The digital divide in rural and regional communities: a survey on the use of digital health technology and implications for supporting technology use.

OBJECTIVE: A digital divide exists for people from rural and regional areas where they are less likely and confident to engage in digital health technologies. The aim of this study was to evaluate the digital health literacy and engagement of people from rural and regional communities, with a focus on identifying barriers and facilitators to using technology. RESULTS: Forty adults living in rural/regional areas completed a survey consisting of the eHealth Literacy Scale (eHEALS) with additional items surveying participants' experience with a range of digital health technologies. All participants had used at least one digital health technology. Most (80%) participants had an eHEALS score of 26 or above indicating confidence in online health information. Commonly reported barriers to digital health technology use centred on product complexity and reliability, awareness of resources, lack of trust, and cost. Effective digital health technology use is becoming increasingly important, there may be a need to prioritise and support people with lower levels of digital health literacy. We present opportunities to support community members in using and accessing digital health technology.

Understanding nursing perceptions of intravenous fluid management practices.

PURPOSE: Intravenous (IV) fluids are routinely used in hospitalized patients. As IV fluids are an everyday occurrence, their importance is often overlooked. Many patients receive large volumes of fluid during resuscitation to aid in the promotion of tissue perfusion. Nurses regularly administer IV fluids as part of maintenance infusions or as life-saving therapies and, therefore, need to understand these fluids' impact on their patients. Understanding nurses' existing perceptions of IV fluid management practices are crucial to improving practice. METHODS: This study used an online survey to gather information on nursing perceptions of IV fluids. Four hundred and sixty-two Canadian nurses from diverse backgrounds were surveyed, including registered nurses, licensed practical nurses and student nurses. RESULTS: The study found that the majority of participants agreed that IV fluids, including type, amount, and rationale for infusion, were important. They also agreed that fluids could impact patient outcomes. However, the study found that, despite recognizing the value and importance of fluid management, many nurses struggled with recognizing how to determine a patient's fluid status versus fluid responsiveness. CONCLUSION: This study supports improving nursing education to understand better the differences between fluid volume status and volume responsiveness. Our study also provides evidence that nurses need access to more sophisticated tools to conduct dynamic assessments and better meet patients' needs.

When chronic critical illness is a family affair: A multi-perspective qualitative study of family involvement in long-term care.

OBJECTIVE: Those with chronic critical illness (CCI) remain dependent on life-sustaining treatments and increasingly reside in long-term care facilities equipped to meet their needs. The nature of family involvement in care remains undetermined thwarting approaches to mitigate poor family outcomes. The research objective was to explicate family involvement in the care of an individual with CCI who resides in long-term care. METHODS: In this qualitative research, we used thematic analysis and constant comparative techniques to analyze data from interviews with 38 participants: 11 family members, 6 residents with CCI, and 21 healthcare providers. RESULTS: Involvement in care entailed family: (1) reorienting their life despite the stress and emotional toll; (2) assuming responsibility for meaningful activities and management of practical matters, yet struggling alone; (3) advocating for care by being present, reminding and pushing, and picking their battles; and (4) figuring out how to contribute to nursing care, but with unclear expectations. DISCUSSION: The burden of family caregiving was substantial, contrasting the assumption that family are relieved of their caregiver responsibilities when the patient with CCI is in a care facility. Research to address unmet family needs specific to their roles and responsibilities could potentially improve family outcomes and is warranted.

The mental health impact of the COVID-19 pandemic on Canadian critical care nurses.

OBJECTIVE: Focusing on Canadian critical care nurses (CCNs), the study objectives were to examine the impact of the COVID-19 pandemic on: mental health, quality of work life, and intent to stay in their current positions. RESEARCH DESIGN: Mixed-methods study using an online cross-sectional survey and integration of closed- and open-ended survey data. SETTING: Canadian CCNs working in an intensive care unit, high acuity unit, or intensive care step-down unit during the COVID-19 pandemic between May 2021 to June 2021. MAIN OUTCOME MEASURES: The survey consisted of four instruments: (1) the impact of event scale - revised, (2) the depression, anxiety, and stress scale, (3) the professional quality of life scale, and (4) intent to turnover tool, as well as one optional open-ended question. RESULTS: From across Canada, 425 CCNs responded. The large majority reported symptoms of post traumatic stress disorder (74%), depression (70%), anxiety (57%), and stress (61%). All (100%) reported moderate to high burnout, 87% were suffering from signs of secondary traumatic stress, and 22% intended to quit their current employment. Qualitative analysis of written comments submitted by 147 (34.5%) of the respondents depicted an immense mental health toll on CCNs that stemmed from 1) failed leadership and 2) the traumatic nature of the work environment, that led to 3) a sense of disillusionment, defeat, and an intent to leave. CONCLUSION: The mental health toll of the pandemic has been significant for Canadian CCNs and highlights the urgent need for individual supports and systems level changes.

Coping with Covid-19: stress, control and coping among pregnant women in Ireland during the Covid-19 pandemic.

BACKGROUND: The aim of the current study is to investigate the relationship between perceived control, coping and psychological distress among pregnant women in Ireland during the Covid-19 pandemic. It is hypothesised that lower levels of perceived control, greater use of avoidant coping and greater Covid-19 related pregnancy concern will be associated with psychological distress. In addition, it is hypothesised that the relationship between Covid-19 related pregnancy concern and psychological distress will be moderated by perceived control and avoidant coping. METHOD: The study is cross-sectional, utilizing an online questionnaire, which was completed by 761 women in January 2021. The questionnaire includes measures of perceived control, coping style, perceived stress, anxiety and depression. RESULTS: Correlation analyses found that lower levels of perceived control were associated with higher levels of avoidant coping and psychological distress. There was also a significant positive relationship between avoidant coping and psychological distress. Using multiple regression, perceived control, avoidant coping and Covid-19 related pregnancy concern were found to predict 51% of the variance in psychological distress. However, in the moderation analysis, perceived control and avoidant coping were not found to moderate the relationship between Covid-19 related pregnancy concern and psychological distress. CONCLUSION: The results from this study suggest that pregnant women in Ireland are experiencing increased levels of psychological distress during the Covid-19 pandemic. The findings also suggest that perceptions of control and avoidant coping are associated with psychological distress in this group and could be used as intervention targets.

Impact of restricted visitation policies in hospitals on patients, family members and healthcare providers during the COVID-19 pandemic: a scoping review protocol.

INTRODUCTION: Flexible visitation policies in hospitals are an important component of care that contributes to reduced stress and increased satisfaction among patients and their family members. Early evidence suggests restricted visitation policies enacted in hospitals during the COVID-19 pandemic are having unintended consequences on patients, family members and healthcare providers. There is a need for a comprehensive summary of the impacts of restricted visitation policies on key stakeholders and approaches to mitigate that impact. METHODS AND ANALYSIS: We will conduct a scoping review as per the Arksey-O'Malley 5-stage scoping review method and the Scoping Review Methods Manual by the Joanna Briggs Institute. We will search relevant electronic databases (eg, CINAHL, MEDLINE, PsycINFO), grey literature and preprint repositories. We will include all study designs including qualitative and quantitative methodologies (excluding protocols) as well as reports, opinions and editorials, to identify the broad impact of restricted hospital visitation policies due to the COVID-19 pandemic on patients, family members or healthcare providers of hospitalised patients, and approaches taken or proposed to mitigate this impact. Two reviewers will calibrate the screening criteria and data abstraction form and will independently screen studies and abstract the data. Narrative synthesis with thematic analysis will be performed. ETHICS AND DISSEMINATION: Ethical approval is not applicable as this review will be conducted on published literature only. This scoping review will identify, describe and categorise impacts of restricted hospital visitation policies due to the COVID-19 pandemic on patients, family members and healthcare providers of hospitalised patients, and approaches that have been taken to mitigate impact. We will provide a comprehensive synthesis by developing a framework of restricted visitation policies and associated impacts. Our results will inform the development of consensus statements on restricted visitation policies to be implemented in future pandemics. PROSPERO REGISTRATION NUMBER: CRD42020221662.

Attending to Methodological Challenges in Qualitative Research to Foster Participation of Individuals with Chronic Critical Illness and Communication Impairments.

Individuals with chronic critical illness experience multiple complex physiological disturbances including ongoing respiratory failure, requiring prolonged mechanical ventilation, and thus communication impairments. In conducting a qualitative interpretive description study, we sought to ensure that individuals with chronic critical illness themselves were included as participants. Our commitment to recruiting these individuals to the study and ensuring their data meaningfully informed the analysis and findings required us to reconsider and challenge some of the traditional notions of high-quality qualitative research and develop appropriate practical strategies. These strategies included: (1) centering participant abilities and preferences, (2) adopting a flexible approach to conducting interviews, (3) engaging in a therapeutic relationship, and (4) valuing "thin" data. In this article, we extend existing literature describing the complexities of conducting research with individuals with communication impairments and strategies to consider in the hopes of informing future research with other populations historically excluded from study participation.

Health-related expectations of the chronically critically ill: a multi-perspective qualitative study.

BACKGROUND: Those who survive critical illness only to become chronically critically ill (CCI) experience a high symptom burden, repeat episodes of illness exacerbation, communication barriers, and poor health outcomes. Yet, it is unclear how CCI individuals and their family understand their health and the importance of prognostic information following hospitalization. The research purpose was to examine expectations about health and disease prognosis of CCI residents in long-term care from the perspectives of the CCI themselves and their family members, as well as to describe healthcare provider (HCP) interpretations of, and reactions to, these health-related expectations. METHODS: In this qualitative interpretive descriptive study, conducted in British Columbia, Canada, 38 semi-structured interviews were conducted (6 CCI residents, 11 family members, and 21 HCPs) and inductively analyzed using thematic and constant comparative techniques. RESULTS: There was divergence in CCI resident, family and HCP expectations about health and the importance of disease prognosis, which contributed to conflict. CCI residents and family viewed conflict with HCPs in relation to their day-to-day care needs, while HCPs viewed this as arising from the unrealistically high expectations of residents and family. The CCI residents and family focussed on the importance of maintaining hope, and the HCPs highlighted the complexity of end-of-life decisions in conjunction with the high expectations and hopes of family. CONCLUSIONS: The emotional and ongoing process of formulating health-related expectations points to the need for future research to inform the development and/or adapting of existing communication, psychosocial and health services interventions to ease the burden experienced by those who are CCI.

The effect of COVID-19 pandemic on the mental health of Canadian critical care nurses providing patient care during the early phase pandemic: A mixed method study.

BACKGROUND: Healthcare workers have historically experienced symptoms of post-traumatic stress disorder, depression and anxiety with previous infectious outbreaks. It is unknown if critical care nurses have similar experiences. OBJECTIVES: The study aimed to examine the mental health of Critical Care Registered Nurses providing direct patient care during the initial phase of the COVID-19 pandemic in Canada. DESIGN: This was a convergent parallel mixed method study utilizing validated questionnaires and semi-structured qualitative interviews. SETTING: Critical care units in a single large 650 bed academic teaching hospital in western Canada. The critical care units serve a general mixed medical - surgical adult patient population. PARTICIPANTS: Critical Care Registered Nurses providing direct patient care in the intensive care and high acuity units at the designated site. METHODS: 109 participants completed two self-reported validated surveys, the Impact of Events Scale - Revised and the Depression, Anxiety and Stress Scale. 15 participants completed one-on-one semi-structured interviews that were analyzed using inductive thematic analysis. RESULTS: In the surveys, the participants reported clinical concern for (23%), probable (13%) and significant (38%) symptoms of post-traumatic stress disorder, as well as mild to severe depression (57%), anxiety (67%) and stress (54%). In the interviews, psychological distress was described as anxiety, worry, distress and fear related to: 1) rapidly changing policy and information, 2) overwhelming and unclear communication, 3) meeting patient care needs in new ways while staying safe, and 4) managing home and personal commitments to self and family. CONCLUSIONS: Critical care nurses experienced psychological distress associated with providing care to COVID-19 patients during the early phases of the pandemic.

Sources of Distress for Residents With Chronic Critical Illness and Ventilator Dependence in Long-Term Care.

Limited understanding of the psychological challenges experienced by individuals with chronic critical illness hampers efforts to deliver quality care. We used an interpretive description approach to explore sources of distress for individuals with chronic critical illness in residential care, wherein we interviewed six residents, 11 family members, and 21 staff. Rather than discuss physical symptoms, sources of distress for residents were connected to feeling as though they were a patient receiving medical care as opposed to an individual living in their home. The tension between medical care and the unmet need for a sense of home was related to care beyond the physical being overlooked, being dependent on others but feeling neglected, frustration with limited choice and participation in decision making, and feeling sad and alone. Efforts to refine health care for individuals with chronic critical illness must foster a sense of home while ensuring individuals feel safe and supported to make decisions.

Prone Position after Liberation from Prolonged Mechanical Ventilation in COVID-19 Respiratory Failure.

DESIGN: This is a retrospective case series describing the feasibility and tolerability of postextubation prone positioning (PEPP) and its impact on physiologic parameters in a tertiary intensive care unit during the COVID-19 pandemic. Setting and Patients. This study was conducted on patients with COVID-19 respiratory failure hospitalized in a tertiary Intensive Care Unit at Surrey Memorial Hospital during the COVID-19 pandemic. Measurements and Results. We did not find prior reports of PEPP following prolonged intubation in the literature. Four patients underwent a total of 13 PEPP sessions following liberation from prolonged mechanical ventilation. Each patient underwent a median of 3 prone sessions (IQR: 2, 4.25) lasting a median of 1.5 hours (IQR: 1.2, 2.1). PEPP sessions were associated with a reduction in median oxygen requirements, patient respiratory rate, and reintubation rate. The sessions were well tolerated by patients, nursing, and the allied health team. CONCLUSIONS: The novel practice of PEPP after liberation from prolonged mechanical ventilation in patients with COVID-19 respiratory failure is feasible and well tolerated, and may be associated with favourable clinical outcomes including improvement in oxygenation and respiratory rate and a low rate of reintubation. Larger prospective studies of PEPP are warranted.

Caractéristiques de départ et issues chez des patients atteints de COVID-19 hospitalisés dans des unités de soins intensifs à Vancouver (Canada) : série de cas.

CONTEXTE: La pandémie de maladie à coronavirus du syndrome respiratoire aigu sévère 2 (SRAS-CoV-2) est associée à une mortalité élevée dans les unités de soins intensifs (USI). Nous avons voulu décrire les caractéristiques cliniques et les issues des patients gravement atteints de la maladie à coronavirus 2019 (COVID-19) en contexte canadien. MÉTHODES: Nous avons procédé à l'étude rétrospective d'une série de cas graves d'infection au SRAS-CoV-2 confirmée en laboratoire hospitalisés dans l'une des 6 USI du Vancouver métropolitain, en Colombie-Britannique (Canada), entre le 21 février et le 14 avril 2020. Les données démographiques, les renseignements sur la prise en charge et les résultats ont été recueillis à partir des dossiers médicaux, électroniques ou non, des patients. RÉSULTATS: Entre le 21 février et le 14 avril 2020, 117 patients ont été admis dans une USI avec un diagnostic confirmé de COVID-19. L'âge médian était de 69 ans (écart interquartile [EI] 60­75 ans); et 38 (32,5 %) étaient des femmes. Au moins une comorbidité était présente chez 86 patients (73,5 %). La ventilation mécanique a été nécessaire chez 74 patients (63,2 %). La durée de la ventilation mécanique a été de 13,5 jours (EI 8­22 jours) dans l'ensemble et de 11 jours (II 6­16) chez les patients qui ont reçu leur congé de l'USI. Du tocilizumab a été administré à 4 patients et de l'hydroxychloroquine à 1 patient. En date du 5 mai 2020, 18 patients (15,4 %) étaient décédés, 12 (10,3 %) étaient toujours à l'USI, 16 (13,7 %) avaient obtenu leur congé de l'USI, mais restaient hospitalisés, et 71 (60,7 %) avaient pu retourner à la maison. INTERPRÉTATION: Dans cette étude, la mortalité chez les patients gravement malades de la COVID-19 hospitalisés dans une USI a été moins élevée que chez les patients d'études précédentes. Ces résultats donnent à penser que le pronostic des cas graves de COVID-19 pourrait ne pas être aussi sombre que ce qui avait d'abord été rapporté.

Baseline characteristics and outcomes of patients with COVID-19 admitted to intensive care units in Vancouver, Canada: a case series.

BACKGROUND: Pandemic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with high intensive care unit (ICU) mortality. We aimed to describe the clinical characteristics and outcomes of critically ill patients with coronavirus disease 2019 (COVID-19) in a Canadian setting. METHODS: We conducted a retrospective case series of critically ill patients with laboratory-confirmed SARS-CoV-2 infection consecutively admitted to 1 of 6 ICUs in Metro Vancouver, British Columbia, Canada, between Feb. 21 and Apr. 14, 2020. Demographic, management and outcome data were collected by review of patient charts and electronic medical records. RESULTS: Between Feb. 21 and Apr. 14, 2020, 117 patients were admitted to the ICU with a confirmed diagnosis of COVID-19. The median age was 69 (interquartile range [IQR] 60-75) years, and 38 (32.5%) were female. At least 1 comorbidity was present in 86 (73.5%) patients. Invasive mechanical ventilation was required in 74 (63.2%) patients. The duration of mechanical ventilation was 13.5 (IQR 8-22) days overall and 11 (IQR 6-16) days for patients successfully discharged from the ICU. Tocilizumab was administered to 4 patients and hydroxychloroquine to 1 patient. As of May 5, 2020, a total of 18 (15.4%) patients had died, 12 (10.3%) remained in the ICU, 16 (13.7%) were discharged from the ICU but remained in hospital, and 71 (60.7%) were discharged home. INTERPRETATION: In our setting, mortality in critically ill patients with COVID-19 admitted to the ICU was lower than in previously published studies. These data suggest that the prognosis associated with critical illness due to COVID-19 may not be as poor as previously reported.

Health solutions to improve post-intensive care outcomes: a realist review protocol.

BACKGROUND: While 80% of critically ill patients treated in an intensive care unit (ICU) will survive, survivors often suffer a constellation of new or worsening physical, cognitive, and psychiatric complications, termed post-intensive care syndrome. Emerging evidence paints a challenging picture of complex, long-term complications that are often untreated and culminate in substantial dependence on acute care services. Clinicians and decision-makers in the Fraser Health Authority of British Columbia are working to develop evidence-based community healthcare solutions that will be successful in the context of existing healthcare services. The objective of the proposed review is to provide the theoretical scaffolding to transform the care of survivors of critical illness by a synthesis of relevant clinical and healthcare service programs. METHODS: Realist review will be used to develop and refine a theoretical understanding of why, how, for whom, and in what circumstances post-ICU program impact ICU survivors' outcomes. This review will follow the recommended five steps of realist review which include (1) clarifying the scope of the review and articulating a preliminary program theory, (2) searching for evidence, (3) appraising primary studies and extracting data, (4) synthesizing evidence and sharing conclusions, and (5) disseminating and implementing recommendations. DISCUSSION: This realist review will provide a program theory, encompassing the contexts, mechanisms, and outcomes, to explain how clinical and health service interventions to improve ICU survivor outcomes operate in different contexts for different survivors, and with what effect. This review will be an evidentiary pillar for health service development and implementation by our knowledge user team members as well as advance scholarly knowledge relevant nationally and internationally. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018087795.

Frailty in Critical Care: Examining Implications for Clinical Practices.

Frailty is an aging-related, multisystem clinical state characterized by loss of physiological reserves and diminished capacity to withstand exposure to stressors. Frailty increases the risk of serious adverse outcomes, compared with that of nonfrail people of the same age. Adverse outcomes can be severe and may include procedural complications, delirium, significant functional decline and disability, prolonged hospital length of stay, extended recovery periods, and death. As older adults make up a continually growing proportion of hospitalized patients, critical care nurses need to understand how to recognize frailty and be familiar with related clinical practice implications. Such knowledge underpins effective organization and delivery of care strategies aimed at minimizing harm and maximizing positive outcomes for frail older adults. Drawing from recent literature, this article explores frailty and critical illness by discussing 2 dominant models of the concept. Using a clinical case study, links between frailty and critical care nursing practices are highlighted and clinical considerations are explored.

The impact of simulation based education on nursing confidence, knowledge and patient outcomes on general medicine units.

The ability to quickly and reliably detect a clinically deteriorating patient and intervene appropriately is a skill nurses are expected to bring into practice. Simulation education has been shown to improve nurses' knowledge, confidence and communication, especially when focused on deteriorating patients. In a simulation center at a large tertiary level Canadian teaching hospital, a 4 h simulation based education session was developed for general medicine nursing staff. The education included a didactic lecture followed by four 40 min simulation scenarios focused on deteriorating patient. This study was designed as a pre- and post-analytic design. It utilized a paper based survey completed at three separate time points to measure confidence and knowledge. The study also examined data from the Critical Care Outreach nurse audits and site code blue audit data. Results demonstrated statistically significant improvements in nursing confidence and knowledge, and were sustained over the three month follow-up period.

Understanding the factors which promote registered nurses' intent to stay in emergency and critical care areas.

AIMS AND OBJECTIVE: To explore the influential factors and strategies that promote an experienced nurse's intent to stay in their emergency or critical care area. BACKGROUND: Turnover among registered nurses (herein referred to as nurses) working in specialty areas of practice can result in a range of negative outcomes. The retention of specialty nurses at the unit level has important implications for hospital and health systems. These implications include lost knowledge and experience which may in turn impact staff performance levels, patient outcomes, hiring, orientating, development of clinical competence and other aspects of organizational performance. DESIGN: This qualitative study used an interpretive descriptive design to understand nurses' perceptions of the current factors and strategies that promote them staying in emergency or critical care settings for two or more years. METHODS: Focus groups were conducted with 13 emergency and critical care nurses. Data analysis involved thematic analysis that evolved from codes to categories to themes. RESULTS: Four themes were identified: leadership, interprofessional relationships, job fit and practice environment. In addition, the ideas of feeling valued, respected and acknowledged were woven throughout. CONCLUSIONS: Factors often associated with nurse attrition such as burnout and job stresses were not emphasised by the respondents in our study as critical to their intent to stay in their area of practice. This study has highlighted positive aspects that motivate nurses to stay in their specialty areas. RELEVANCE TO CLINICAL PRACTICE: To ensure quality care for patients, retention of experienced emergency and critical care nurses is essential to maintaining specialty expertise in these practice settings.

The Genetic Basis of Natural Variation in Drosophila (Diptera: Drosophilidae) Virgin Egg Retention.

Drosophila melanogaster is able to thrive in harsh northern climates through adaptations in life-history traits and physiological mechanisms that allow for survival through the winter. We examined the genetic basis of natural variation in one such trait, female virgin egg retention, which was previously shown to vary clinally and seasonally. To further our understanding of the genetic basis and evolution of virgin egg retention, we performed a genome-wide association study (GWAS) using the previously sequenced Drosophila Genetic Reference Panel (DGRP) mapping population. We found 29 single nucleotide polymorphisms (SNPs) associated with virgin egg retention and assayed 6 available mutant lines, each harboring a mutation in a candidate gene, for effects on egg retention time. We found that four out of the six mutant lines had defects in egg retention time as compared with the respective controls: mun, T48, Mes-4, and Klp67A Surprisingly, none of these genes has a recognized role in ovulation control, but three of the four genes have known effects on fertility or have high expression in the ovaries. We also found that the SNP set associated with egg retention time was enriched for clinal SNPs. The majority of clinal SNPs had alleles associated with longer egg retention present at higher frequencies in higher latitudes. Our results support previous studies that show higher frequency of long retention times at higher latitude, providing evidence for the adaptive value of virgin egg-retention.

End-of-life care in the ICU: Supporting nurses to provide high-quality care.

ICU care has traditionally focused on curative treatment, but making the decision to withdraw life-sustaining therapies, the there is an increasing awareness of the key role palliative and barriers to providing good end-of-life care, factors that support comfort care play. Through a review of recent literature on end- good end-of-life care, and specific guidelinesfor the withdrawal of-life care and withdrawal of life-sustaining therapies in the of life-sustaining therapies. Using this information, a checklist to intensive care unit, four themes have emerged: the challenges of support end-of-life care by critical care nurses was created.

Learning to keep your cool: reducing aggression through the experimental modification of cognitive control.

Prior research suggests that recruiting cognitive control resources following exposure to hostile stimuli may allow individuals to more effectively override their aggressive urges. In the current study, a cognitive modification procedure was developed to encourage participants to perform this cognitive operation. It successfully encouraged cognitive control recruitment following hostile primes. More importantly, this procedure allowed individuals prone to hostile attributions to override their aggressive urges. Interestingly, it also led to a slight increase in aggression at low levels of hostile attributions. Discussion focused on theoretical and practical implications of the hypothesised effect, as well as possible explanations for the non-hypothesised effect.