Nurses' cognitive and perceptual bias in the identification of clinical deterioration cues.

BACKGROUND: Perception and processing of clinical cues have rarely been investigated in the nursing literature despite their relevance to the early identification and management of clinical deterioration. AIM: This study used a hypovolemic shock scenario from the Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST2ACT) virtual simulation program, equipped with an eye tracker, to investigate cue processing during the management of patient deterioration. RESULT: The study revealed that attention deviation distorted interpretation of subsequent cues, causing 63% of participants to exhibit a cognitive bias (heightened sensitivity to specific but noncritical cues) and 65% to exhibit at least one episode of nonfixation on clinically relevant cues. Attention deviation and distorted interpretations of clinical cues will have an impact on patient safety. CONCLUSION: The findings are likely to have important implications for understanding error and associated training implications.

Video strategies improved health professional knowledge across different contexts: a helix counterbalanced randomized controlled study.

OBJECTIVE: This study aimed to apply a novel helix counterbalanced randomized controlled trial design to evaluate the effectiveness of video vs. written knowledge translation strategies for improving health professional knowledge of evidence provided in scientific journal articles. STUDY DESIGN AND SETTING: A Helix counterbalanced randomized controlled trial was used to compare the impact of delivering research information via video or written modalities compared to a no-information control across three health contexts. Interventions were delivered and data collected via an online survey to nursing and allied health professionals across five hospitals within a public health service in Melbourne, Australia. A knowledge test measuring alignment between respondent perceived benefit of the intervention and conclusions listed in the journal article was the primary outcome. RESULTS: There were 119 participants recruited with n = 13 incomplete responses. Exposure to the video increased the likelihood of a knowledge test response that was aligned with the research evidence compared to the no-information control (OR 2.61; 95% CI 1.40, 4.89; P = 0.003), but this was not the case for exposure to the written modality (OR 1.39; 95% CI 0.75, 2.57; P = 0.294). CONCLUSION: Providing video knowledge translation strategies to nursing and allied health professionals increases the likelihood they will understand the main findings from scientific journal articles.

Emotional Awareness and Decision-Making in the Context of Computer-Mediated Psychotherapy.

Emotional awareness has been previously investigated among clinicians. In this work, we bring to the fore of research the interest to uncover emotional awareness of clinicians during the tele-mental health session. The study reported here aimed at determining whether clinicians process their own emotions, as well as those of the client, in a computer-mediated context. Also, clinicians' decision-making process was assessed because such action appears to be related to the way they feel and recognise how those emotions may change their thinking and impact their interaction with clients. We estimated that such ability in clinicians' would be contrasted when the psychotherapy-session level is conducted via various technologies. Participant of the study were presented by stimuli in different modes of delivery (e.g. text, audio, and video). The experiment indicates that the ability to manage, perceive, and utilise emotions was as being satisfactory during all modes of delivery. In essence, the findings contribute to the field of remote therapy suggesting emotional awareness as a key cognitive factor in diagnosis.

Clinical deterioration of ward patients in the presence of antecedents: A systematic review and narrative synthesis.

AIM: The aim of this review was to identify and synthesise published accounts of recognising and responding to patient deterioration in the presence of deterioration antecedents. DESIGN: The systematic review canvassed four electronic databases/search engines for studies of adult ward patients who had altered physiological parameters before developing major adverse events. SYNTHESIS METHODS: The findings were synthesised using a narrative approach. RESULTS: Clinical deterioration can be missed by nurses, even with adequate charting. Delays in recognising and responding to patient deterioration remains an international patient safety concern, and strategies to enhance recognition of patient deterioration have not achieved consistent improvements. The lack of significant and sustained improvement through targeted training suggests the problem may be rooted in human behaviour and local ward culture. Nurses play a pivotal role in recognising and responding to patient deterioration; however, patient records do not facilitate tracking of all nurse decisions and actions, and any undocumented care cannot be easily captured by auditing processes. CONCLUSION: Failure to recognise clinical deterioration was evident even with adequate charting. It is not clear if nurses do not recognise clinical deterioration because they failed to interpret the signs of deterioration or they made a conscious decision not to escalate based on their clinical judgement or they lacked attention at the time of the event. Whatever the reason, focus is warranted for nurses' decision-making after the recording of clinical deterioration signs and the role of human factors in delayed recognition, before maximum benefit of any strategy can be achieved.

Simulated versus traditional occupational therapy placements: A randomised controlled trial.

BACKGROUND/AIM: Professional practise placements in occupational therapy education are critical to ensuring graduate competence. Australian occupational therapy accreditation standards allow up to 200 of a mandated 1000 placement hours to include simulation-based learning. There is, however, minimal evidence about the effectiveness of simulation-based placements compared to traditional placements in occupational therapy. We evaluated whether occupational therapy students completing a 40 hour (one week block) Simulated Clinical Placement (SCP) attained non-inferior learning outcomes to students attending a 40 hour Traditional Clinical Placement (TCP). METHODS: A pragmatic, non-inferiority, assessor-blinded, multicentre, randomised controlled trial involving students from six Australian universities was conducted. Statistical power analysis estimated a required sample of 425. Concealed random allocation was undertaken with a 1:1 ratio within each university. Students were assigned to SCP or TCP in one of three settings: vocational rehabilitation, mental health or physical rehabilitation. SCP materials were developed, manualised and staff training provided. TCPs were in equivalent practice areas. Outcomes were assessed using a standardised examination, unit grades, the Student Practice Evaluation Form-Revised and student confidence survey. A generalised estimating equation approach was used to assess non-inferiority of the SCP to the TCP. RESULTS: Of 570 randomised students (84% female), 275 attended the SCP and 265 the TCP (n = 540, 94.7% retention). There were no significant differences between the TCP and SCP on (i) examination results (marginal mean difference 1.85, 95% CI: 0.46-3.24; P = 0.087); (ii) unit score (mean (SD) SCP: 71.9 (8.8), TCP: 70.34 (9.1); P = 0.066); or (iii) placement fail rate, assessed using the Student Practice Evaluation Form-Revised (100% passed both groups). CONCLUSION: Students can achieve equivalent learning outcomes in a 40 hour simulated placement to those achieved in a 40 hour traditional placement. These findings provide assurance to students, educators and professional accreditation bodies that simulation can be embedded in occupational therapy education with good effect.

Inattentional blindness and pattern-matching failure: The case of failure to recognize clinical cues.

Eye-tracking methodology was used to investigate lapses in the appropriate treatment of ward patients due to not noticing critical cues of deterioration. Forty nursing participants with different levels of experience participated in an interactive screen-based simulation of hypovolemic shock. The results show that 65% of the participants exhibited at least one episode of non-fixation on clinically relevant, fully visible cues that were in plain sight. Thirty-five percent of participants dwelt for sufficient time (>200 ms) on important cues for perception to take place, but no action followed, indicating they had pattern-matching failure. When participants fail to notice what, they should notice in patient status until it is too late, this can have serious consequences. Much work needs to be done, since these human perceptual limitations can affect patient safety in general wards.

Effectiveness and cost-effectiveness of embedded simulation in occupational therapy clinical practice education: study protocol for a randomised controlled trial.

BACKGROUND: Clinical placements are a critical component of the training for health professionals such as occupational therapists. However, with growing student enrolments in professional education courses and workload pressures on practitioners, it is increasingly difficult to find sufficient, suitable placements that satisfy program accreditation requirements. The professional accrediting body for occupational therapy in Australia allows up to 200 of the mandatory 1000 clinical placement hours to be completed via simulation activities, but evidence of effectiveness and efficiency for student learning outcomes is lacking. Increasingly placement providers charge a fee to host students, leading educators to consider whether providing an internal program might be a feasible alternative for a portion of placement hours. Economic analysis of the incremental costs and benefits of providing a traditional versus simulated placement is required to inform decision-making. METHODS/DESIGN: This study is a pragmatic, non-inferiority, single-blind, multicentre, two-group randomised controlled trial (RCT) with an embedded economic analysis. The RCT will compare a block of 40 hours of simulated placement (intervention) with a 40-hour block of traditional placement (comparator), with a focus on student learning outcomes and delivery costs. Six universities will instigate the educational intervention within their respective occupational therapy courses, randomly assigning their cohort of students (1:1 allocation) to the simulated or traditional clinical placements. The primary outcome is achievement of professional behaviours (e.g. communication, clinical reasoning) as assessed by a post-placement written examination. Secondary outcomes include proportions passing the placement assessed using the Student Practice Evaluation Form-Revised, changes in student confidence pre-/post-placement, student and educator evaluation of the placement experience and cost-effectiveness of simulated versus traditional clinical placements. Comprehensive cost data will be collected for both the simulated and traditional placement programs at each site for economic evaluation. DISCUSSION: Use of simulation in health-related fields like occupational therapy is common, but these activities usually relate to brief opportunities for isolated skill development. The simulated clinical placement evaluated in this trial is less common because it encapsulates a 5-day block of integrated activities, designed and delivered in a manner intended to emulate best-practice placement experiences. The planned study is rare due to inclusion of an economic analysis that aims to provide valuable information about the relationship between costs and outcomes across participating sites. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12616001339448 . Registered 26 September 2016.

Measuring teamwork performance: Validity testing of the Team Emergency Assessment Measure (TEAM) with clinical resuscitation teams.

AIM: To test the resuscitation non-technical Team Emergency Assessment Measure (TEAM) for feasibility, validity and reliability, in two Australian Emergency Departments (ED). BACKGROUND: Non-technical (teamwork) skills have been identified as inadequate and as such have a significant impact on patient safety. Valid and reliable teamwork assessment tools are an important element of performance assessment and debriefing processes. METHODS: A quasi experimental design based on observational ratings of resuscitation non-technical skills in two metropolitan ED. Senior nursing staff rated 106 adult resuscitation team events over a ten month period where three or more resuscitation team members attended. Resuscitation events, team performance and validity and reliability data was collected for the TEAM. RESULTS: Most rated events were for full cardiac resuscitation (43%) with 3-15 team members present for an average of 45 min. The TEAM was found to be feasible and quickly completed with minimal or no training. Discriminant validity was good as was internal consistency with a Cronbach alpha of 0.94. Uni-dimensional and concurrent validity also reached acceptable standards, 0.94 and >0.63 (p=<0.001), respectively, and a single 'teamwork' construct was identified. Non-technical skills overall were good but leadership was rated notably lower than task and teamwork performance indicating a need for leadership training. CONCLUSION: The TEAM is a feasible, valid and reliable non-technical assessment measure in simulated and real clinical settings. Emergency teams need to develop leadership skills through training and reflective debriefing.

Can you tickle yourself if you swap bodies with someone else?

The effect of the body transfer illusion on the perceived strength of self- and externally-generated "tickle" sensations was investigated. As expected, externally generated movement produced significantly higher ratings of tickliness than those associated with self-generated movements. Surprisingly, the body transfer illusion had no influence on the ratings of tickliness, suggesting that highly surprising, and therefore hard to predict, experiences of body image and first-person perspective do not abolish the attenuation of tickle sensations. In addition, evidence was found that a version of the rubber hand illusion exists within the body transfer illusion. We situate our findings within the larger debate over sensory attenuation: (1) there is an attenuation of prediction errors that depends upon the context in which sensory input is predicted (i.e., efference copy), and (2) sensory attenuation is a necessary consequence of self-generated movement irrespective of context (i.e., active inference). The results support the notion of active inference.

Population based case-control study of serious non-fatal motorcycle crashes.

BACKGROUND: Motorcycle sales, registration and use are increasing in many countries. The epidemiological literature on risk factors for motorcycle injury is becoming outdated, due to changes in rider demography, licensing regulations, traffic mix and density, road environments, and motorcycle designs and technologies. Further, the potential contribution of road infrastructure and travel speed has not yet been examined. METHODS/DESIGN: A population based case-control study together with a nested case-crossover study is planned. Cases will be motorcycle riders who are injured but not killed in a motorcycle crash on a public road within 150 km radius of Melbourne, Australia, and admitted to one of the study hospitals. Controls will be motorcycle riders who ride through the crash site on the same type of day (weekday or weekend) within an hour of the crash time. Data on rider, bike, and trip characteristics will be collected from the participants by questionnaire. Data on crash site characteristics will be collected in a structured site inspection, and travel speed for the cases will be estimated from these data. Travel speed for the controls will be measured prior to recruitment with a radar traffic detection device as they ride through the crash site. Control sites for the case-crossover study will be selected 1 km upstream from the crash site and matched on either intersection status or road curvature (either straight or cornered). If the initial site selected does not match the case site on these characteristics, then the closest matching site on the case route will be selected. Conditional multivariate logistic regression models will be used to compare risk between the matched case and control riders and to examine associations between road infrastructure and road environment characteristics and crash occurrence. Interactions between type of site and speed will be tested to determine if site type is an effect modifier of the relationship between speed and crash risk. The relationship between rider factors and travel speed generally will be assessed by multivariate regression methods. DISCUSSION: In the context of the changing motorcycling environment, this study will provide evidence on contemporary risk factors for serious non-fatal motorcycle crashes.

Touch can be as accurate as passively-guided kinaesthesis in length perception.

Two experiments were designed to investigate the contribution of touch and kinaesthesis to haptic perception of the length of raised lines. Experiment 1 showed that judgements based on kinaesthetic information were not more accurate than those based on cutaneous information. Instead, kinaesthetic and cutaneous inputs appear to be weighted almost equally in the haptic percept, with haptic performance more closely approximated by cutaneous performance than by kinaesthetic. In Experiment 2 it was shown that effects attributed to condition (modality) were not due to the speed with which the stimulus or exploring finger moved. Our results challenge the view that kinaesthesis is more important than touch for identification of raised line drawings.

Capture of kinesthesis by a competing cutaneous input.

In four experiments, blindfolded participants were presented with pairs of stimuli simultaneously, one to each index finger. Participants moved one index finger, which was presented with cutaneous and/or kinesthetic stimuli, and this movement caused a raised line to move underneath the other, stationary index finger in a yoked manner. The stimuli were 180º rotations of each other (e.g., < and >), and thus when a < was traced with the moving finger, it caused a > to be felt at the stationary finger. When asked to report the experience, participants predominantly reported the cutaneous stimulus, seemingly being ignorant of the kinesthetic stimulus. This appears to be an intrahaptic capture phenomenon, which is of interest because it suggests that conflict between intrahaptic sensory stimuli can go unnoticed; sometimes we are unaware of how we moved, and sometimes we do not know what we touched. The results are interpreted in light of optimal integration, perceptual suppression, reafference suppression, and inattentional blindness.

Visual and haptic influence on perception of stimulus size.

In six experiments, subjects judged the sizes of squares that were presented visually and/or haptically, in unimodal or bimodal conditions. We were interested in which mode most affected size judgments in the bimodal condition when the squares presented to each mode actually differed in size. Three factors varied: whether haptic exploration was passive or active, whether the choice set from which the subjects selected their responses was visual or haptic, and whether cutaneous information was provided in addition to kinesthetic information. To match the task for each mode, visual presentations consisted of a cursor that moved along a square pathway to correspond to the haptic experience of successive segments revealed during exploration. We found that the visual influence on size judgments was greater than the influence of haptics when the haptic experience involved only kinesthesis, passive movement, and a visual choice set. However, when cutaneous input was added to kinesthetic information, size judgments were most influenced by the haptic mode. The results support hypotheses of sensory integration, rather than capture of one sense by the other.

Components of haptic information: skin rivals kinaesthesis.

Four components of the haptic system were investigated, in isolation and in various combinations, during passive-guided exploration of raised-line drawings. The components were kinaesthesis, cutaneous input from the presence of a raised line, shear forces from relative movement between the skin and a textured surface, and attenuated distortions at the fingertip resulting from relative movement between the fingertip and a surface. Although the presence of kinaesthetic information was found to be positively correlated with performance in a task of identifying raised-line letters, conditions involving touch alone yielded performance equivalent to that when kinaesthesis was involved. Together, these results suggest that tactile information could be as effective as kinaesthetic information. The results are discussed in terms of applications to the design of human-machine interfaces.

Intrasensory attention: kinaesthetic versus cutaneous inputs.

Blindfolded participants felt pairs of raised-line drawings simultaneously, one with each index finger. The stimuli presented at each fingertip were 180 degrees rotations of each other (eg 6 and 9). One finger moved (either actively or passively), and this in turn caused movement of a matched raised line underneath the stationary finger on the other hand, in a yoked manner. Thus, a 6 at the moving finger would be felt as a 9 on the stationary finger. On all trials there was a raised line moving underneath the stationary fully passive finger. For the moving finger, a raised line was present on only half of the trials. When a raised line could be felt at the moving fingertip, the shape followed by this finger was more often reported than was the shape present at the other (stationary) fingertip. However, when no line was present under the moving finger (ie when movement became the major cue for shape), subjects reported experiencing the shape moved under the stationary fingertip. Results are interpreted as an indication that cutaneous information can be more 'attention-getting' than kinaesthetic information, and are considered to support the modality-appropriateness theory.

Active and passive movements give rise to different judgments of coldness.

When the right index fingertip of twelve subjects was moved across a cold (15 degrees C) tile by a machine (passive-guided condition), the subjects rated the temperature of the tile as being colder than when they moved the finger across the stimulus themselves (active condition). Results confirmed that active movements were associated with an attenuation of 'coldness'. When these findings are considered alongside those of earlier experiments (see VanDoorn et al, 2005 Perception 34 231 236), it may be concluded that intentionality of movement plays some role in this attenuation.

Modification of magnitude estimations in thermotactile perception during self-generated and externally generated movements.

Fourteen participants felt a 'cold' stimulus move across a fingertip. When movement was self-controlled, the stimulus was reported as feeling less 'cold' than when movement was externally generated.