[Career perspectives of hospital health workers after maternity and paternity leave: survey and observational study in Germany]. / Weggegangen - Platz vergangen?

OBJECTIVE: A term of maternity and paternity (parental) leave becomes frequent on the career paths of medical personnel. Hospitals are highly competitive environments. The question employees universally face is how such a leave will alter their personal work situation and prospects upon return. DESIGN AND PARTICIPANTS: We questioned 709 leave-takers and 88 department heads of a German university hospital (2009-12; full data sets: n = 406 and n = 63) about their experiences. This data was validated by epidemiology data extraction and expert interviews, also in a Swiss and in a Norwegian institution. RESULTS: Parental leave elicited high emotionality (score: 4.0 +/- 2 out of 5). Superiors' appraisal of employees' parental leave was more positive than negative (p < 0.001, mean + 0.8 +/- 0.9 on a bipolar Likert scale (BLS) from - 2 to + 2). However, the annual labor turnover in leave takers doubled to 39 %; 51 % of leave-takers experienced significant task profile changes. 58 % of doctors thought about changing their employer and 17 % of leave-taking executives lost status after return. Employees' "power" and "influence" dropped significantly (p < 0.05; determined on BLS) whereas the "professional workload" increased (p < 0.001). Consequently, after return career perspectives (measured on a bipolar visual analogue scale from - 5 to + 5) were perceived significantly more negative than positive (p < 0.0001, mean: - 1.3 +/-  2), especially by high-commitment staff (i. e. female executives, mean: - 2.1 +/- 2, pΔ < 0.05 vs. others). These perceptions significantly influenced future choices concerning further terms of leave. The Swiss and Norwegian comparators appeared to have more liberal substitution and part-time schemes than the German institution. DISCUSSION: A competitive hospital environment can effectively demote leave-taking medical employees in their jobs. Despite sufficient financial arrangements high-commitment staff will only take parental leave of adequate length when an institutional framework protects their status. Data support four requirements: 1. Formal recognition of the leave taker's status pre-leave. 2. Establishment of a written ("claimable") return policy. 3. Substitution scheme for each individual, preferably by a locum. 4. Redirection of funds to facilitate part-time work schemes temporarily after return.

Adaptation in anaesthesia team coordination in response to a simulated critical event and its relationship to clinical performance.

BACKGROUND: Recent studies in anaesthesia and intensive care indicate that a team's ability to adapt its coordination activities to changing situational demands is crucial for effective teamwork and thus, safe patient care. This study addresses the relationship between adaptation of team coordination and markers of clinical performance in response to a critical event, particularly regarding which types of coordination activities are used and which team member engages in those coordination activities. METHODS: Video recordings of 15 two-person anaesthesia teams (anaesthesia trainee plus anaesthesia nurse) performing a simulated induction of general anaesthesia were coded, using a structured observation system for coordination activities. The simulation involved a critical event-asystole during laryngoscopy. Clinical performance was assessed using two separate reaction times related to the critical event. RESULTS: Analyses of variance revealed a significant effect of the critical event on team coordination: after the occurrence of the asystole, team members adapted their coordination activities by spending more time on information management-a specific type of coordination activity (F(1,28)=15.17, P=0.001). No significant effect was found for task management. The increase in information management was related to faster decisions regarding how to respond to the critical event, but only for trainees and not for nurses. CONCLUSIONS: Our findings support the claim that adaptation of coordination activities is related to improved team performance in healthcare. Moreover, adaptation and its relationship to team performance were found to vary with regard to type of coordination activities and team member.

Adaptive coordination and heedfulness make better cockpit crews.

Team coordination during a simulated clean approach performed by 42 civil aviation cockpit crews was analysed. Several hypotheses regarding the adaptive use of implicit and explicit coordination, leadership and heedful interrelating were tested. The results indicate the adaptiveness of coordination to different levels of standardisation and task load and the general importance of explicit coordination for good performance. Leadership seems to be required mainly for work phases with little standardisation. In exploratory lag sequential analyses, heedful behaviour in the seven best and six worst performing crews was examined. The coordination sequences in high performance crews were found to be more succinct and well balanced, indicating that a shared sense of heedfulness is crucial for effectiveness. Theoretical implications for the conceptualisation of adaptive coordination and heedfulness and practical implications for improving crew training are discussed. Statement of Relevance: Analyses of team coordination during a simulated clean approach performed by civil aviation cockpit crews demonstrated the occurrence and effectiveness of adaptive coordination in response to different levels of task load and standardisation. Results also indicated the importance of heedful interrelating, both as a form of coordination and as a way of regulating the adaptiveness of coordination efforts. These findings have important implications for improving crew training, leadership practices and possibly also standard operating procedures.

The influence of standardisation and task load on team coordination patterns during anaesthesia inductions.

BACKGROUND: The use of different forms of coordination according to situational demands plays a crucial role in teams working in complex environments. This study aimed to describe patterns of coordinative actions (CAs) as they occur during anaesthesia induction and to analyse the influence of two crucial situational factors on these patterns, namely the amount of existing standards and the level of task load. METHODS: 23 anaesthesia inductions were videotaped, and CAs of the anaesthesia teams were coded. The coding system distinguished between implicit and explicit coordination, coordination via leadership and heedful inter-relating as the individual effort to reach smooth coordination. Five phases within anaesthesia inductions were determined according to their level of standardisation and task load. RESULTS: Overall, 67.7% of all CAs were rated as explicit CA and 32.3% as implicit CAs. When we considered the duration of those CAs, we found the reverse tendency (coordination was explicit 40% of the time and implicit 60% of the time). In highly standardised phases, we observed less explicit coordination, less leadership behaviour and less heedful interrelating compared with less standardised phases. In high-task-load phases, we observed more heedful interrelating than in low-task-load phases. CONCLUSIONS: The anaesthesia teams relied greatly on implicit coordination, which contrasts with findings indicating a performance benefit through explicit coordination in other work settings. Standardisation in the form of written departmental directives may have a supportive effect on coordination by partially substituting for other forms of coordination. The effect of high task load should be tested further in a simulator setting, where high task load can be induced in a more controlled fashion.

Evaluation of critical incidents in general surgery.

BACKGROUND: The analysis of adverse events is a central step in critical incident reporting, but has not been described in a surgical setting. The aim of this study was to develop an evaluation protocol and assess its feasibility. METHODS: All incidents were analysed by a multidisciplinary team. A coding system based on three published theories was used to assess all incidents and their underlying causes. A risk analysis was also conducted. RESULTS: Between July 2004 and December 2005, 9785 inpatients were treated and 139 critical incidents reported. Classification of active errors revealed 47.7 per cent to be execution failures and 45.9 per cent knowledge-based errors. The distribution of medical errors was 12.9 per cent diagnostic, 46.0 per cent treatment, 17.3 per cent preventive and 23.7 per cent other. Some 282 latent failures were identified among the 139 incidents. Risk analysis revealed a severe incident rate of 21.6 per cent. CONCLUSION: This study has shown the feasibility of an evaluation protocol based on a combination of three classification systems and a risk analysis. It allows a thorough assessment of critical incidents, identification of priorities and tailored countermeasures.

Effect of desonide ointment, 0.05%, on the hypothalamic-pituitary-adrenal axis of children with atopic dermatitis.

Desonide ointment has demonstrated a good safety and efficacy profile during the many years it has been used in treating dermatoses. However, there have been no controlled clinical trials to evaluate its systemic safety when used in treating children. Suppression of the hypothalamic-pituitary-adrenal (HPA) axis can occur after repeated application of topical corticosteroids. In general, the degree of suppression of the HPA axis function is related to the daily dosage of steroid given, the duration of its administration, the extent of body surface covered, and the potency of the corticosteroid. This study sought to determine the comparative effects of 0.05 percent desonide and 2.5 percent hydrocortisone ointments on the HPA axis of children with atopic dermatitis. There was no suppression of early morning cortisol in either treatment group. The ACTH-stimulated mean cortisol values after four weeks of treatment were not significantly different from the baseline values for either treatment group. We conclude that neither 0.05 percent desonide ointment nor 2.5 percent hydrocortisone ointment compromised the HPA axis of children with atopic dermatitis treated topically for four weeks.

Testing Behavioral Consistency and Coherence with the Situation-Response Measure of Achievement Motivation.

The Situation-Response (S-R) Measure of Achievement Motivation was developed to analyze the cross-situational consistency of achievement-related behavior. This measure was based on a conceptualization of achievement motivation that included the following three components: need to achieve, need to avoid failure, and perceived self-efficacy. Data obtained from 246 college students provided evidence for the validity of the new instrument. However, exploratory factor analyses performed on the items in the instrument indicated the presence of only two factors, namely Striving and Apprehensiveness. Regression analyses further indicated the possible inappropriateness of a theoretically-based difference score, which combined the striving and apprehensiveness composites into a resultant tendency. Confirmatory factor analysis was used to test behavioral consistency of the responses to the S-R measure. Although all of the models tested had relatively poor fits with the data, the results (a) provided evidence for item-specific covariation that inflated the cross-situational correlations among the achievement-related composites of the S-R measure, and (b) indicated, after this item-specific covariation had been partialled out, a lack of support for second-order factors representing general achieving tendencies across situations. A final set of analyses indicated the presence of three distinct types of response patterns. These types were tentatively called socially anxious, cynically motivated, and anxiously striving. It was found that membership in one of these subgroups was more informative of an individual's pattern of achievement motivation than conventionally used personality tests.