Variable Stiffness and Damping Mechanism for CPR Manikin to Simulate Mechanical Properties of Human Chest.

OBJECTIVE: This study introduces a novel system that can simulate diverse mechanical properties of the human chest to enhance the experience of CPR training by reflecting realistic chest conditions of patients. METHODS: The proposed system consists of Variable stiffness mechanisms (VSMs) and Variable damper (VD) utilizing stretching silicone bands and dashpot dampers with controllable valves to modulate stiffness and damping, respectively. Cyclic loading was applied with a robot manipulator to the system. Compression force and displacement were measured and analyzed to evaluate the system's mechanical response. Long-term stability of the system was also validated. RESULTS: A non-linear response of the human chest under compression is realized through this design. Test results indicated non-linear force-displacement curves with hysteresis, similar to those observed in the chest of patients. Controlling the VSM and VD allowed for intentional changes in the slope and area of curves that are related to stiffness and damping, respectively. Stiffness and damping of the system were computed using performance test results. The stiffness ranged from 5.34 N/mm to 13.59 N/mm and the damping ranges from 0.127 N[Formula: see text] s/mm to 0.511 N[Formula: see text] s/mm. These properties cover a significant portion of the reported mechanical properties of the human chests. The system demonstrated satisfactory stability even when it was subjected to maximum stiffness conditions of the long-term compression test. CONCLUSION: The system is capable of emulating the mechanical properties and behavior of the human chests, thereby enhancing the CPR training experience.

Simulation Modalities in Clinical Practice.

For maximum effectiveness of a simulation-based educational experience, the correct modality must be chosen. Modality refers to the equipment or platform used to conduct the simulation. There are a variety of options available to clinical simulation educators, ranging from simple task trainers to full-body manikins to virtual experiences. The correctly chosen modality will allow the learners to achieve the learning objectives.

A new physiological manikin to test and compare ventilation devices during cardiopulmonary resuscitation.

Background: There is a lack of bench systems permitting to evaluate ventilation devices in the specific context of cardiac arrest. Objectives: The objective of the study is to assess if a new physiological manikin may permit to evaluate the performances of medical devices dedicated to ventilation during cardiopulmonary resuscitation (CPR). Methods: Specific CPR-related features required to reproduce realistic ventilation were implemented into the SAM (Sarthe Anjou Mayenne) manikin. In the first place, the manikin ability to mimic ventilation during CPR was assessed and compared to real-life tracings of airway pressure, flow and capnogram from three out of hospital cardiac arrest (OHCA) patients. In addition, to illustrate the interest of this manikin, ventilation was evaluated during mechanical continuous chest compressions with two devices dedicated to CPR: the Boussignac cardiac arrest device (B-card - Vygon; Ecouen France) and the Impedance Threshold Device (ITD - Zoll; Chelmsford, MA). Results: The SAM manikin enabled precise replication of ventilation tracings as observed in three OHCA patients during CPR, and it allowed for comparison between two distinct ventilation devices. B-card generated a mean, maximum and minimum intrathoracic pressure of 6.3 (±0.1) cmH2O, 18.9 (±1.1) cmH2O and -0.3 (±0.2) cmH2O respectively; while ITD generated a mean, maximum and minimum intrathoracic pressure of -1.6 (±0.0) cmH2O, 5.7 (±0.1) cmH2O and -4.8 (±0.1) cmH2O respectively during CPR. B-card allowed to increase passive ventilation compared to the ITD which resulted in a dramatic limitation of passive ventilation. Conclusion: The SAM manikin is an innovative model integrating specific physiological features that permit to accurately evaluate and compare ventilation devices during CPR.

Artificial Intelligence and Healthcare Simulation: The Shifting Landscape of Medical Education.

The impact of artificial intelligence (AI) will be felt not only in the arena of patient care and deliverable therapies but will also be uniquely disruptive in medical education and healthcare simulation (HCS), in particular. As HCS is intertwined with computer technology, it offers opportunities for rapid scalability with AI and, therefore, will be the most practical place to test new AI applications. This will ensure the acquisition of AI literacy for graduates from the country's various healthcare professional schools. Artificial intelligence has proven to be a useful adjunct in developing interprofessional education and team and leadership skills assessments. Outcome-driven medical simulation has been extensively used to train students in image-centric disciplines such as radiology, ultrasound, echocardiography, and pathology. Allowing students and trainees in healthcare to first apply diagnostic decision support systems (DDSS) under simulated conditions leads to improved diagnostic accuracy, enhanced communication with patients, safer triage decisions, and improved outcomes from rapid response teams. However, the issue of bias, hallucinations, and the uncertainty of emergent properties may undermine the faith of healthcare professionals as they see AI systems deployed in the clinical setting and participating in diagnostic judgments. Also, the demands of ensuring AI literacy in our healthcare professional curricula will place burdens on simulation assets and faculty to adapt to a rapidly changing technological landscape. Nevertheless, the introduction of AI will place increased emphasis on virtual reality platforms, thereby improving the availability of self-directed learning and making it available 24/7, along with uniquely personalized evaluations and customized coaching. Yet, caution must be exercised concerning AI, especially as society's earlier, delayed, and muted responses to the inherent dangers of social media raise serious questions about whether the American government and its citizenry can anticipate the security and privacy guardrails that need to be in place to protect our healthcare practitioners, medical students, and patients.

Efficacy of bougie first approach for endotracheal intubation with video laryngoscopy during continuous chest compression: a randomized crossover manikin trial.

BACKGROUND: Endotracheal intubation is challenging during cardiopulmonary resuscitation, and video laryngoscopy has showed benefits for this procedure. The aim of this study was to compare the effectiveness of various intubation approaches, including the bougie first, preloaded bougie, endotracheal tube (ETT) with stylet, and ETT without stylet, on first-attempt success using video laryngoscopy during chest compression. METHODS: This was a randomized crossover trial conducted in a general tertiary teaching hospital. We included anesthesia residents in postgraduate year one to three who passed the screening test. Each resident performed intubation with video laryngoscopy using the four approaches in a randomized sequence on an adult manikin during continuous chest compression. The primary outcome was the first-attempt success defined as starting ventilation within a one minute. RESULTS: A total of 260 endotracheal intubations conducted by 65 residents were randomized and analyzed with 65 procedures in each group. First-attempt success occurred in 64 (98.5%), 57 (87.7%), 56 (86.2%), and 46 (70.8%) intubations in the bougie-first, preloaded bougie, ETT with stylet, and ETT without stylet approaches, respectively. The bougie-first approach had a significantly higher possibility of first-attempt success than the preloaded bougie approach [risk ratio (RR) 8.00, 95% confidence interval (CI) 1.03 to 62.16, P = 0.047], the ETT with stylet approach (RR 9.00, 95% CI 1.17 to 69.02, P = 0.035), and the ETT without stylet approach (RR 19.00, 95% CI 2.62 to 137.79, P = 0.004) in the generalized estimating equation logistic model accounting for clustering of intubations operated by the same resident. In addition, the bougie first approach did not result in prolonged intubation or increased self-reported difficulty among the study participants. CONCLUSIONS: The bougie first approach with video laryngoscopy had the highest possibility of first-attempt success during chest compression. These results helped inform the intubation approach during CPR. However, further studies in an actual clinical environment are warranted to validate these findings. TRIAL REGISTRATION: Clinicaltrials.gov; identifier: NCT05689125; date: January 18, 2023.

Characterization of human extreme heat exposure using an outdoor thermal manikin.

Extreme heat is a current and growing global health concern. Current heat exposure models include meteorological and human factors that dictate heat stress, comfort, and risk of illness. However, radiation models simplify the human body to a cylinder, while convection ones provide conflicting predictions. To address these issues, we introduce a new method to characterize human exposure to extreme heat with unprecedented detail. We measure heat loads on 35 body surface zones using an outdoor thermal manikin ("ANDI") alongside an ultrasonic anemometer array and integral radiation measurements (IRM). We show that regardless of body orientation, IRM and ANDI agree even under high solar conditions. Further, body parts can be treated as cylinders, even in highly turbulent flow. This geometry-rooted insight yields a whole-body convection correlation that resolves prior conflicts and is valid for diverse indoor and outdoor wind flows. Results will inform decision-making around heat protection, adaptation, and mitigation.

Multilevel analysis of positive emotional induction: Which is the role of gender and valence on cognitive control processes?

How emotions are processed affects people's cognition and behavior. One of the most used measures to study the physiological component of emotions is heart rate (HR), where greater HR variation (range) implies greater emotional processing. Several investigations established the importance of gender modulation of these processes due to the different cultural treatment given to emotions among genders. However, very heterogeneous results are reported today, and few studies incorporated these parameters when investigating emotion modulation of cognitive processes according to individual factors. The present work consists of two studies. In a pilot study, 97 young adults, through the Self-Assessment Manikin (SAM), ranged the valence and arousal to select two positive and neutral videos. The second study analyses the role of gender and valence in the variation of subjective (SAM) and physiological (HR) indicators of emotional processing associated with performance in two cognitive tasks (Stroop and Tower of London) under two different emotional conditions. Participants were 60 adults, who were randomly assigned to positive or neutral video visualization, and their HR was registered. There was a tendency for women to have higher HR during positive videos than in neutral. While the subjective reports indicated variances in the appraisal of the videos, the heart rate did not exhibit differences across the experimental conditions. Few studies integrate emotional and cognitive components, and include physiological and subjective measures of emotional processing. These findings illustrate the importance of including various measures of emotional and cognitive processing.

Modulation of intracortical circuits in primary motor cortex during automatic action tendencies.

Humans display automatic action tendencies toward emotional stimuli, showing faster automatic behavior (i.e., approaching a positive stimulus and avoiding a negative stimulus) than regulated behavior (i.e., avoiding a positive stimulus and approaching a negative stimulus). Previous studies have shown that the primary motor cortex is involved in the processing of automatic actions, with higher motor evoked potential amplitudes during automatic behavior elicited by single-pulse transcranial magnetic stimulation. However, it is unknown how intracortical circuits are involved with automatic action tendencies. Here, we measured short-interval intracortical inhibition and intracortical facilitation within the primary motor cortex by using paired-pulse transcranial magnetic stimulation protocols during a manikin task, which has been widely used to explore approaching and avoiding behavior. Results showed that intracortical facilitation was stronger during automatic behavior than during regulated behavior. Moreover, there was a significant negative correlation between reaction times and intracortical facilitation effect during automatic behavior: individuals with short reaction times had stronger faciliatory activity, as shown by higher intracortical facilitation. By contrast, no significant difference was found for short-interval intracortical inhibition between automatic behavior and regulated behavior. The results indicated that the intracortical facilitation circuit, mediated by excitatory glutamatergic neurons, in the primary motor cortex, plays an important role in mediating automatic action tendencies. This finding further supports the link between emotional perception and the action system.

Articulating Video Stylet Compared to Other Techniques for Endotracheal Intubation in Normal Airways: A Simulation Study in Consultants with No Prior Experience.

Simulation for airway management allows for acquaintance with new devices and techniques. Endotracheal intubation (ETI), most commonly performed with direct laryngoscopy (DL) or video laryngoscopy (VLS), can be achieved also with combined laryngo-bronchoscopy intubation (CLBI). Finally, an articulating video stylet (ProVu) has been recently introduced. A single-center observational cross-sectional study was performed in a normal simulated airway scenario comparing DL, VLS-Glidescope, VLS-McGrath, CLBI and ProVu regarding the success rate (SR) and corrected time-to-intubation (cTTI, which accounts for the SR). Up to three attempts/device were allowed (maximum of 60 s each). Forty-two consultants with no experience with ProVu participated (15 ± 9 years after training completion). The DL was significantly faster (cTTI) than all other devices (p = 0.033 vs. VLSs, and p < 0.001 for CLBI and Provu), no differences were seen between the two VLSs (p = 0.775), and the VLSs were faster than CLBI and ProVu. Provu had a faster cTTI than CLBI (p = 0.004). The DL and VLSs showed similar SRs, and all the laryngoscopes had a higher SR than CLBI and ProVu at the first attempt. However, by the third attempt, the SR was not different between the DL/VLSs and ProVu (p = 0.241/p = 0.616); ProVu was superior to CLBI (p = 0.038). In consultants with no prior experience, ProVu shows encouraging results compared to DL/VLSs under simulated normal airway circumstances and further studies are warranted.

Chest compression quality comparing 1-min vs 2-min rotation of rescuers wearing N95 masks.

BACKGROUND: During the COVID-19 pandemic, cardiopulmonary resuscitation (CPR) performed by rescuers wearing well-sealed respirators such as N95 masks, was associated with significant reduction in the chest compression rate and depth. This was attributed to fatigue during the standard 2-min rescuer rotations. We hypothesized that in such situations, rotating rescuers every one minute, instead of the standard two minutes would improve CPR quality. AIM: To compare the quality of chest compressions when rescuers wearing N95 masks are rotated every one minute, instead of the standard practice of two-minute rotations. METHODS: A randomized, controlled, crossover trial was conducted, with the approval of the institutional Ethics Committee. Medical students who volunteered as rescuers were trained to perform high-quality chest compressions on a manikin, and then randomly allocated into pairs. Each pair was randomized to one of two trial groups viz. one-minute rotations crossed-over to two-minute rotations; and vice versa. Thus, each pair performed CPR with one-minute rotations, as well as two-minute rotations Each CPR session included chest compressions for a duration of 12 min. The outcome parameters included CPR quality, compression depth, compression rate, and chest compression fraction. Rescuer fatigue was measured before and after each study session using the modified Borg scale. RESULTS: Fifty-six participants completed the study. The overall CPR quality was statistically similar in the study arms (median 88% vs. 81%, p = 0.09). However, the minute-to-minute inter-arm comparison revealed significantly lower CPR quality in the 2-min rotation arm, at the end of minutes 4, 6, 8, 10 and 12 (respective p-values 0.03, 0.001, 0.008, 0.02, 0.002). A similar trend was observed in compression depth also. Rescuer fatigue score was significantly less with 1-min rotations compared to 2-min rotations (p < 0.001). Rescuer vital signs and cardiorespiratory parameters were not different with the two types of rotations. CONCLUSION: During CPR performed by rescuers wearing N95 masks, the quality of CPR appears to be superior with rescuers rotating at 1-min instead of 2-min intervals. More frequent rotation was also associated with less rescuer fatigue.

Mitigating heat effects in the workplace with a ventilation jacket: Simulations of the whole-body and local human thermophysiological response with a sweating thermal manikin in a warm-dry environment.

Climate change is increasingly affecting human well-being and will inevitably impact on occupational sectors in terms of costs, productivity, workers' health and injuries. Among the cooling garment developed to reduce heat strain, the ventilation jacket could be considered for possible use in workplaces, as it is wearable without limiting the user's mobility and autonomy. In this study, simulations with a sweating manikin are carried out to investigate the effects of a short-sleeved ventilation jacket on human thermophysiological responses in a warm-dry scenario. Simulations were performed in a climatic chamber (air temperature = 30.1 °C; air velocity = 0.29 m/s; relative humidity = 30.0 %), considering two constant levels of metabolic rate M (M1 = 2.4 MET; M2 = 3.2 MET), a sequence of these two (Work), and three levels of fan velocities (lf = 0; lf=2; lf=4). The results revealed a more evident impact on the mean skin temperature (Tsk) compared to the rectal temperature (Tre), with significant decreases (compared to fan-off) at all M levels, for Tsk from the beginning and for Tre from the 61st minute. Skin temperatures of the torso zones decreased significantly (compared to fan-off) at all M levels, and a greater drop was registered for the Back. The fans at the highest level (lf=4) were significantly effective in improving whole-body and local thermal sensations when compared to fan-off, at all M levels. At the intermediate level (lf=2), the statistical significance varied with thermal zone, M and time interval considered. The results of the simulations also showed that the Lower Torso needs to be monitored at M2 level, as the drop in skin temperature could lead to local overcooling and thermal discomfort. Simulations showed the potential effectiveness of the ventilation jacket, but human trials are needed to verify its cooling power in real working conditions.

A novel CPR-assist device vs. established chest compression techniques in infant CPR: A manikin study.

INTRODUCTION: Guidelines for infant CPR recommend the two-thumb encircling hands technique (TTT) and the two-finger technique (TFT) for chest compression. Some devices have been designed to assist with infant CPR, but are often not readily available. Syringe plungers may serve as an alternative infant CPR assist device given their availability in most hospitals. In this study, we aimed to determine whether CPR using a syringe plunger could improve CPR quality measurements on the Resusci-Baby manikin compared with traditional methods of infant CPR. METHODS: Compression area with a diameter of 1 to 2 cm is recommended in previous infant CPR device researches. In this is a randomized crossover manikin study, we examined the efficacy of the Syringe Plunger Technique (SPT) which uses the plunger of the 20 ml syringe with a 2 cm diameter flat piston, commonly available in hospital, for infant External Chest Compressions (ECC). Participants performed TTT, TFT and SPT ECC on Resusci® Baby QCPR® according to 2020 BLS guidelines. RESULTS: Sixty healthcare providers participated in this project. The median (IQR) ECC depths in the TTT, TFT and SPT in the first minute were 41 mm (40-42), 40 mm (38-41) and 40 mm (39-41), respectively, with p < 0.001. The median (IQR) ECC recoil in the TTT, TFT and SPT groups in the first minute was 15% (1-93), 64% (18-96) and 53% (8-95), respectively, with p = 0.003. The result in the second minute had similar findings. The SPT had the best QCPR score and less fatigue. CONCLUSION: The performance of chest compression depth and re-rebound ratio was statistically different among the three groups. TTT has good ECC depth and depth accuracy but poor recoil. TFT is the complete opposite. SPT can achieve a depth close to TTT and has a good recoil performance as TFT. Regarding comprehensive performance, SPT obtains the highest QCPR score, and SPT is also less fatigued. SPT may be an effective alternative technique for infant CPR.

Emotional processing of math-related words in people with math anxiety.

BACKGROUND: Research exploring emotional responses to math-related words in individuals with math anxiety (MA) is scarce. Here, we examined MA participants' subjective emotional processing of math-related cues within Lang's bioinformational model of emotion to further understand the role of those cues in MA. METHODS: In total, 41 high-MA and 32 low-MA undergraduates rated math-related words, along with neutral, pleasant, and unpleasant words, from the Affective Norms for English Words. The Self-Assessment Manikin was used to calculate valence, arousal, and dominance scores for each word. RESULTS: The low-MA group rated math-related words as neutral on the three emotional scales, however, the high-MA group rated them lower and higher for valence and dominance than neutral and unpleasant words, respectively. Moreover, math-related words were rated as more and less activating than neutral and unpleasant words, respectively. The two groups significantly differed in scores on the three scales only for the math-related words. CONCLUSIONS: These results provide evidence that individuals with high MA show altered emotional processing of math-related words, experiencing them as moderately aversive and moderately activating. The findings emphasize that the altered emotional processing of words associated with math should be considered a symptom of MA.

The placement of four different supraglottic airway devices by medical students: a manikin study.

BACKGROUND AND OBJECTIVES: Although endotracheal intubation is the gold standard in airway management, this procedure requires both technical training and experience. Supraglottic airway devices are an alternative to endotracheal intubation and are simpler, less invazive, and require less time for placement compared with endotrakeal intubation. Aim of the study was to evaluate the success rates, ease of use, duration of application, and maneuver performance of different supraglottic airway devices (SADs) used by term-5 medical students on a manikin. MATERIALS AND METHODS: This cross-sectional study was conducted in Zonguldak Bülent Ecevit University Hospital, Turkey, between April and June 2022. Term 5 Medical students (n = 111) were asked to place four different SAD [classical laryngeal mask, suprema laryngeal mask, ProSeal laryngeal mask (pLMA), I-gel] on an adult airway manikin. After the students were trained in the use of the devices, the ease of use for each, duration of successful application, success of application and use of optimization maneuvers were recorded. The participants were asked to distinguish the device they felt most confident to place and the most difficult to implement. RESULTS: There was a significant difference between the groups in ease and duration of application (p < 0.001). The most difficult and longest application time was with pLMA and the easiest and shortest was with I-gel (p < 0.05). The number of application failure was also highest for pLMA (p < 0.001). It was found that the participants distinguished (41%) I-gel as the most confident device to use, (84%) pLMA as the most difficult device to use for airway control. CONCLUSIONS: I-gel was found to be superior to others in terms of ease of use, duration and success of application.

Repeated response execution and inhibition alter subjective preferences but do not affect automatic approach and avoidance tendencies toward an object.

Background: Repeated action or inaction toward objects changes preferences for those objects. However, it remains unclear whether such training activates approach-avoidance motivation toward the objects, which leads to actual behavior. We conducted a pre-registered online experiment to examine whether approach and avoidance tendencies were affected by the experience of having executed or withheld a button-press response to a stimulus. Methods: Participants (N = 236) performed a Go/NoGo task in which they were asked to repeatedly execute a response to a picture of a mug (i.e., Go-primed stimulus) and suppress a response to another picture of a mug (i.e., NoGo-primed stimulus). They then received one of two manikin tasks, which were implicit association tests designed to assess approach-avoidance tendencies. One manikin task measured the reaction times of moving a manikin toward or away from the Go-primed stimulus and the other picture of a mug (i.e., unprimed stimulus). The other manikin task measured the reaction times of moving a manikin toward or away from the NoGo-primed stimulus and the unprimed stimulus. The participants then rated their preference for the Go-primed, NoGo-primed, and unprimed items. Results: The Go-primed item was evaluated as more highly preferable than the unprimed item in the Go condition, while the NoGo-primed item was evaluated as less preferable than the unprimed item in the NoGo condition. In contrast, the mean approach/avoidance reaction times in the manikin task showed no difference between the Go-primed and unprimed stimuli or between the NoGo-primed and unprimed stimuli. Conclusion: When participants repeatedly responded or inhibited their responses to an object, their explicit preference for the object increased or decreased, respectively. However, the effect did not occur in approach-avoidance behaviors toward the object.

Development of a new testing protocol to evaluate cooling systems.

Thermal comfort is defined as the user's sensation of thermal well-being. This sensation can be modified by extreme environmental conditions changing the body temperature of the user. Different mechanisms, the thermoregulatory system itself or an external textile system, are required to allow the body to return to their state of well-being. A cooling vest is an example of a smart garment that helps to reduce the user's body temperature in situations of heat stress. There are two different standards to evaluate the performance of this type of clothing: the ASTM F2371-16 standard that uses a thermal manikin and the ASTM F2300-10 standard that uses human subjects for the evaluation. There is a need for simple, objective and affordable tests to evaluate the thermal comfort associated with personal protective equipment use. The aim of this work is to develop a new testing method that combines a thermal manikin with a simulation software and allows to study physiological parameters of a human subject in the body of the thermal manikin.

Evaluation of compressor fatigue at 150 compressions per minute during cardiopulmonary resuscitation using a large dog manikin.

OBJECTIVE: To determine whether CPR providers can perform chest compressions (CC) appropriately at a rate of 150 compressions per minute during a 2-minute cycle and to identify the presence of rescuer fatigue. DESIGN: High fidelity simulator study. SETTING: University veterinary teaching hospital. SUBJECTS: Sixty subjects, 30 women and 30 men. INTERVENTIONS: Subjects performed CC at 150 compressions per minute on a dog manikin for 2 minutes. Real-time depth of compressions, compression release, and compression rate were measured using a CPR training device. Demographic data from the subjects were analyzed alongside data obtained from the monitoring device. MEASUREMENTS AND MAIN RESULTS: Only 38.3% of participants were able to perform CC with appropriate depth and release at 150 compressions per minute during a 2-minute cycle. There was a decay in the quality of CC between the first and the second minute. The number of compressions and percentage of compressions with correct release were similar among various genders, ages, and professions. In contrast, the percentage of compressions with correct depth was significantly higher among individuals with higher body mass index (correlation coefficient [r] = 0.293; P = 0.023) and higher biceps brachii muscle circumference during muscle contraction (r = 0.423; P = 0.001). CONCLUSIONS: This study suggests that increasing the compression rate to 150 compressions per minute in large dogs using the thoracic pump technique might not be viable because most participants were not able to sustain enough appropriate CC. Rescuer fatigue affects compression depth at this rate, leading to a decay in CPR quality.

Dental Hygiene Educators' Perspectives Towards Manikin Testing for Clinical Licensure Examination.

Purpose The use of manikin testing was recently introduced for dental hygiene licensure examinations. There is currently a lack of research about the efficacy and accuracy of manikin testing for clinical licensure. The purpose of this study is to identify perceptions of dental hygiene educators regarding the use of manikins for the dental hygiene clinical licensure exam.Methods This qualitative study used an exploratory, online, focus group design with 20 dental hygiene educator participants recruited through purposive sampling. Pseudonyms were used to protect participants confidentiality. Two groups of educators were from institutions that did not use manikin testing during COVID-19, and two groups of educators were from institutions that did use manikin testing during the same time period. Themes were analyzed using the classic analysis strategy. Validity was established using investigator triangulation, member checks, and saturation.Results Lack of knowledge including preconceived assumptions regarding manikin examinations; testing considerations with benefits and concerns regarding manikins versus live patients; and perceptions regarding the value of single point in time clinical licensure examinations were the three major themes identified by the participants.Conclusion The manikin exam appeared to address ethical concerns, however, there were limitations in relation to assessing critical thinking and decision-making skills. Some participants expressed that graduation from an accredited dental hygiene program was considered sufficient for licensure. Future studies should include comparisons of recent graduates who complete a clinical licensure examination versus those who do not complete a clinical licensure examination.

Conflict in a word-based approach-avoidance task is stronger with positive words.

BACKGROUND: Valence and motivational direction are linked. We approach good things and avoid bad things, and experience overriding these links as conflicting. Positive valence is more consistently linked with approach than negative valence is linked with avoidance. Therefore, avoiding positive stimuli should produce greater behavioral and neural signs of conflict than approaching negative stimuli. METHODS: In the present event-related potential study, we tested this assumption by contrasting positive and negative conflict. We used the manikin task, in which we read positive and negative words that they needed to approach and avoid. RESULTS: Consistent with our prediction, positive conflict prolonged reaction times more than negative conflict did. A late (500-1000 ms following word onset) event-related potential that we identified as the Conflict slow potential, was only sensitive to positive conflict. CONCLUSION: The results of this study support the notion that avoiding positive stimuli is more conflicting than approaching negative stimuli. The fact that the conflict slow potential is typically sensitive to response conflict rather than stimulus conflict suggests that the manikin task primarily requires people to override prepotent responses rather than to identify conflicting stimuli. Thus, the present findings also shed light on the psychological processes subserving conflict resolution in the manikin task.