Leaders' experiences of embedding a simulation-based education programme in a teaching hospital: an interview study informed by normalisation process theory.

There is limited research on the experiences of people in working to embed, integrate and sustain simulation programmes. This interview-based study explored leaders' experiences of normalising a simulation-based education programme in a teaching hospital. Fourteen known simulation leaders across Australia and North America were interviewed. Semi-structured interviews were analysed using reflexive thematic analysis sensitised by normalisation process theory, an implementation science theory which defines 'normal' as something being embedded, integrated and sustained. We used a combined social and experiential constructivist approach. Four themes were generated from the data: (1) Leadership, (2) business startup mindset, (3) poor understanding of simulation undermines normalisation and (4) tension of competing objectives. These themes were interlinked and represented how leaders experienced the process of normalising simulation. There was a focus on the relationships that influence decision-making of simulation leaders and organisational buy-in, such that what started as a discrete programme becomes part of normal hospital operations. The discourse of 'survival' was strong, and this indicated that simulation being normal or embedded and sustained was still more a goal than a reality. The concept of being like a 'business startup' was regarded as significant as was the feature of leadership and how simulation leaders influenced organisational change. Participants spoke of trying to normalise simulation for patient safety, but there was also a strong sense that they needed to be agile and innovative and that this status is implied when simulation is not yet 'normal'. Leadership, change management and entrepreneurship in addition to implementation science may all contribute towards understanding how to embed, integrate and sustain simulation in teaching hospitals without losing responsiveness. Further research on how all stakeholders view simulation as a normal part of a teaching hospital is warranted, including simulation participants, quality and safety teams and hospital executives. This study has highlighted that a shared understanding of the purpose and breadth of simulation is a prerequisite for embedding and sustaining simulation. An approach of marketing simulation beyond simulation-based education as a patient safety and systems improvement mindset, not just a technique nor technology, may assist towards simulation being sustainably embedded within teaching hospitals.

Long-term exclusion of invasive ungulates alters tree recruitment and functional traits but not total forest carbon.

Forests are major carbon (C) sinks, but their ability to sequester C and thus mitigate climate change, varies with the environment, disturbance regime, and biotic interactions. Herbivory by invasive, nonnative ungulates can have profound ecosystem effects, yet its consequences for forest C stocks remain poorly understood. We determined the impact of invasive ungulates on C pools, both above- and belowground (to 30 cm), and on forest structure and diversity using 26 paired long-term (>20 years) ungulate exclosures and adjacent unfenced control plots located in native temperate rainforests across New Zealand, spanning 36-41° S. Total ecosystem C was similar between ungulate exclosure (299.93 ± 25.94 Mg C ha-1 ) and unfenced control (324.60 ± 38.39 Mg C ha-1 ) plots. Most (60%) variation in total ecosystem C was explained by the biomass of the largest tree (mean diameter at breast height [dbh]: 88 cm) within each plot. Ungulate exclusion increased the abundance and diversity of saplings and small trees (dbh ≥2.5, <10 cm) compared with unfenced controls, but these accounted for ~5% of total ecosystem C, demonstrating that a few, large trees dominate the total forest ecosystem C but are unaffected by invasive ungulates at a timescale of 20-50 years. However, changes in understory C pools, species composition, and functional diversity did occur following long-term ungulate exclusion. Our findings suggest that, although the removal of invasive herbivores may not affect total forest C at the decadal scale, major shifts in the diversity and composition of regenerating species will have longer term consequences for ecosystem processes and forest C.

Competency domains of educators in medical, nursing, and health sciences education: An integrative review.

PURPOSE: Competencies for educators of healthcare professionals are important for demonstrating accountability, defining roles and responsibilities, structuring activities for training and development, defining standards, quality assurance, performance reviews, career development, and promoting the professionalisation of teaching. The frameworks and domains of educator competencies have not previously been reviewed or systematically described. Through this integrative review, the authors sought to identify an inclusive structure for competency domains that may be applied to educators. METHODS: Keywords were identified in a pilot search, followed by a multi-database search strategy of records published from 2000 to January 2020 with subsequent backward and forward reference searches. We included all record types that listed or described educator competency domains in medical, nursing and health sciences education. We excluded records that described 'ideal traits' or 'characteristics of good teachers/educators,' presented competencies as part of a larger curricular framework, and teaching assessment tool content. RESULTS: The multi-database search retrieved 2942 initial citations. From a full-text review of 301 records, 67 were identified as describing educator competency domains eligible for analysis. Documents contained a median of six domains (interquartile range = 5-7) and 14.9% incorporated at least one overarching element across their domains. Following an inductive thematic analysis, six distinct domains of educator competence were identified: Teaching and facilitating learning; Designing and planning learning; Assessment of learning; Educational research and scholarship; Educational leadership and management; Educational environment, quality, and safety. The two latter domains contained sub-themes that were able to be further categorised. Documents and frameworks were described for a wide variety of health and allied health disciplines. CONCLUSION: Distinct educator competency domains were identified in this analysis, applicable across a range of healthcare disciplines. Along with the description of design elements, these provide a guide for the development and evaluation of educator competency frameworks.

Neoadjuvant therapy at local versus outside institutions does not adversely impact surgical timing or long-term outcomes in patients with pancreatic adenocarcinoma.

BACKGROUND: Although high-volume centers are known to have better surgical outcomes, patients with pancreatic adenocarcinoma often receive chemotherapy at treatment centers closer to home. This study aimed to determine whether treatment site of neoadjuvant therapy relative to surgery location impacts surgical timing and long-term outcomes. METHODS: All patients with pancreatic adenocarcinoma who underwent oncologic resection at a single, high-volume institution between January 2016 and February 2020 and had neoadjuvant chemotherapy before surgery were queried from a prospectively maintained database. Patients were sorted based on location of neoadjuvant chemotherapy. RESULTS: A total of 179 patients were included in the study. Seventy-four (41.3%) patients received neoadjuvant chemotherapy at the same institution as their surgery (group A), 20 (11.2%) received chemotherapy outside of their surgical institution but within the same hospital/healthcare system (group B), and 85 (47.5%) received chemotherapy at an outside location (group C). The time from completion of neoadjuvant therapy to surgery was not significantly different between groups (A vs B vs C median [interquartile range]: 34.5 [14] vs 41.5 [24] vs 36 [22] days, P = .08). Thirty-day readmission rate was lower in group A (n (%): 1 (1.4%) vs 2 (10.0%) vs 11 (12.9%), P = .02). However, the 90-day mortality and overall survival did not differ significantly between groups. CONCLUSION: Patients may receive neoadjuvant therapy at local centers without impacting surgical scheduling. Although these patients may experience higher postoperative readmission rates, perioperative mortality and long-term survival are not adversely affected by location of chemotherapy. Multidisciplinary care can be effectively practiced in different locations without affecting overall outcomes in patients with pancreatic adenocarcinoma.

Eight years of CRASH: A bi-national initiative helping critical care doctors return to work.

Returning to work in critical care after a break in clinical practice can be a daunting process. This article describes development and evolution of the Critical Care, Resuscitation, Airway Skills: Helping you return to work (CRASH) course, including the supporting literature. CRASH is the first bi-national course assisting return to work (RTW) for critical care practitioners. It evolved as a collaborative effort across Australia and New Zealand, involving anaesthetists, emergency physicians and intensivists. The course is based around tailored sessions practising skills and clinical decision-making using simulation and case discussions, incorporating practical tips on returning to work. Participants receive resources to assist RTW including questionnaires and checklists developed by the faculty, which have been used to aid RTW in more than 30 hospitals in Australia and New Zealand. Attendance is open to all critical care practitioners who are registered with the relevant medical board and returning to work, who have taken leave from work for any reason. Since 2014, 197 participants have attended CRASH in-person or virtually, one of the largest RTW groups described in the literature. The aim of this article is to outline the literature around inactivity and RTW, and describe the development and adaptation of the CRASH course.

Evolutionary history constrains microbial traits across environmental variation.

Organisms influence ecosystems, from element cycling to disturbance regimes, to trophic interactions and to energy partitioning. Microorganisms are part of this influence, and understanding their ecology in nature requires studying the traits of these organisms quantitatively in their natural habitats-a challenging task, but one which new approaches now make possible. Here, we show that growth rate and carbon assimilation rate of soil microorganisms are influenced more by evolutionary history than by climate, even across a broad climatic gradient spanning major temperate life zones, from mixed conifer forest to high-desert grassland. Most of the explained variation (~50% to ~90%) in growth rate and carbon assimilation rate was attributable to differences among taxonomic groups, indicating a strong influence of evolutionary history, and taxonomic groupings were more predictive for organisms responding to resource addition. With added carbon and nitrogen substrates, differences among taxonomic groups explained approximately eightfold more variance in growth rate than did differences in ecosystem type. Taxon-specific growth and carbon assimilation rates were highly intercorrelated across the four ecosystems, constrained by the taxonomic identity of the organisms, such that plasticity driven by environment was limited across ecosystems varying in temperature, precipitation and dominant vegetation. Taken together, our results suggest that, similar to multicellular life, the traits of prokaryotes in their natural habitats are constrained by evolutionary history to a greater degree than environmental variation.

Direct and cascading impacts of tropical land-use change on multi-trophic biodiversity.

The conversion of tropical rainforest to agricultural systems such as oil palm alters biodiversity across a large range of interacting taxa and trophic levels. Yet, it remains unclear how direct and cascading effects of land-use change simultaneously drive ecological shifts. Combining data from a multi-taxon research initiative in Sumatra, Indonesia, we show that direct and cascading land-use effects alter biomass and species richness of taxa across trophic levels ranging from microorganisms to birds. Tropical land use resulted in increases in biomass and species richness via bottom-up cascading effects, but reductions via direct effects. When considering direct and cascading effects together, land use was found to reduce biomass and species richness, with increasing magnitude at higher trophic levels. Our analyses disentangle the multifaceted effects of land-use change on tropical ecosystems, revealing that biotic interactions on broad taxonomic scales influence the ecological outcome of anthropogenic perturbations to natural ecosystems.

Land-use choices follow profitability at the expense of ecological functions in Indonesian smallholder landscapes.

Smallholder-dominated agricultural mosaic landscapes are highlighted as model production systems that deliver both economic and ecological goods in tropical agricultural landscapes, but trade-offs underlying current land-use dynamics are poorly known. Here, using the most comprehensive quantification of land-use change and associated bundles of ecosystem functions, services and economic benefits to date, we show that Indonesian smallholders predominantly choose farm portfolios with high economic productivity but low ecological value. The more profitable oil palm and rubber monocultures replace forests and agroforests critical for maintaining above- and below-ground ecological functions and the diversity of most taxa. Between the monocultures, the higher economic performance of oil palm over rubber comes with the reliance on fertilizer inputs and with increased nutrient leaching losses. Strategies to achieve an ecological-economic balance and a sustainable management of tropical smallholder landscapes must be prioritized to avoid further environmental degradation.

Ecological and socio-economic functions across tropical land use systems after rainforest conversion.

Tropical lowland rainforests are increasingly threatened by the expansion of agriculture and the extraction of natural resources. In Jambi Province, Indonesia, the interdisciplinary EFForTS project focuses on the ecological and socio-economic dimensions of rainforest conversion to jungle rubber agroforests and monoculture plantations of rubber and oil palm. Our data confirm that rainforest transformation and land use intensification lead to substantial losses in biodiversity and related ecosystem functions, such as decreased above- and below-ground carbon stocks. Owing to rapid step-wise transformation from forests to agroforests to monoculture plantations and renewal of each plantation type every few decades, the converted land use systems are continuously dynamic, thus hampering the adaptation of animal and plant communities. On the other hand, agricultural rainforest transformation systems provide increased income and access to education, especially for migrant smallholders. Jungle rubber and rubber monocultures are associated with higher financial land productivity but lower financial labour productivity compared to oil palm, which influences crop choice: smallholders that are labour-scarce would prefer oil palm while land-scarce smallholders would prefer rubber. Collecting long-term data in an interdisciplinary context enables us to provide decision-makers and stakeholders with scientific insights to facilitate the reconciliation between economic interests and ecological sustainability in tropical agricultural landscapes.

Impact of Lowland Rainforest Transformation on Diversity and Composition of Soil Prokaryotic Communities in Sumatra (Indonesia).

Prokaryotes are the most abundant and diverse group of microorganisms in soil and mediate virtually all biogeochemical cycles in terrestrial ecosystems. Thereby, they influence aboveground plant productivity and diversity. In this study, the impact of rainforest transformation to intensively managed cash crop systems on soil prokaryotic communities was investigated. The studied managed land use systems comprised rubber agroforests (jungle rubber), rubber plantations and oil palm plantations within two Indonesian landscapes Bukit Duabelas and Harapan. Soil prokaryotic community composition and diversity were assessed by pyrotag sequencing of bacterial and archaeal 16S rRNA genes. The curated dataset contained 16,413 bacterial and 1679 archaeal operational taxonomic units at species level (97% genetic identity). Analysis revealed changes in indigenous taxon-specific patterns of soil prokaryotic communities accompanying lowland rainforest transformation to jungle rubber, and intensively managed rubber and oil palm plantations. Distinct clustering of the rainforest soil communities indicated that these are different from the communities in the studied managed land use systems. The predominant bacterial taxa in all investigated soils were Acidobacteria, Actinobacteria, Alphaproteobacteria, Betaproteobacteria, and Gammaproteobacteria. Overall, the bacterial community shifted from proteobacterial groups in rainforest soils to Acidobacteria in managed soils. The archaeal soil communities were mainly represented by Thaumarchaeota and Euryarchaeota. Members of the Terrestrial Group and South African Gold Mine Group 1 (Thaumarchaeota) dominated in the rainforest and members of Thermoplasmata in the managed land use systems. The alpha and beta diversity of the soil prokaryotic communities was higher in managed land use systems than in rainforest. In the case of bacteria, this was related to soil characteristics such as pH value, exchangeable Ca and Fe content, C to N ratio, and extractable P content. Archaeal community composition and diversity were correlated to pH value, exchangeable Fe content, water content, and total N. The distribution of bacterial and archaeal taxa involved in biological N cycle indicated functional shifts of the cycle during conversion of rainforest to plantations.

Soil Nitrogen-Cycling Responses to Conversion of Lowland Forests to Oil Palm and Rubber Plantations in Sumatra, Indonesia.

Rapid deforestation in Sumatra, Indonesia is presently occurring due to the expansion of palm oil and rubber production, fueled by an increasing global demand. Our study aimed to assess changes in soil-N cycling rates with conversion of forest to oil palm (Elaeis guineensis) and rubber (Hevea brasiliensis) plantations. In Jambi Province, Sumatra, Indonesia, we selected two soil landscapes - loam and clay Acrisol soils - each with four land-use types: lowland forest and forest with regenerating rubber (hereafter, "jungle rubber") as reference land uses, and rubber and oil palm as converted land uses. Gross soil-N cycling rates were measured using the 15N pool dilution technique with in-situ incubation of soil cores. In the loam Acrisol soil, where fertility was low, microbial biomass, gross N mineralization and NH4+ immobilization were also low and no significant changes were detected with land-use conversion. The clay Acrisol soil which had higher initial fertility based on the reference land uses (i.e. higher pH, organic C, total N, effective cation exchange capacity (ECEC) and base saturation) (P≤0.05-0.09) had larger microbial biomass and NH4+ transformation rates (P≤0.05) compared to the loam Acrisol soil. Conversion of forest and jungle rubber to rubber and oil palm in the clay Acrisol soil decreased soil fertility which, in turn, reduced microbial biomass and consequently decreased NH4+ transformation rates (P≤0.05-0.09). This was further attested by the correlation of gross N mineralization and microbial biomass N with ECEC, organic C, total N (R=0.51-0. 76; P≤0.05) and C:N ratio (R=-0.71 - -0.75, P≤0.05). Our findings suggest that the larger the initial soil fertility and N availability, the larger the reductions upon land-use conversion. Because soil N availability was dependent on microbial biomass, management practices in converted oil palm and rubber plantations should focus on enriching microbial biomass.

Gaseous oxidized mercury dry deposition measurements in the southwestern USA: a comparison between Texas, eastern Oklahoma, and the Four Corners area.

Gaseous oxidized mercury (GOM) dry deposition measurements using aerodynamic surrogate surface passive samplers were collected in central and eastern Texas and eastern Oklahoma, from September 2011 to September 2012. The purpose of this study was to provide an initial characterization of the magnitude and spatial extent of ambient GOM dry deposition in central and eastern Texas for a 12-month period which contained statistically average annual results for precipitation totals, temperature, and wind speed. The research objective was to investigate GOM dry deposition in areas of Texas impacted by emissions from coal-fired utility boilers and compare it with GOM dry deposition measurements previously observed in eastern Oklahoma and the Four Corners area. Annual GOM dry deposition rate estimates were relatively low in Texas, ranging from 0.1 to 0.3 ng/m(2)h at the four Texas monitoring sites, similar to the 0.2 ng/m(2)h annual GOM dry deposition rate estimate recorded at the eastern Oklahoma monitoring site. The Texas and eastern Oklahoma annual GOM dry deposition rate estimates were at least four times lower than the highest annual GOM dry deposition rate estimate previously measured in the more arid bordering western states of New Mexico and Colorado in the Four Corners area.

Sensitivity of the rate of spontaneous eye blinking to type of stimuli in young infants.

Although progress has been made toward understanding the mechanisms of spontaneous eye blinking (SB), few reports focus on the ontogeny of SB. The purpose of the present work was to investigate SB in infants by attempting to manipulate SB and examine potential correlates of SB. Fifty-two infants were observed in a quiet baseline condition then presented with either moving stimuli or a social stimulus. SB, eye movement, body movement and various background variables were measured. Results demonstrate that SB can be manipulated and that SB rate is differentially sensitive to the type of stimulus presented. Eye and body movements did not systematically relate to the rate of SB. Implications for mechanisms of SB regulation are discussed.

Bilateral vocal cord palsy during carotid endarterectomy under cervical plexus block.

We describe a case of vocal cord palsy leading to respiratory obstruction during carotid endarterectomy under cervical plexus block in a patient who had preexisting contralateral vocal cord paralysis subsequent to a previous thyroidectomy. The patient required immediate tracheal intubation and subsequent tracheostomy to maintain the airway postoperatively. Care must be given to avoid contralateral vocal cord paralysis in the presence of a preexisting vocal cord palsy.