Educational strategies in the health professions to mitigate cognitive and implicit bias impact on decision making: a scoping review.

BACKGROUND: Cognitive and implicit biases negatively impact clinicians' decision-making capacity and can have devastating consequences for safe, effective, and equitable healthcare provision. Internationally, health care clinicians play a critical role in identifying and overcoming these biases. To be workforce ready, it is important that educators proactively prepare all pre-registration healthcare students for real world practice. However, it is unknown how and to what extent health professional educators incorporate bias training into curricula. To address this gap, this scoping review aims to explore what approaches to teaching cognitive and implicit bias, for entry to practice students, have been studied, and what are the evidence gaps that remain. METHODS: This scoping review was guided by the Joanna Briggs Institute (JBI) methodology. Databases were searched in May 2022 and included CINAHL, Cochrane, JBI, Medline, ERIC, Embase, and PsycINFO. The Population, Concept and Context framework was used to guide keyword and index terms used for search criteria and data extraction by two independent reviewers. Quantitative and qualitative studies published in English exploring pedagogical approaches and/or educational techniques, strategies, teaching tools to reduce the influence of bias in health clinicians' decision making were sought to be included in this review. Results are presented numerically and thematically in a table accompanied by a narrative summary. RESULTS: Of the 732 articles identified, 13 met the aim of this study. Most publications originated from the United States (n=9). Educational practice in medicine accounted for most studies (n=8), followed by nursing and midwifery (n=2). A guiding philosophy or conceptual framework for content development was not indicated in most papers. Educational content was mainly provided via face-to-face (lecture/tutorial) delivery (n=10). Reflection was the most common strategy used for assessment of learning (n=6). Cognitive biases were mainly taught in a single session (n=5); implicit biases were taught via a mix of single (n=4) and multiple sessions (n=4). CONCLUSIONS: A range of pedagogical strategies were employed; most commonly, these were face-to-face, class-based activities such as lectures and tutorials. Assessments of student learning were primarily based on tests and personal reflection. There was limited use of real-world settings to educate students about or build skills in biases and their mitigation. There may be a valuable opportunity in exploring approaches to building these skills in the real-world settings that will be the workplaces of our future healthcare workers.

Do palliative care patients and relatives think it would be acceptable to use Bispectral index (BIS) technology to monitor palliative care patients' levels of consciousness? A qualitative exploration with interviews and focus groups for the I-CAN-CARE research programme.

BACKGROUND: Bispectral index (BIS) monitoring uses electroencephalographic data as an indicator of patients' consciousness level. This technology might be a useful adjunct to clinical observation when titrating sedative medications for palliative care patients. However, the use of BIS in palliative care generally, and in the UK in particular, is under-researched. A key area is this technology's acceptability for palliative care service users. Ahead of trialling BIS in practice, and in order to ascertain whether such a trial would be reasonable, we conducted a study to explore UK palliative care patients' and relatives' perceptions of the technology, including whether they thought its use in palliative care practice would be acceptable. METHODS: A qualitative exploration was undertaken. Participants were recruited through a UK hospice. Focus groups and semi-structured interviews were conducted with separate groups of palliative care patients, relatives of current patients, and bereaved relatives. We explored their views on acceptability of using BIS with palliative care patients, and analysed their responses following the five key stages of the Framework method. RESULTS: We recruited 25 participants. There were ten current hospice patients in three focus groups, four relatives of current patients in one focus group and one individual interview, and eleven bereaved relatives in three focus groups and two individual interviews. Our study participants considered BIS acceptable for monitoring palliative care patients' consciousness levels, and that it might be of use in end-of-life care, provided that it was additional to (rather than a replacement of) usual care, and patients and/or family members were involved in decisions about its use. Participants also noted that BIS, while possibly obtrusive, is not invasive, with some seeing it as equivalent to wearable technological devices such as activity watches. CONCLUSIONS: Participants considered BIS technology might be of benefit to palliative care as a non-intrusive means of assisting clinical assessment and decision-making at the end of life, and concluded that it would therefore be acceptable to trial the technology with patients.

Experiences of siblings of children with congenital heart disease during Coronavirus disease 2019; A qualitative interview study.

PURPOSE: To explore siblings' perceptions of having a brother or sister with congenital heart disease in the UK during the COVID-19 pandemic. DESIGN AND METHODS: Siblings of children with congenital heart disease aged 8-17 years old were interviewed via video call technology between September 2020 and February 2021. We conducted reflexive thematic analysis of these interviews to generate themes. FINDINGS: Interviews took place with 17 siblings, predominantly of white ethnicity n = 15 (86%). Most siblings interviewed were first born in the family n = 15 (88%), and most children with CHD were the youngest n = 15(88%). Four themes were generated; My sibling is vulnerable, what does this mean for my family, I have a responsibility to protect my brother or sister, our family time during the pandemic and adjustment and adaptations to pandemic life. CONCLUSIONS: Siblings identified difficult aspects of the pandemic and these related to concerns about their brother's or sister's vulnerability, family impact, and keeping their sibling safe. They also identified adjustments they made to keep their family functioning throughout the COVID-19 pandemic. Despite the worry and uncertainty siblings experienced, they valued increased family cohesion which helped to mitigate some challenges of the restrictions imposed in the UK. PRACTICE IMPLICATIONS: Honest and open communication is valued by siblings. It is vital to ensure siblings receive the support they need to ensure they keep up with their schooling and social commitments as pandemic related restrictions ease.

A comparative validation of biodosimetry and physical dosimetry techniques for possible triage applications in emergency dosimetry.

Large-scale radiological accidents or nuclear terrorist incidents involving radiological or nuclear materials can potentially expose thousands, or hundreds of thousands, of people to unknown radiation doses, requiring prompt dose reconstruction for appropriate triage. Two types of dosimetry methods namely, biodosimetry and physical dosimetry are currently utilized for estimating absorbed radiation dose in humans. Both methods have been tested separately in several inter-laboratory comparison exercises, but a direct comparison of physical dosimetry with biological dosimetry has not been performed to evaluate their dose prediction accuracies. The current work describes the results of the direct comparison of absorbed doses estimated by physical (smartphone components) and biodosimetry (dicentric chromosome assay (DCA) performed in human peripheral blood lymphocytes) methods. For comparison, human peripheral blood samples (biodosimetry) and different components of smartphones, namely surface mount resistors (SMRs), inductors and protective glasses (physical dosimetry) were exposed to different doses of photons (0-4.4 Gy; values refer to dose to blood after correction) and the absorbed radiation doses were reconstructed by biodosimetry (DCA) and physical dosimetry (optically stimulated luminescence (OSL)) methods. Additionally, LiF:Mg,Ti (TLD-100) chips and Al2O3:C (Luxel) films were used as reference TL and OSL dosimeters, respectively. The best coincidence between biodosimetry and physical dosimetry was observed for samples of blood and SMRs exposed toγ-rays. Significant differences were observed in the reconstructed doses by the two dosimetry methods for samples exposed to x-ray photons with energy below 100 keV. The discrepancy is probably due to the energy dependence of mass energy-absorption coefficients of the samples extracted from the phones. Our results of comparative validation of the radiation doses reconstructed by luminescence dosimetry from smartphone components with biodosimetry using DCA from human blood suggest the potential use of smartphone components as an effective emergency triage tool for high photon energies.

Identification and evaluation of observational measures for the assessment and/or monitoring of level of consciousness in adult palliative care patients: A systematic review for I-CAN-CARE.

BACKGROUND: The use of observational measures to assess palliative care patients' level of consciousness may improve patient care and comfort. However, there is limited knowledge regarding the validity and reliability of these measures in palliative care settings. AIM: To identify and evaluate the psychometric performance of observational level of consciousness measures used in palliative care. DESIGN: Systematic review; PROSPERO registration: CRD42017073080. DATA SOURCES: We searched six databases until November 2018, using search terms combining subject headings and free-text terms. Psychometric performance for each identified tool was appraised independently by two reviewers following established criteria for developing and evaluating health outcome measures. RESULTS: We found 35 different levels of consciousness tools used in 65 studies. Only seven studies reported information about psychometric performance of just eight tools. All other studies used either ad hoc measures for which no formal validation had been undertaken (n = 21) or established tools mainly developed and validated in non-palliative care settings (n = 37). The Consciousness Scale for Palliative Care and a modified version of the Richmond Agitation-Sedation Scale received the highest ratings in our appraisal, but, since psychometric evidence was limited, no tool could be assessed for all psychometric properties. CONCLUSION: An increasing number of studies in palliative care are using observational measures of level of consciousness. However, only a few of these tools have been tested for their psychometric performance in that context. Future research in this area should validate and/or refine the existing measures, rather than developing new tools.

Manifestation and parental assessment of children's cancer pain at home: An exploratory mixed-methods study.

AIMS AND OBJECTIVES: To describe pain manifestation in children with cancer at home and understand how parents assess this pain. BACKGROUND: Pain is experienced by children with cancer throughout their cancer journey. Short-term, and into survivorship, pain has negative physical and psychological consequences. Changes in treatment location mean children with cancer spend more time at home. Little is known about pain experienced by children at home or how parents assess this pain. DESIGN: A mixed-methods convergent parallel study was reported using STROBE. METHOD: Parents of children with cancer on active treatment were recruited from one tertiary cancer centre. Parental attitudes towards pain expression were assessed using surveys. Parents recorded their child's pain manifestation in pain diaries kept for one month. Interviews captured a deeper understanding of pain manifestation and how parents assess this pain at home. Integration occurred after each data collection method was analysed separately. RESULTS: Predominantly children were not in pain at home. However, most children experienced at least one episode of problematic pain over the pain diary period. Surveys showed parents held misconceptions regarding children's pain expression. Interviews diverge from surveys and suggest parents used a range of information sources to assess pain. CONCLUSION: Children with cancer may differ from one another in the manifestation of pain at home resulting in multiple pain trajectories. Parents of children with cancer are able to adequately assess their child's pain using information from multiple sources. RELEVANCE TO CLINICAL PRACTICE: It is not currently possible to predict which children will experience problematic pain at home, so all parents require pain management education prior to discharge. Teaching parents to use bundled approaches to pain assessment may accelerate their learning. Healthcare professionals may benefit from using multiple information sources to assess pain.

An Integrative Review of Interventions to Support Parents When Managing Their Child's Pain at Home.

To identify interventions aimed at helping parents manage their child's pain at home and to establish which aspects of interventions were effective. Integrative narrative review. MEDLINE, CINAHL Plus, PsychINFO, PsychArticles, AMED, PubMed, Scopus and Web of Knowledge databases were searched in 2016. This narrative synthesis followed Centre for Reviews and Dissemination and Economic and Social Research Council guidance. Reasons attributed to intervention success were analyzed using content analysis. From 2,534 papers, 17 were included. A majority were randomized controlled trials (n = 13) and most addressed postoperative pain (n = 15). A range of interventions were found that directly targeted parents, including child-parent interactions and health care professional-parent interactions, as well as complex interventions. Three studies were successful in reducing child pain at home and seven in increasing appropriate analgesic drug administration. Analysis of reasons attributed to interventions success revealed characteristics of interventions, components of parental pain management, and key features of research that aid researchers in designing and evaluating interventions. Risk of bias was present because of inadequate randomization, lack of a control group, and underpowered studies. Nurses should be aware that targeting parents directly is the most effective way of reducing child pain at home. Nurses need to advocate for effective analgesics for their child patients because the ineffectiveness of many interventions was attributed to inadequate analgesic drugs. Once this is achieved, success in increasing analgesic drug administration is most likely reached via parent-targeted interventions and those targeting health care professional-parent interactions. Successful interventions will be tailored to the child and adequately powered. Including a measure of sedation will ensure sedation is not mistaken for analgesic effectiveness. Interventions should address multiple facets of pain management and include a measure of pain over a period as opposed to a snapshot in time.

Nurse titrated analgesia and sedation in intensive care increases the frequency of comfort assessment and reduces midazolam use in paediatric patients following cardiac surgery.

BACKGROUND: Pain and sedation protocols are suggested to improve the outcomes of patients within paediatric intensive care. However, it is not clear how protocols will influence practice within individual units. OBJECTIVES: Evaluate a nurse led pain and sedation protocols impact on pain scoring and analgesic and sedative administration for post-operative cardiac patients within a paediatric intensive care unit. METHODS: A retrospective chart review was performed on 100 patients admitted to a tertiary paediatric intensive care unit pre and post introduction of an analgesic and sedative protocol. Stata12 was used to perform Chi-squared or Student's t-test to compare data between the groups. RESULTS: Post protocol introduction documentation of pain assessments increased (pre protocol 3/24h vs post protocol 5/24h, p=0.006). Along with a reduction in administration of midazolam (57.6mcg/kg/min pre protocol vs 24.5mcg/kg/min post protocol, p=0.0001). Children's pain scores remained unchanged despite this change, with a trend towards more scores in the optimal range in the post protocol group (5 pre protocol vs 12 post protocol, p=0.06). CONCLUSIONS: Introducing a pain and sedation protocol changed bedside nurse practice in pain and sedation management. The protocol has enabled nurses to provide pain and sedation management in a consistent and timely manner and reduced the dose of midazolam required to maintain comfort according to the patients COMFORT B scores. Individual evaluation of practice change is recommended to units who implement nurse led analgesic and sedative protocols to monitor changes in practice.

Stability of X-band EPR signals from fingernails under vacuum storage.

EPR signals of different origin have been tested in human finger- and toe-nails with an X-band EPR technique for different conditions of nail storage. Three different signals were identified, namely a singlet at g=2.005, a doublet at g=2.004 with a splitting constant A=1.8 mT, and an anisotropic signal at g1=2.057, g2=2.029 and g3=2.003 (positions of local extrema). All EPR spectra from nails, whether irradiated or mechanically stressed, can be described as a superposition of these three signals. The singlet is responsible for the background signal (BG), is the main component of radiation-induced signals (RIS) for low doses (100 Gy or lower) and also contributes to mechanically-induced signals (MIS). This signal is quite stable under vacuum storage, but can be reduced almost to zero by soaking in water. The behavior of this signal under ambient conditions depends on many factors, such as absorbed dose, air humidity, and ambient illumination intensity at the place of storage. The doublet arises after exposure of nails to high (few hundreds Gy and higher) doses or after mechanical stress of samples. Depending on how this signal was obtained, it may have bulk or surface locations with quite different stability properties. The surface-located doublet (generated on the nail edges during cutting or clipping) is quite unstable and decays over about two hours for samples stored at ambient conditions and within several seconds for samples immersed in water. The volume-distributed doublet decays within a few minutes in water, several hours at ambient conditions and several days in vacuum. The anisotropic signal may also be generated by both ionizing radiation and mechanical stress; this signal is quite stable in vacuum and decays over several days at ambient conditions or a few tens of minutes in water. The reference lines for the above-described three EPR signals were obtained and a procedure of spectra deconvolution was developed and tested on samples exposed to both ionizing radiation and mechanical stress.

Engaging a Nursing Workforce in Evidence-Based Practice: Introduction of a Nursing Clinical Effectiveness Committee.

This column shares the best evidence-based strategies and innovative ideas on how to facilitate the learning of EBP principles and processes by clinicians as well as nursing and interprofessional students. Guidelines for submission are available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787.

Sevoflurane-induced changes in infants' quantifiable electroencephalogram parameters.

BACKGROUND: Electroencephalogram (EEG) based depth of anesthesia algorithms developed in the adult population have not demonstrated the same reliability when applied to infants. This may be due to frequency changes occurring in the EEG during development. Amplitude-integrated EEG (aEEG) is based primarily in the time domain and hence may have greater utility in infants. OBJECTIVE: To investigate the relationship between age adjusted Minimal Alveolar Concentration (MAC) multiples and aEEG in children under 2 years of age. METHODS: The aEEG, Spectral Edge Frequency 90% (SEF90) and Bispectral Index™ (BIS) were investigated in a prospective study of children <2 years of age. After anesthetic induction, and caudal block administration, EEG data were collected simultaneously with BrainZ BRM2™ and BIS™ monitors. Using a randomized crossover design, children received up to three age adjusted concentrations of sevoflurane: 0.75, 1 and 1.25 MAC. After 15 min of stable anesthetic delivery EEG readings were obtained. Prediction Probability (Pk ) and correlation coefficients were calculated for each EEG parameter. RESULTS: From 51 children 102 stable anesthetics concentrations were obtained. For all age groups Pk of aEEG to multiple of age adjusted MAC was <0.72 indicating a poor predictive power for aEEG. In contrast for the SEF90 and BIS there was evidence for better predictive properties in children aged between 6 months and 2 years, with a Pk >0.81. CONCLUSION: The aEEG is unlikely to be a useful measure of anesthesia depth in young children.

Employing a clinical governance framework to engage nurses in research.

The theoretical benefits of engaging in quality and research activities are readily apparent; however, engagement of clinical nurses in these pursuits remains challenging. In addition, the separation of quality improvement and research as distinct endeavors can impair desired improvements in patient outcomes. We propose that employing a clinical governance framework to inform nursing research in the clinical setting enhances the engagement of nurses in the generation and utilization of evidence to improve the quality of care.

Research behind a webcam: an exploration of virtual interviewing with children and young people.

BACKGROUND: Societal use of digital technology rapidly increased during the COVID-19 pandemic. Face-to-face services converted to online provision where possible. This affected many nurse researchers. AIM: To explore conducting research interviews online with children and young people (CYP) about sensitive topics. DISCUSSION: This article considers digital inclusion, as well as ethical issues surrounding safety, support and consent, along with choosing tools for collecting data. It also presents a discussion of physical proximity in qualitative interviews with this population and its role in data quality. The authors investigate benefits in the context of researchers' personal experiences. They acknowledge the disadvantages of conducting interviews online and discuss ways to mitigate these. CONCLUSION: The advantages for researchers include cost-effectiveness, time-efficiency and greater geographical reach of participants. However, CYP's perspectives are unknown and the specific ethical issues of using this method with CYP need careful consideration. IMPLICATIONS FOR PRACTICE: More research is needed to examine virtual interviews from the perspectives of CYP as participants. Virtual acquisition of consent and assent should be investigated to standardise good research practices.

Understanding the toolbox: A mixed methods study of attitudes, barriers and facilitators in parental intervention of children's cancer pain at home.

Children with cancer experience pain throughout their cancer trajectory. Pain has short- and long-term negative consequences for children physically and psychologically. Children with cancer spend more time at home with their families and less time in hospital. While this has benefits for quality of life, it shifts responsibility for pain management from healthcare professionals to parents. Little is known about parents' pain management abilities in this setting. This study aimed to understand how parents of children with cancer manage their child's pain at home. A convergent, parallel, mixed methods design including pain diaries, surveys and interviews was used. Participants were parents of children with cancer on active treatment recruited from one tertiary cancer centre. Each data collection method was analysed separately and then integrated. Parents frequently under-medicate their child's pain at home. Practical barriers including the analgesic context and children finding medications unpalatable led parents to prefer non-pharmacological interventions. Attitudinal and practical barriers result in parents having an "empty toolbox" of pharmacological interventions. Consequently non-pharmacological interventions are essential to parents managing their child's cancer pain at home.

Impact of congenital heart disease on siblings: A review.

Congenital heart disease (CHD) is the most common birth defect. Little is known of the impact of having a sibling with CHD. Available literature documents negative impact of having a sibling with other chronic conditions. This literature review considers empirical evidence investigating the impact of having a sibling with CHD. Twelve databases were searched, and 202 articles retrieved. Eleven articles met the inclusion criteria and were subject to data extraction, quality appraisal, and narrative synthesis. Three themes emerged: changes in normal life, impact on siblings, and factors affecting the extent of impact on siblings. Only one intervention study was identified, 5 of 10 studies were conducted over 20 years ago, and only 4 studies included children as participants. Evidence suggests siblings of children with CHD experience adverse life changes which lead to negative impacts in several domains. Evidence is inconclusive regarding mitigating factors of these impacts. Further research is needed to understand the experiences of being a sibling of a child with CHD.

Astronaut's organ doses inferred from measurements in a human phantom outside the international space station.

Space radiation hazards are recognized as a key concern for human space flight. For long-term interplanetary missions, they constitute a potentially limiting factor since current protection limits for low-Earth orbit missions may be approached or even exceeded. In such a situation, an accurate risk assessment requires knowledge of equivalent doses in critical radiosensitive organs rather than only skin doses or ambient doses from area monitoring. To achieve this, the MATROSHKA experiment uses a human phantom torso equipped with dedicated detector systems. We measured for the first time the doses from the diverse components of ionizing space radiation at the surface and at different locations inside the phantom positioned outside the International Space Station, thereby simulating an extravehicular activity of an astronaut. The relationships between the skin and organ absorbed doses obtained in such an exposure show a steep gradient between the doses in the uppermost layer of the skin and the deep organs with a ratio close to 20. This decrease due to the body self-shielding and a concomitant increase of the radiation quality factor by 1.7 highlight the complexities of an adequate dosimetry of space radiation. The depth-dose distributions established by MATROSHKA serve as benchmarks for space radiation models and radiation transport calculations that are needed for mission planning.

Causes of ATtrition in CHIldren's NursinG (CATCHING): An exploratory mixed method study.

Professional, financial and ethical reasons necessitate nursing improves its understanding of student attrition. Previous studies identify causes of attrition as multifactorial. However, few studies focus on children's nursing. This study aimed to explore causes of pre-registration children's nursing attrition. Exploring the causes of attrition was achieved through quantitative and qualitative approaches. Three years of quantitative data relating to attrition rates and causes was obtained. These data informed semi-structured interviews of children's nursing students, from four London universities. These students had faced challenges and either 'left' (n = 5) or 'stayed on' (n = 13) their pre-registration programme. Most attrition occurred in the first year of programmes and was primarily due to academic failure or personal circumstances; clinical placements also played a role. Emergent themes were 'expectations of pre-registration children's nursing'; 'realities of a pre-registration children's nursing course', and 'factors that influence students leaving or staying on the course'. Many participants reported a reluctance to disclose issues while on their course. Support to continue on the programme was frequently obtained away from university and students described relying on self-determination to complete programmes. Findings indicated several areas of potential improvement for student support including targeted interventions focusing on a student's first year and reducing variation in support services provided.

UNCERTAINTY ON RADIATION DOSES ESTIMATED BY BIOLOGICAL AND RETROSPECTIVE PHYSICAL METHODS.

Biological and physical retrospective dosimetry are recognised as key techniques to provide individual estimates of dose following unplanned exposures to ionising radiation. Whilst there has been a relatively large amount of recent development in the biological and physical procedures, development of statistical analysis techniques has failed to keep pace. The aim of this paper is to review the current state of the art in uncertainty analysis techniques across the 'EURADOS Working Group 10-Retrospective dosimetry' members, to give concrete examples of implementation of the techniques recommended in the international standards, and to further promote the use of Monte Carlo techniques to support characterisation of uncertainties. It is concluded that sufficient techniques are available and in use by most laboratories for acute, whole body exposures to highly penetrating radiation, but further work will be required to ensure that statistical analysis is always wholly sufficient for the more complex exposure scenarios.