceived by non-physician care professionals are classified on two main levels: 1) team-related barriers (factors internally related to the team) and 2) external barriers (factors related to healthcare management and policy). A group of non-physician care professionals also belief that their information does not add value in the decision-making proces and as such, they underestimate their own role in MDTMs. To conclude, a change of culture is needed towards an interdisciplinary collaboration in which knowledge and expertise of different professions are equally assimilated into an integrated perspective to guarantee a true patient-centred approach for cancer MDTMs.

Role of Social and App-Related Factors in Behavioral Engagement With mHealth for Improved Well-being Among Chronically Ill Patients: Scenario-Based Survey Study.

BACKGROUND: The last decade has seen a considerable increase in the number of mobile health (mHealth) apps in everyday life. These mHealth apps have the potential to significantly improve the well-being of chronically ill patients. However, behavioral engagement with mHealth apps remains low. OBJECTIVE: The aim of this study was to describe the behavioral engagement of chronically ill patients with mHealth apps by investigating (1) how it is affected by social factors (ie, physician recommendation) and app-related factors (ie, app integration) and (2) how it affects patient well-being. This study also considers the moderating effect of attachment to traditional health care and the mobile app experience among patients. METHODS: We carried out a scenario-based survey study of chronically ill patients (N=521). A Bayesian structural equation modeling with mediation and moderation analysis was conducted in MPlus. RESULTS: Both physician recommendations for mHealth app use and app integration have positive effects on the behavioral engagement of chronically ill patients with mHealth apps. Higher behavioral engagement positively affects the hedonic well-being (extent of pleasure) and the eudaemonic well-being (extent of self-efficacy) of chronically ill patients. Mobile app experience, however, positively moderates the relationship between app integration and behavioral engagement, whereas patient attachment to traditional care does not moderate the relationship between physician recommendation and behavioral engagement. Taken together, the proportion of variance explained (R²) equals 21% for behavioral engagement and 52.8% and 62.2% for hedonic and eudaemonic well-being, respectively, thereby providing support for the strong influence of app integration and physician recommendation via the mediation of the patients' behavioral engagement on both patients' hedonic and eudaemonic well-being. CONCLUSIONS: Physician recommendation and app integration enable behavioral engagement and promote well-being among chronically ill patients. It is thus important to take social and app-related factors into consideration during and after the development of mHealth apps.

Understanding the Complexity, Underlying Processes, and Influencing Factors for Optimal Multidisciplinary Teamwork in Hospital-Based Cancer Teams: A Systematic Integrative Review.

BACKGROUND: Multidisciplinary teamwork has become the standard in care for oncological patients and their treatment trajectory when comprehensive, holistic, and high-quality cancer care is needed. Working together from a variety of perspectives is difficult to achieve and has well-known pitfalls, such as miscommunication and poor coordination. OBJECTIVE: To describe and synthesize the factors influencing and the processes underlying optimal multidisciplinary teamwork. METHODS: An integrative review was conducted, guided by the framework of Whittemore and Knafl. The systematic search for literature published since 2010 in 3 databases (PubMed, Web of Science, and Scopus) yielded 49 articles. RESULTS: Eighty-eight percent of the included studies focus on multidisciplinary team meetings, rather than on the wider notion of multidisciplinary teamwork. We identified influencing factors on the basis of structural features of the team, hospital, and health system, as well as process features of multidisciplinary teamwork in multidisciplinary team meetings. CONCLUSION: To improve multidisciplinary teamwork, the focus needs to be on the process of collaboration throughout the cancer care trajectory of the patient. A more integrated, interdisciplinary approach should be aimed for to recognize the role and contribution of all disciplines involved. IMPLICATIONS: A cultural change is needed toward interdisciplinary practice in hospitals to reach partnership between all involved professionals as part of a participatory, collaborative, and coordinated approach.

Balancing hospital governance: A systematic review of 15 years of empirical research.

It is crucial that we gain a deeper understanding of the features of organizational governance and how they contribute to hospital performance. Health care governance research has traditionally had a strong focus on the size and composition (i.e., the attributes) of the governing bodies, but less attention has been given to the dynamics, processes, and roles. Furthermore, evidence regarding the interconnection between the board and the executive management is lacking. This systematic literature review is thus intended to give a detailed summary of the attributes, the dynamics, and the processes, as well as the roles of governing bodies, by synthesizing the findings of published empirical studies. The framework of Kane et al. (2009) was used to position the results, taking into account external constraints and outputs/performance. Sixty-three studies were included in the systematic review. The majority of these studies deal with attributes (n = 34) and roles (n = 27); the smallest number of studies (n = 11) focus on dynamics and processes. There is a lack of consistency in the research findings on attributes and there is too little research into the dynamics and processes of hospital governance. However, it has been shown that clinical participation on the hospital board and the focus on quality in hospital board roles can have a beneficial effect. The studies do not provide sufficient direction on what best practice for governing hospitals should be. For this reason, we here provide a useful framework for understanding the aspects of governance and their impact on performance in hospitals and compare these with general corporate governance literature. Therefrom we propose avenues for further research.

Development and Evaluation of an Integrated Digital Patient Platform During Oncology Treatment.

BACKGROUND: Patient platforms are seen as promising technologies in an integrated care approach to involve cancer patients in their own health care and to support them in managing their personal health information. However, few digital platforms have been codesigned with patients and caregivers. OBJECTIVE: To develop, implement, and evaluate the feasibility and applicability of a digital oncology platform (DOP) for patients with cancer. METHOD: A mixed-method study was used, employing a survey, interviews, and logged data from caregivers and patients. The DOP was designed in cooperation with Information Technology (IT) staff, caregivers, and patients. RESULTS: The DOP was actively used by half of the patients. These active patients were positive about the DOP. Caregivers acknowledged the added value but also indicate that additional workload was involved. Oncology nurse specialists are the users of the platform. General practitioners have indicated their interest in the platform. CONCLUSION: Thanks to the codesign process, the DOP could be tailored to the expectations of the end users. This study provides insight into which DOP functionalities the patients were interested in and includes further recommendations for implementation.

The role of governance in different types of interhospital collaborations: A systematic review.

CONTEXT: Financial challenges and the need for high-quality care have vastly increased the number of hospital collaborations in recent decades. The governance of these collaborations remains a challenge. The goal of this study is twofold: (1) to investigate the governance characteristics in an interhospital collaboration and (2) explore the impact on the performance of the interhospital collaboration. METHODS: A systematic review was conducted to provide a comprehensive overview of the evidence on governance in interhospital collaborations. Database searches yielded 9304 candidate articles, of which 26 studies fulfilled the inclusion criteria. FINDINGS: Governance in collaborations differs in collaboration structure, governance characteristics and contextual factors. Although outcome factors are influenced by contextual determinants and the collaboration structure itself, governance characteristics are of great importance. CONCLUSIONS: A critical challenge for managers is to successfully adapt collaborations structures and governance characteristics to rapidly changing conditions. Policy makers should ensure that new legislation and guidelines for internal governance can be adapted to different contextual factors. Research in the future should investigate the impact of governance as a dynamic process. More longitudinal case study research is needed to provide an in-depth view of the relationship between this process and the performance of a collaboration.

The introduction of hospital networks in Belgium: The path from policy statements to the 2019 legislation.

In April 2015, the Belgian Federal Minister for Social Affairs and Public Health launched an Action Plan to reform the hospital landscape. With the creation of "localregional clinical hospital networks" with their own governance structures, the plan follows the international trend towards hospital consolidation and collaboration. The major complicating factors in the Belgian context are (1) that policy instruments for the redesign of the hospital service delivery system are divided between the federal government and the federated authorities, which can result in an asymmetric hospital landscape with a potentially better distribution of clinical services in the Flanders hospital collaborations than in the other federated entities; and (2) the current regulations stipulate that only hospitals (and not networks) are entitled to hospital budgets. Although the reform is the most significant and drastic transformation of the Belgian hospital sector in the last three decades, networks mainly offer a framework in which hospitals can collaborate. More regulation and policy measures are needed to enhance collaboration and distribution of clinical services.

Basic life support refresher training of nurses: individual training and group training are equally effective.

BACKGROUND AND OBJECTIVES: Basic life support (BLS) skills of hospital nurses are often poor. We compared individual BLS refresher training (IT; one instructor to one trainee) with group refresher training (GT; one instructor to six trainees). We hypothesised that IT would result in better skill acquisition and retention. METHODS: Nurses from non-critical care wards (n=120) were randomised to IT or GT. Skills were assessed by a 3 min BLS test on a computerised manikin (Laerdal, Norway) immediately before training (T0), immediately after training (T1), and 10 months after training (T2). Results are expressed as median and [interquartile range]. RESULTS: The study was completed by 103 nurses (IT 56, GT 47). For GT the median group size was 5 [4-5]. The median duration of IT was 20 [17-21] min. The median duration of GT was 90 [84-95] or 19 min per trainee. Baseline skills did not differ between GT and IT, except for less compressions with correct depth for IT. At T1 and T2 there were no clinically significant differences between GT and IT for number of ventilations, ventilation volume, number of compressions, compression depth, compression rate and hands off time. Total instructor time was similar for IT and GT training strategies. CONCLUSIONS: There was no difference in IT and GT immediately and 10 months after training. However, training time per nurse for IT was only one fifth, whereas total instructor time did not increase. Although not superior in outcome, IT may be a cost-effective alternative for GT.

Hospital networks: how to make them work in Belgium? Facilitators and barriers of different governance models.

Objectives This study aims to identify the facilitators and barriers to governance models of hospital collaborations. The country-specific characteristics of the Belgian healthcare system and legislation are taken into account. Methods A case study was carried out in six Belgian hospital collaborations. Different types of governance models were selected: two health systems, two participant-governed networks, and two lead-organization-governed networks. Within these collaborations, 43 people were interviewed. Results All structures have both advantages and disadvantages. It is important that the governance model fits the network. However, structural, procedural, and especially contextual factors also affect the collaborations, such as alignment of hospitals' and professionals' goals, competition, distance, level of integrated care, time needed for decision-making, and legal and financial incentives. Conclusion The fit between the governance model and the collaboration can facilitate the functioning of a collaboration. The main barriers we identified are contextual factors. The Belgian government needs to play a major role in facilitating collaboration.

Service quality and patient experiences of ambulatory care in a specialized clinic vs. a general hospital.

OBJECTIVES: Health care organizations are constantly looking for ways to establish a differential advantage to attract customers. To this end, service quality has become an important differentiator in the strategy of health care organizations. In this study, we compared the service quality and patient experience in an ambulatory care setting of a physician-owned specialized facility with that of a general hospital. METHOD: A comparative case study with a mixed method design was employed. Data were gathered through a survey on health service quality and patient experience, completed with observations, walkthroughs, and photographic material. RESULTS: Service quality and patient experiences are high in both the investigated health care facilities. A significant distinction can be made between the two facilities in terms of interpersonal quality (p = 0.001) and environmental quality (P ≤ 0.001), in favor of the medical center. The difference in environmental quality is also indicated by the scores given by participants who had been in both facilities. Qualitative analysis showed higher administrative quality in the medical center. Environmental quality and patient experience can predict the interpersonal quality; for environmental quality, interpersonal quality and age are significant predictors. CONCLUSIONS: Service quality and patient experiences are high in both facilities. The medical center has higher service quality for interpersonal and environmental service quality and is more process-centered.

Retention of ventilation skills of emergency nurses after training with the SMART BAG compared to a standard bag-valve-mask.

BACKGROUND AND PURPOSE: Studies show that nurses retain resuscitation skills poorly and that retention of ventilation skills is particularly difficult. We formed the hypothesis that the SMART BAG (SB, O-Two Medical Technologies Inc., Canada), i.e. a bag-valve-mask device with a pressure/flow responsive valve, would assist nurses in providing more efficient ventilation six months after training. MATERIALS AND METHODS: Prior to training, 39 emergency nurses performed CPR for 2 min, in pairs, using a standard bag-valve-mask device (STBVM, Laerdal, Norway) to assess their base line skills. A CPR training manikin (Simulaids, USA) equipped with a PEEP valve in the oesophagus set at 20 cm H2O was used to measure inspiratory time, tidal volume (Vt), peak pressure and gastric insufflation (GI). Immediately following training they were tested using an O-Two STBVM and a SB. Half of the nurses were retested after three months, the other half after six months. Efficient ventilation was defined as a mean Vt>400 ml and GI<50 ml in 1 min. RESULTS: Before training, only 16% of nurses ventilated efficiently: 63% had GI and 28% had Vt<400 ml. Three months after training the efficiency of the STBVM and the SB was high (81 and 75%, respectively). Six months after training, there was a trend towards higher efficiency for the SB (63%) compared to the STBVM (25%) (p=0.07). For instances with the STBVM producing a Vt>400 ml, those without GI had a lower peak pressure than those with GI (7.8 cm H2O versus 17.7 cm H2O, p=0.0001) and showed a trend towards a longer inspiratory time (1.28 s versus 1.08 s, p=0.08). Of all efficient ventilations with a STBVM, 26% had a Vt>600 ml. CONCLUSIONS: Six months after training, nurses ventilated at least as efficiently with the SB, compared with the STBVM. This illustrates the ability of the SB to compensate for the deterioration over time in skill. On the other hand, training with a STBVM should focus primarily on prolonging the inspiratory time, and therefore the peak pressure, whilst maintaining an adequate Vt.