Challenges for conducting and teaching handovers as collaborative conversations: an interview study at teaching ICUs.

INTRODUCTION: Whereas medical shift handovers are increasingly recognized to fulfil important functions beyond information transfer, studies suggest that shift handovers continue to be variably used for reflection, learning or discussion. Little is known of the dynamics of incorporating such functions into ICU shift handovers, resulting in a challenge for the design of educational programs whose underlying philosophies align with the specific requirements of the ICU. METHODS: Intensivists, residents and fellows (n = 21) from three ICUs were interviewed to determine perceptions of handover functionality and the boundaries to what must or can be achieved in handover conversations. Interviews were analyzed to isolate training requirements and factors that challenge interactions. RESULTS: The analysis revealed that ICU physicians value three functions for shift handovers: information transfer, enhancing shared understanding and decision-making, and learning. The functions towards which physicians are oriented were found to be affected by situational characteristics of cases, individuals, teams, and the unit workflow. Whereas some factors are helpful cues for determining communication needs, others raise dilemmas and misaligned expectations with regards to what can be achieved in the handover. DISCUSSION: Our findings add to the growing case for the education of handovers in complex settings to involve more than information transfers. As residents gain experience, training should be gradually shifted towards more fluid and adaptable approaches to the handover and residents' ability to engage in joint reflections and discussions. Challenges for engaging in such interactions need to be alleviated, in order to allow the redefinition of handovers as potential sources of safety and learning, rather than error.

Taxonomy of Trauma Leadership Skills: A Framework for Leadership Training and Assessment.

PURPOSE: Good leadership is essential for optimal trauma team performance, and targeted training of leadership skills is necessary to achieve such leadership proficiency. To address the need for a taxonomy of leadership skills that specifies the skill components to be learned and the behaviors by which they can be assessed across the five phases of trauma care, the authors developed the Taxonomy of Trauma Leadership Skills (TTLS). METHOD: Critical incident interviews were conducted with trauma team leaders and members from different specialties-emergency physicians, trauma surgeons, anesthesiologists, and emergency ward nurses-at three teaching hospitals in the Netherlands during January-June 2013. Data were iteratively analyzed for examples of excellent leadership skills at each phase of trauma care. Using the grounded theory approach, elements of excellent leadership skills were identified and classified. Elements and behavioral markers were sorted and categorized using multiple raters. In a two-round verification process in late 2013, the taxonomy was reviewed and rated by trauma team leaders and members from the multiple specialties for its coverage of essential items. RESULTS: Data were gathered from 28 interviews and 14 raters. The TTLS details 5 skill categories (information coordination, decision making, action coordination, communication management, and coaching and team development) and 37 skill elements. The skill elements are captured by 67 behavioral markers. The three-level taxonomy is presented according to five phases of trauma care. CONCLUSIONS: The TTLS provides a framework for teaching, learning, and assessing team leadership skills in trauma care and other complex, acute care situations.

The role of depth of encoding in attentional capture.

The aim of the current study was to examine whether depth of encoding influences attentional capture by recently attended objects. In Experiment 1, participants first had to judge whether a word referred to a living or a nonliving thing (deep encoding condition) or whether the word was written in lower- or uppercase (shallow encoding condition), and they then had to identify a digit displayed midway in a rapid serial visual presentation (RSVP) stream of 8 pictures. A picture corresponding to the previously processed word was presented either before or after the target digit. The results showed that this picture captured attention, thus resulting in an attentional blink for identification of a target digit, in the deep encoding condition but not in the shallow encoding condition. In Experiment 2, this capture effect was found to be abolished when an additional working-memory (WM) task was performed directly after the word-judgment task, suggesting that the capture effect stemmed from residual WM activation that could be erased by means of a secondary WM task. Taken together, these results suggest that deep and shallow encoding result in different degrees of WM activation, which in turn influences the likelihood of memory-driven attentional capture.

Dissociable mechanisms underlying individual differences in visual working memory capacity.

Individuals scoring relatively high on measures of working memory tend to be more proficient at controlling attention to minimize the effect of distracting information. It is currently unknown whether such superior attention control abilities are mediated by stronger suppression of irrelevant information, enhancement of relevant information, or both. Here we used steady-state visual evoked potentials (SSVEPs) with the Eriksen flanker task to track simultaneously the attention to relevant and irrelevant information by tagging target and distractors with different frequencies. This design allowed us to dissociate attentional biasing of perceptual processing (via SSVEPs) and stimulus processing in the frontal cognitive control network (via time-frequency analyses of EEG data). We show that while preparing for the upcoming stimulus, high- and low-WMC individuals use different strategies: High-WMC individuals show attentional suppression of the irrelevant stimuli, whereas low-WMC individuals demonstrate attentional enhancement of the relevant stimuli. Moreover, behavioral performance was predicted by trial-to-trial fluctuations in strength of distractor-suppression for high-WMC participants. We found no evidence for WMC-related differences in cognitive control network functioning, as measured by midfrontal theta-band power. Taken together, these findings suggest that early suppression of irrelevant information is a key underlying neural mechanism by which superior attention control abilities are implemented.

Working memory capacity predicts conflict-task performance.

The relationship between the ability to maintain task goals and working memory capacity (WMC) is firmly established, but evidence for WMC-related differences in conflict processing is mixed. We investigated whether WMC (measured using two complex-span tasks) mediates differences in adjustments of cognitive control in response to conflict. Participants performed a Simon task in which congruent and incongruent trials were equiprobable, but in which the proportion of congruency repetitions (congruent trials followed by congruent trials or incongruent trials followed by incongruent trials) and thus the need for trial-by-trial adjustments in cognitive control varied by block. The overall Simon effect did not depend on WMC capacity. However, for the low-WMC participants the Simon effect decreased as the proportion of congruency repetitions decreased, whereas for the high- and average-WMC participants it was relatively constant across conditions. Distribution analysis of the Simon effect showed more evidence for the inhibition of stimulus location in the low- than in the high-WMC participants, especially when the proportion of congruency repetitions was low. We hypothesize that low-WMC individuals exhibit more interference from task-irrelevant information due to weaker preparatory control prior to stimulus presentation and, thus, stronger reliance on reactive recruitment of cognitive control.

National culture moderates the influence of mental effort on subjective and cardiovascular measures.

Subjective measures of mental effort have been shown to be relatively insensitive in Indonesian participants. An open question is whether this insensitivity reflects how mental effort is experienced or how it is reported. We compared the performance, subjective workload ratings, heart rate and heart-rate variability (HRV) of 31 Dutch and 30 Indonesian participants under single- and dual-task conditions. Indonesians performed faster but less accurately and used a narrower range of subjective workload ratings than did the Dutch. Dutch participants showed a decrease in HRV both in the mid-frequency (MF) and high-frequency bands and an increase in heart rate during task performance compared with the resting period. Indonesians showed this pattern in the MF band only. The decrease of HRV in the MF band in both groups suggests that the relative insensitivity of subjective mental effort scales among Indonesians has to do with how workload is reported rather than with how it is experienced. PRACTITIONER SUMMARY: The sensitivity of the subjective measures of mental workload has been shown to depend on culture. Here, we show that heart-rate variability reacts similarly to workload in Eastern as in Western participants. This suggests that culture influences more how invested mental effort is reported than how it is experienced psychophysiologically.

Comparing crowding in human and ideal observers.

A visual target is more difficult to recognize when it is surrounded by other, similar objects. This breakdown in object recognition is known as crowding. Despite a long history of experimental work, computational models of crowding are still sparse. Specifically, few studies have examined crowding using an ideal-observer approach. Here, we compare crowding in ideal observers with crowding in humans. We derived an ideal-observer model for target identification under conditions of position and identity uncertainty. Simulations showed that this model reproduces the hallmark of crowding, namely a critical spacing that scales with viewing eccentricity. To examine how well the model fits quantitatively to human data, we performed three experiments. In Experiments 1 and 2, we measured observers' perceptual uncertainty about stimulus positions and identities, respectively, for a target in isolation. In Experiment 3, observers identified a target that was flanked by two distractors. We found that about half of the errors in Experiment 3 could be accounted for by the perceptual uncertainty measured in Experiments 1 and 2. The remainder of the errors could be accounted for by assuming that uncertainty (i.e., the width of internal noise distribution) about stimulus positions and identities depends on flanker proximity. Our results provide a mathematical restatement of the crowding problem and support the hypothesis that crowding behavior is a sign of optimality rather than a perceptual defect.

Are assumptions of well-known statistical techniques checked, and why (not)?

A valid interpretation of most statistical techniques requires that one or more assumptions be met. In published articles, however, little information tends to be reported on whether the data satisfy the assumptions underlying the statistical techniques used. This could be due to self-selection: Only manuscripts with data fulfilling the assumptions are submitted. Another explanation could be that violations of assumptions are rarely checked for in the first place. We studied whether and how 30 researchers checked fictitious data for violations of assumptions in their own working environment. Participants were asked to analyze the data as they would their own data, for which often used and well-known techniques such as the t-procedure, ANOVA and regression (or non-parametric alternatives) were required. It was found that the assumptions of the techniques were rarely checked, and that if they were, it was regularly by means of a statistical test. Interviews afterward revealed a general lack of knowledge about assumptions, the robustness of the techniques with regards to the assumptions, and how (or whether) assumptions should be checked. These data suggest that checking for violations of assumptions is not a well-considered choice, and that the use of statistics can be described as opportunistic.

Variations in hospital worker perceptions of safety culture.

OBJECTIVE: To compare the attitudes toward and perceptions of institutional practices that can influence patient safety between all professional groups at a university medical center. DESIGN: A questionnaire measuring nine dimensions of organizational and safety culture was distributed to all hospital workers. Each item was rated on a 1 ('strongly disagree') to 5 ('strongly agree') scale. PARTICIPANTS: Professionals (2995), grouped as 'physicians' (16.6%), 'nurses' (40.3%), 'clinical workers' (e.g. psychologists; 21.7%), 'laboratory workers' (e.g. technicians; 11%) and 'non-medical workers' (e.g. managers; 10.4%). MAIN OUTCOME MEASURES: One-way analysis of variances (ANOVAs) carried out separately on each dimension with professional group as the independent variable of interest. RESULTS: Differences in ratings of organizational and safety culture were found across professional groups. Physicians and non-medical workers tended to rate the dimensions of organizational and safety culture more positively than did nurses, clinical workers and laboratory workers. For example, physicians gave more positive ratings of 'institutional commitment to safety' than did nurses, clinical workers and laboratory workers (mean = 3.71 vs. 3.62, 3.61 and 3.58, respectively, P < 0.01) and non-medical workers gave more positive ratings than did physicians, nurses, clinical workers and laboratory workers to 'perceptions towards the hospital' (mean = 3.69 vs. 3.39, 3.36, 3.49 and 3.47, respectively, P < 0.001). CONCLUSIONS: Interventions to promote safety culture should be tailored to the target group as attitudes and perceptions may differ among groups.

Demographic differences between health care workers who did or did not respond to a safety and organizational culture survey.

BACKGROUND: Areas for institutional improvement to enhance patient safety are commonly identified by surveying health care workers' (HCWs) attitudes, values, beliefs, perceptions and assumptions regarding institutional practices. An ideal response rate of 100% is rarely achieved in such surveys, and non-response bias can occur when non-respondents differ from respondents on a dimension likely to influence survey conclusions. The conditions for non-response bias to occur can be detected by comparing demographic characteristics of respondents and non-respondents and relating any differences to findings in the literature of differences in the construct of interest as a function of these demographic characteristics. The current study takes this approach. FINDINGS: All 5,609 HCWs at a university medical center were invited to participate in a survey measuring safety and organizational culture (response rate = 53.40%). Respondents indicated their professional group, gender, age group, years of working in the hospital and executive function. Because all HCWs were invited, the demographic composition of the group who did not respond was known. Differences in the demographic composition of respondents and non-respondents were compared using separate Pearson's chi-square tests for each demographic characteristic.Nurses and clinical workers were generally more likely to respond than were physicians, laboratory workers and non-medical workers. Male HCWs were less likely to respond than were females, HCWs aged younger than 45 years old had a lower response rate than did HCWs aged 45 to 54 years old, HCWs who had worked in the hospital for less than 5 years were less likely to respond than were those who had worked in the hospital for 5 years or more and HCWs without an executive function were less likely to respond than were executives. CONCLUSIONS: Demographic characteristics can be linked to response rates and need to be considered in conducting surveys among HCWs. The possibility of non-response bias can be reduced by conducting analyses separately as a function of relevant demographic characteristics, sampling a higher percentage of groups that are known to be less likely to respond, or weighting responses with the reciprocal of the response rate for the respective demographic group.

The P4pc: an electrophysiological marker of attentional disengagement?

The processing of successive targets requires that attention be engaged and disengaged. Whereas attentional engagement can be studied by means of the N2pc component of the event-related potential (ERP), no ERP component has been linked to attentional disengagement. Here, we report the finding of such a component using an RSVP paradigm with multiple, successive targets and with a spatial-cuing paradigm. In both experiments, disengagement of attention was necessary to attend to subsequent targets. A distinct waveform following the N2pc, which we call the P4pc (Positivity 400 ms post-target posterior contralateral), was found. The P4pc was found when a lateralized cue indicated that attention would be needed for the processing of a target at either the same or a different location as the cue, but not when only the cue was to be responded to, indicating that the need to disengage attention is a prerequisite for the P4pc to occur. We expect the P4pc to provide a valuable addition to the set of electrophysiological measures used to study the dynamics and mechanisms of visual attention and visual search.

Perceptions of personal health risks by medical and non-medical workers in a university medical center: a survey study.

BACKGROUND: Health care workers (HCWs) are faced with many work-related choices which may depend on how they perceive risk, such as whether or not to comply with safety regulations. Little research has investigated risk perception in medical workers in comparison with non-medical workers and the extent to which risk perception differs in these groups. The current study thus investigates risk perception of medical and non-medical workers to inform and complement future research on safety compliance. The study has implications for the design of intervention programmes to increase the level of compliance of HCWs. METHODS: A survey study was conducted in which questionnaires were distributed to 6380 HCWs. The questionnaire asked for ratings of risk perception for cold, annual influenza, pandemic influenza, cancer, heart attack and food poisoning. Of 2495 returned questionnaires (response rate: 39%), 61.40% were from medical workers (24.1% of these were from physicians, 39.7% from nurses and 36.2% from paramedics) and 38.60% were from non-medical workers. RESULTS: Medical workers gave lower risk perception ratings than did non-medical workers for cancer, but not for other health risks. Within the medical workers, physicians rated the risk of getting a cold as higher, but of having a heart attack as lower than did nurses and paramedics; physicians also rated their risk of getting cancer as lower than did nurses. Perceived risk was higher as a function of age for pandemic influenza, cancer and heart attack, but lower for cold and annual influenza. HCWs who lived with a partner and children rated the risk of getting a cold or annual influenza higher than those who lived alone or with a partner only. Full-time HCWs gave lower ratings for annual influenza than did part-time HCWs. CONCLUSIONS: Different base levels of risk perception between medical and non-medical workers need to be taken into account for successful implementation of safety regulations.Intervention programmes to improve compliance with safety regulations may need to be customized for different groups as a function of how they perceive risk.

Do personality traits predict work outcomes of certified nursing assistants?

The purposes of this study were to describe personality traits of certified nursing assistants (CNAs) employed at nursing homes and explore relationships between personality traits, job satisfaction, and job performance. The sample included 177 CNAs providing direct care to residents in three nursing homes. CNAs with high and low job performance skills were distinguished by the cluster of traits associated with teamwork skills. Overall, 21.3% of the variance in job satisfaction was explained by the personality traits of Adjustment, Prudence, Likeability, Excitable, and Dutiful, F(8, 145) = 4.899, p < 0.001. The links found between personality, job satisfaction, and job performance provide important information about the personality traits of nursing staff who are most likely to enjoy and perform well in the nursing home setting. Knowledge of these links may be useful for hiring the appropriate person for direct care nursing home positions.

Using frequency tagging to quantify attentional deployment in a visual divided attention task.

Frequency tagging is an EEG method based on the quantification of the steady state visual evoked potential (SSVEP) elicited from stimuli which flicker with a distinctive frequency. Because the amplitude of the SSVEP is modulated by attention such that attended stimuli elicit higher SSVEP amplitudes than do ignored stimuli, the method has been used to investigate the neural mechanisms of spatial attention. However, up to now it has not been shown whether the amplitude of the SSVEP is sensitive to gradations of attention and there has been debate about whether attention effects on the SSVEP are dependent on the tagging frequency used. We thus compared attention effects on SSVEP across three attention conditions-focused, divided, and ignored-with six different tagging frequencies. Participants performed a visual detection task (respond to the digit 5 embedded in a stream of characters). Two stimulus streams, one to the left and one to the right of fixation, were displayed simultaneously, each with a background grey square whose hue was sine-modulated with one of the six tagging frequencies. At the beginning of each trial a cue indicated whether targets on the left, right, or both sides should be responded to. Accuracy was higher in the focused- than in the divided-attention condition. SSVEP amplitudes were greatest in the focused-attention condition, intermediate in the divided-attention condition, and smallest in the ignored-attention condition. The effect of attention on SSVEP amplitude did not depend on the tagging frequency used. Frequency tagging appears to be a flexible technique for studying attention.

A quick visual mind can be a slow auditory mind. Individual differences in attentional selection across modalities.

The human mind is severely limited in processing concurrent information at a conscious level of awareness. These temporal restrictions are clearly reflected in the attentional blink (AB), a deficit in reporting the second of two targets when it occurs 200-500 ms after the first. However, we recently reported that some individuals do not show a visual AB, and presented psychophysiological evidence that target processing differs between "blinkers" and "nonblinkers". Here, we present evidence that visual nonblinkers do show an auditory AB, which suggests that a major source of attentional restriction as reflected in the AB is likely to be modality-specific. In Experiment 3, we show that when the difficulty in identifying visual targets is increased, nonblinkers continue to show little or no visual AB, suggesting that the presence of an AB in the auditory but not in the visual modality is not due to a difference in task difficulty.

Working memory capacity, intelligence, and the magnitude of the attentional blink revisited.

The attentional blink (AB) is a well-established phenomenon in the study of attention. This deficit in reporting the second of two targets presented in rapid serial visual presentation when it occurs 200-500 ms after the first is considered to reflect a fundamental limitation in attentional processing. However, we recently reported that some individuals do not show an AB, and presented psychophysiological evidence that target processing differs between blinkers and non-blinkers. One possibility is that non-blinkers may have a larger WM capacity, allowing better attentional control. Here we explore the relation between the magnitude of the AB, general intelligence, and different measures of working memory (WM) and short-term memory (STM) capacity. Surprisingly, no correlation was found between memory capacity measures and AB magnitude, raising doubts about the generalizability of earlier findings of such a relationship.

Rethinking neural efficiency: effects of controlling for strategy use.

A sentence verification task (SVT) was used to test whether differences in neural activation patterns that have been attributed to IQ may actually depend on differential strategy use between IQ groups. Electroencephalograms were recorded from 14 low (89 < IQ < 110) and 14 high (121 < IQ < 142) IQ individuals as they performed the SVT with either a spatial or verbal strategy. Event-related desynchronization in upper alpha (9.5-12.5 Hz) and theta (4-6 Hz) bands showed that different strategies evoked different activation patterns, but these patterns did not differ between groups. However, an IQ-related correlate was found in the preparation interval. Thus, although processing patterns during task performance seem to depend on the strategy used for task execution, preparation for task processing may depend on IQ.

Colours sometimes count: awareness and bidirectionality in grapheme-colour synaesthesia.

Three experiments were conducted with 10 grapheme-colour synaesthetes and 10 matched controls to investigate (a) whether awareness of the inducer grapheme is necessary for synaesthetic colour induction and (b) whether grapheme-colour synaesthesia may be bidirectional in the sense that not only do graphemes induce colours, but that colours influence the processing of graphemes. Using attentional blink and Stroop paradigms with digit targets, we found that some synaesthetes did report "seeing" synaesthetic colours even when they were not able to report the inducing digit. Moreover, congruency effects (effects of matching the colour of digit presentation with the synaesthetic colour associated with that digit) suggested that grapheme-colour synaesthesia can be bidirectional, at least for some synaesthetes.

Cross-task repetition amnesia: Impaired recall of RSVP targets held in memory for a secondary task.

People often fail to select and encode the second of two targets presented within less than 500ms in rapid serial visual presentation (RSVP), an effect known as the attentional blink. We investigated how report of the two targets is affected when one of them is maintained in working memory for a secondary, memory-search task. The results showed that report of either target was impaired when it was a member of the memory set relative to when it was not. This effect was independent of both the temporal interval separating the RSVP target from the presentation of the memory set and the interval separating the targets. We propose that the deficit in recall occurs because the association between a target and the memory-search task interferes with the formation of a new association between that target and the following RSVP task, with the result that observers may be biased to ascribe the target only to the memory set.

Cuing and stimulus probability effects on the P3 and the AB.

Two experiments were conducted to investigate the relation between the attentional blink (AB), a deficit in reporting the second of two targets when it occurs 200-500 ms after the first, and the P3 component of the event-related potential. Consistent with the view that the AB reflects a limited ability to consolidate information in working memory and that the P3 reflects working memory updating, increasing the amplitude of the P3 elicited by a first target (T1) by varying T1 probability (Experiment 1) or T1 cue validity (Experiment 2) led to an increase of the AB. Overall, the P3 elicited by T1 was greater when T2 was not identified than when it was. However, the correlation between P3 and AB magnitude across participants was not significant, leaving open the question of how direct the relationship between the P3 and the AB is.