Ethical climate in healthcare: A systematic review and meta-analysis.

BACKGROUND: Ethical climate refers to the shared perception of ethical norms and sets the scope for what is ethical and acceptable behaviour within teams. AIM: This paper sought to explore perceptions of ethical climate amongst healthcare workers as measured by the Ethical Climate Questionnaire (ECQ), the Hospital Ethical Climate Survey (HECS) and the Ethics Environment Questionnaire (EEQ). METHODS: A systematic review and meta-analysis was utilised. PSYCINFO, CINAHL, WEB OF SCIENCE, MEDLINE and EMBASE were searched, and papers were included if they sampled healthcare workers and used the ECQ, HECS or EEQ. ETHICAL CONSIDERATION: Ethical approval was not required. RESULTS: The search returned 1020 results. After screening, 61 papers were included (n = 43 HECS, n = 15 ECQ, n = 3 EEQ). The overall sample size was over 17,000. The pooled mean score for the HECS was 3.60. Mean scores of individual studies ranged from 2.97 to 4.5. For the HECS studies, meta-regression was carried out. No relationship was found between the country of the studies, the study setting (ICU v non-ICU settings) or the mean years of experience that the sample had. For the ECQ, sub-scales had mean scores ranging from 3.41 (instrumental) to 4.34 (law) and were all observed to have significant and substantial heterogeneity. Three studies utilised the EEQ so further analysis was not carried out. CONCLUSIONS: The above results provide insight into the variability of scores as measured by the HECS, ECQ and EEQ. To some extent, this variability is not surprising with studies carried out across 21 countries and in a range of healthcare systems. Results also suggest that it may be that more local and context specific factors are more important when it comes to predicting ethical climate.

A scoping review exploring the impact and negotiation of hierarchy in healthcare organisations.

Healthcare organisations are hierarchical; almost all are organised around the ranking of individuals by authority or status, whether this be based on profession, expertise, gender or ethnicity. Hierarchy is important for several reasons; it shapes the delivery of care, what is prioritised and who receives care. It also has an impact on healthcare workers and how they work and communicate together in organisations. The purpose of this scoping review is to explore the qualitative evidence related to hierarchy in healthcare organisations defined broadly, to address gaps in macro-level healthcare organisational research, specifically focusing on the (1) impact of hierarchy for healthcare workers and (2) how hierarchy is negotiated, sustained and challenged in healthcare organisations. After a search and screening, 32 papers were included in this review. The findings of this review detail the wide-reaching impacts that hierarchy has on healthcare delivery and health workers. The majority of studies spoke to hierarchy's impact on speaking up, that is, how it shaped communication between staff with differential status: not only what was said, but how it had an impact on what was acceptable to say, by whom and at what time. Hierarchy was also noted to have substantial personal costs, impacting on the well-being of those in less powerful positions. These findings also provide insight into the complex ways in which hierarchy was negotiated, challenged and reproduced. Studies not only detailed the way in which hierarchy was navigated day to day but also spoke to the reasons as to why hierarchy is often entrenched and difficult to shift. A number of studies spoke to the impact that hierarchy had in sustaining gender and ethnic inequalities, maintaining historically discriminatory practices. Importantly, hierarchy should not be reduced to differences between or within the professions in localised contexts but should be considered at a broad organisational level.

A systematic scoping review on the evidence behind debriefing practices for the wellbeing/emotional outcomes of healthcare workers.

Introduction: Debriefings give healthcare workers voice through the opportunity to discuss unanticipated or difficult events and recommend changes. The typical goal of routine debriefings has been to improve clinical outcomes by learning through discussion and reflection of events and then transferring that learning into clinical practice. However, little research has investigated the effects of debriefings on the emotional experiences and well-being of healthcare workers. There is some evidence that debriefings are a multi-faceted and cost-effective intervention for minimising negative health outcomes, but their use is inconsistent and they are infrequently adopted with the specific intention of giving healthcare workers a voice. The purpose of this systematic scoping review is therefore to assess the scope of existing evidence on debriefing practices for the well-being and emotional outcomes of healthcare workers. Methods: Following screening, 184 papers were synthesised through keyword mapping and exploratory trend identification. Results: The body of evidence reviewed were clustered geographically, but diverse on many other criteria of interest including the types of evidence produced, debriefing models and practices, and outcomes captured. Discussion: The current review provides a clear map of our existing understanding and highlights the need for more systematic, collaborative and rigorous bodies of evidence to determine the potential of debriefing to support the emotional outcomes of those working within healthcare. Systematic Review Registration: https://osf.io/za6rj.

The impact of Covid-19 on self-employed female psychologists in the UK.

This scoping study reports on the experiences of 41 female self-employed psychologists (or psychologists in private practice) during the first Covid-19 lockdown in the UK. Psychologists are more likely to be female, and unlike employed people, self-employed female psychologists were more likely to be working in lone contexts, and they were unlikely to have had broader organisational and government support available to them. Yet, self-employed female psychologists still made a significant contribution to the UK's response to the Covid-19 pandemic. In addition to supporting children and adults, they have played an important role in shaping government policy, and in the delivery of mass media campaigns and public health messaging. In view of this, the current scoping study focused on how self-employed female psychologists were fairing during the unprecedented circumstances. How were their needs being met? Responses to open-ended survey questions were qualitatively examined using a thematic analysis approach. Overall, the findings suggest that lockdown has afforded some positive opportunities for self-employed female psychologists in the UK. However, for many, it has also had a detrimental impact on their family relationships, and on their own mental health and wellbeing. The findings indicate that self-employed female psychologists may need a more nuanced approach to mitigate against any long-term negative effects of Covid-19.

Structural injustice and dismantling racism in health and healthcare.

Racism in health and healthcare has long been recognised as a structural issue. While there has been growing research and a number of important initiatives that have come from approaching racism as a structural issue, there is a range of implications that yet have to be explored as they relate to health and healthcare. Conceptualising racism in this way provides a means to consider how it shapes and is shaped by a range of global injustices and serves as a foundation for more egregious harms. It also suggests that if we are to dismantle racism, we need to look both within and beyond the traditional domains of health and healthcare and account for a range of broader forces that sustain and re-enforce racism. We first discuss the issue of responsibility, drawing on Young's social connection model to argue that we all have a responsibility to take action in addressing structural racism. We will then deal with a question that naturally follows, namely how we discharge our responsibilities, with a focus on the role of disruptive action in challenging power and ignorance in dismantling racism in health and healthcare.

Comprehensive CRISPR-Cas9 screens identify genetic determinants of drug responsiveness in multiple myeloma.

The introduction of new drugs in the past years has substantially improved outcome in multiple myeloma (MM). However, the majority of patients eventually relapse and become resistant to one or multiple drugs. While the genetic landscape of relapsed/ resistant multiple myeloma has been elucidated, the causal relationship between relapse-specific gene mutations and the sensitivity to a given drug in MM has not systematically been evaluated. To determine the functional impact of gene mutations, we performed combined whole-exome sequencing (WES) of longitudinal patient samples with CRISPR-Cas9 drug resistance screens for lenalidomide, bortezomib, dexamethasone, and melphalan. WES of longitudinal samples from 16 MM patients identified a large number of mutations in each patient that were newly acquired or evolved from a small subclone (median 9, range 1-55), including recurrent mutations in TP53, DNAH5, and WSCD2. Focused CRISPR-Cas9 resistance screens against 170 relapse-specific mutations functionally linked 15 of them to drug resistance. These included cereblon E3 ligase complex members for lenalidomide, structural genes PCDHA5 and ANKMY2 for dexamethasone, RB1 and CDK2NC for bortezomib, and TP53 for melphalan. In contrast, inactivation of genes involved in the DNA damage repair pathway, including ATM, FANCA, RAD54B, and BRCC3, enhanced susceptibility to cytotoxic chemotherapy. Resistance patterns were highly drug specific with low overlap and highly correlated with the treatment-dependent clonal evolution in patients. The functional association of specific genetic alterations with drug sensitivity will help to personalize treatment of MM in the future.

The Effect of the New Eighth Edition Breast Cancer Staging System on 100 Consecutive Patients.

BACKGROUND: In October 2016 the American Joint Committee on Cancer published the early eighth edition breast cancer prognostic staging system, incorporating biomarkers into previously accepted staging. The updated and current eighth edition became effective nationwide in January 2018 after a large update to its staging guidelines. This study's aim was to compare patients' anatomic seventh edition (anatomic), early eighth (pre-update, prognostic), and current eighth (post-update, prognostic) pathological stages and to assess the utility of recent inclusions to staging criteria. Additionally, we observed how the aforementioned stage changes aligned with breast cancer histologic subtypes. METHODS: An Institutional Review Board (IRB)-approved retrospective chart review was performed. Inclusion criteria included female patients between the ages of 35 to 95 years with a diagnosis of invasive ductal or lobular carcinoma of the breast (n = 100) at three Hackensack Meridian Health hospitals. The study evaluated any trends in patients' stage changes between the seventh edition, early eighth edition, and current eighth edition breast cancer staging guidelines. Breast cancer restaging was performed using a novel staging tool on Microsoft Excel. RESULTS: Only 26% of patients' stages changed when comparing the seventh edition stage vs. current eighth edition prognostic staging, most of which were downstaged. When comparing the seventh with early eighth edition prognostic staging, 38% of the patients' stages changed, with a majority of them being upstaged. Lastly, 95% of total stage changes were downstages between the early eighth and current eighth edition staging guidelines. CONCLUSIONS: When comparing the seventh edition vs. current eighth edition staging, few patients (especially those with early stage cancer) underwent a stage change. However, there were significant changes in stage when comparing early eighth vs. current eighth stages. Considering these changes were mostly downstages and many patients reverted to their original seventh edition stage, the current eighth edition is based on a personalized, less radical staging approach, one that is more synonymous with original seventh edition staging.

High-power-load DCLM monochromator for a computed tomography program at BMIT at energies of 25-150 keV.

The research program at the biomedical imaging facility requires a high-flux hard-X-ray monochromator that can also provide a wide beam. A wide energy range is needed for standard radiography, phase-contrast imaging, K-edge subtraction imaging and monochromatic beam therapy modalities. The double-crystal Laue monochromator, developed for the BioMedical Imaging and Therapy facility, is optimized for the imaging of medium- and large-scale samples at high energies with the resolution reaching 4 µm. A pair of 2 mm-thick Si(111) bent Laue-type crystals were used in fixed-exit beam mode with a 16 mm vertical beam offset and the first crystal water-cooled. The monochromator operates at energies from 25 to 150 keV, and the measured size of the beam is 189 mm (H) × 8.6 mm (V) at 55 m from the source. This paper presents our approach in developing a complete focusing model of the monochromator. The model uses mechanical properties of crystals and benders to obtain a finite-element analysis of the complete assembly. The modeling results are compared and calibrated with experimental measurements. Using the developed analysis, a rough estimate of the bending radius and virtual focus (image) position of the first crystal can be made, which is also the real source for the second crystal. On the other hand, by measuring the beam height in several points in the SOE-1 hutch, the virtual focus of the second crystal can be estimated. The focusing model was then calibrated with measured mechanical properties, the values for the force and torque applied to the crystals were corrected, and the actual operating parameters of the monochromator for fine-tuning were provided.

Novel risk scores for survival and intracranial failure in patients treated with radiosurgery alone to melanoma brain metastases.

PURPOSE: Stereotactic radiosurgery (SRS) alone is an increasingly common treatment strategy for brain metastases. However, existing prognostic tools for overall survival (OS) were developed using cohorts of patients treated predominantly with approaches other than SRS alone. Therefore, we devised novel risk scores for OS and distant brain failure (DF) for melanoma brain metastases (MBM) treated with SRS alone. METHODS AND MATERIALS: We retrospectively reviewed 86 patients treated with SRS alone for MBM from 2009-2014. OS and DF were estimated using the Kaplan-Meier method. Cox proportional hazards modeling identified clinical risk factors. Risk scores were created based on weighted regression coefficients. OS scores range from 0-10 (0 representing best OS), and DF risk scores range from 0-5 (0 representing lowest risk of DF). Predictive power was evaluated using c-index statistics. Bootstrapping with 200 resamples tested model stability. RESULTS: The median OS was 8.1 months from SRS, and 54 (70.1 %) patients had DF at a median of 3.3 months. Risk scores for OS were predicated on performance status, extracranial disease (ED) status, number of lesions, and gender. Median OS for the low-risk group (0-3 points) was not reached. For the moderate-risk (4-6 points) and high-risk (6.5-10) groups, median OS was 7.6 months and 2.4 months, respectively (p < .0001). Scores for DF were predicated on performance status, ED status, and number of lesions. Median time to DF for the low-risk group (0 points) was not reached. For the moderate-risk (1-2 points) and high-risk (3-5 points) groups, time to DF was 4.8 and 2.0 months, respectively (p < .0001). The novel scores were more predictive (c-index = 0.72) than melanoma-specific graded prognostic assessment or RTOG recursive partitioning analysis tools (c-index = 0.66 and 0.57, respectively). CONCLUSIONS: We devised novel risk scores for MBM treated with SRS alone. These scores have implications for prognosis and treatment strategy selection (SRS versus whole-brain radiotherapy).

Higher dose rate Gamma Knife radiosurgery may provide earlier and longer-lasting pain relief for patients with trigeminal neuralgia.

OBJECT: Gamma Knife radiosurgery (GKRS) utilizes cobalt-60 as its radiation source, and thus dose rate varies as the fixed source decays over its half-life of approximately 5.26 years. This natural decay results in increasing treatment times when delivering the same cumulative dose. It is also possible, however, that the biological effective dose may change based on this dose rate even if the total dose is kept constant. Because patients are generally treated in a uniform manner, radiosurgery for trigeminal neuralgia (TN) represents a clinical model whereby biological efficacy can be tested. The authors hypothesized that higher dose rates would result in earlier and more complete pain relief but only if measured with a sensitive pain assessment tool. METHODS: One hundred thirty-three patients were treated with the Gamma Knife Model 4C unit at a single center by a single neurosurgeon during a single cobalt life cycle from January 2006 to May 2012. All patients were treated with 80 Gy with a single 4-mm isocenter without blocking. Using an output factor of 0.87, dose rates ranged from 1.28 to 2.95 Gy/min. The Brief Pain Inventory (BPI)-Facial was administered before the procedure and at the first follow-up office visit 1 month from the procedure (mean 1.3 months). Phone calls were made to evaluate patients after their procedures as part of a retrospective study. Univariate and multivariate linear regression was performed on several independent variables, including sex, age in deciles, diagnosis, follow-up duration, prior surgery, and dose rate. RESULTS: In the short-term analysis (mean 1.3 months), patients' self-reported pain intensity at its worst was significantly correlated with dose rate on multivariate analysis (p = 0.028). Similarly, patients' self-reported interference with activities of daily living was closely correlated with dose rate on multivariate analysis (p = 0.067). A 1 Gy/min decrease in dose rate resulted in a 17% decrease in pain intensity at its worst and a 22% decrease in pain interference with activities of daily living. In longer-term follow-up (mean 1.9 years), GKRS with higher dose rates (> 2.0 Gy/min; p = 0.007) and older age in deciles (p = 0.012) were associated with a lower likelihood of recurrence of pain. DISCUSSION: Prior studies investigating the role of dose rate in Gamma Knife radiosurgical ablation for TN have not used validated outcome tools to measure pain preoperatively. Consequently, differences in pain outcomes have been difficult to measure. By administering pain scales both preoperatively as well as postoperatively, the authors have identified statistically significant differences in pain intensity and pain interference with activities of daily living when comparing higher versus lower dose rates. Radiosurgery with a higher dose rate results in more pain relief at the early follow-up evaluation, and it may result in a lower recurrence rate at later follow-up.

Stereotactic radiosurgery to the resection bed for intracranial metastases and risk of leptomeningeal carcinomatosis.

OBJECT: Following resection of a brain metastasis, stereotactic radiosurgery (SRS) to the cavity is an emerging alternative to postoperative whole-brain radiation therapy (WBRT). This approach attempts to achieve local control without the neurocognitive risks associated with WBRT. The authors aimed to report the outcomes of a large patient cohort treated with this strategy. METHODS: A retrospective review identified 91 patients without a history of WBRT who received Gamma Knife (GK) SRS to 96 metastasis resection cavities between 2007 and 2013. Patterns of intracranial control were examined in the 86 cases with post-GK imaging. Survival, local failure, and distant failure were estimated by the Kaplan-Meier method. Prognostic factors were tested by univariate (log-rank test) and multivariate (Cox proportional hazards model) analyses. RESULTS: Common primary tumors were non-small cell lung (43%), melanoma (14%), and breast (13%). The cases were predominantly recursive partitioning analysis Class I (25%) or II (70%). Median preoperative metastasis diameter was 2.8 cm, and 82% of patients underwent gross-total resection. A median dose of 16 Gy was delivered to the 50% isodose line, encompassing a median treatment volume of 9.2 cm(3). Synchronous intact metastases were treated in addition to the resection bed in 43% of cases. Patients survived a median of 22.3 months from the time of GK. Local failure developed in 16 cavities, for a crude rate of 18% and 1-year actuarial local control of 81%. Preoperative metastasis diameter ≥ 3 cm and residual or recurrent tumor at the time of GK were associated with local failure (p = 0.04 and 0.008, respectively). Distant intracranial failure occurred in 55 cases (64%) at a median of 7.3 months from GK. Salvage therapies included WBRT and additional SRS in 33% and 31% of patients, respectively. Leptomeningeal carcinomatosis developed in 12 cases (14%) and was associated with breast histology and infratentorial cavities (p = 0.024 and 0.012, respectively). CONCLUSIONS: This study bolsters the existing evidence for SRS to the resection bed. Local control rates are high, but patients with larger preoperative metastases or residual/recurrent tumor at the time of SRS are more likely to fail at the cavity. While most patients develop distant intracranial failure, an SRS approach spared or delayed WBRT in the majority of cases. The risk of leptomeningeal carcinomatosis does not appear to be elevated with this strategy.

Achieving sustainable first door-to-balloon times of 90 minutes for regional transfer ST-segment elevation myocardial infarction.

OBJECTIVES: A network approach to transfer ST-segment elevation myocardial infarction (STEMI) patients can achieve durable first door-to-balloon times (1st D2B) for percutaneous coronary intervention (PCI) within 90 min. BACKGROUND: Nationally, a minority of STEMI patients from referral centers obtain 1st D2B in <2 h and even fewer in <90 min. METHODS: Included were transfer STEMI patients from 9 network hospitals treated in 2007 compared with 2008 to 2011 after installing the following initiatives: 1) established hospital referral system; 2) goal-oriented performance protocols; 3) expedited transport by ground or air; 4) first hospital activation of the PCI hospital catheterization laboratory; and 5) outreach coordinator and patient-level web-based feedback to the referring hospital. RESULTS: A total of 101 STEMI patients transported in 2007 were compared with 442 STEMI patients transferred after starting these initiatives for STEMI from 2008 to 2011, with the median door-in to door-out time decreased from 44 to 35 min (p < 0.0001), the median 1st D2B decreasing from 109.5 to 88.0 min (p < 0.0001), and the percentage under 90 min increased from 22.8% to 55.9% (p < 0.0001). Overall, throughout the study period (2007 to 2011), the transport times remained consistent (median 36.5 vs. 36.0 min, p = 0.98), whereas the PCI hospital D2B decreased from 20.0 to 16.0 min (p < 0.0001). Length of stay and in-hospital mortality remained low at 3.0 days and under 4%, respectively. CONCLUSIONS: A system-wide network program can achieve sustained (over 4 years) 1st D2B times of <90 min.

The Flinders Program™ of chronic condition self-management in New Zealand: survey findings.

INTRODUCTION: The Flinders Program™ of Chronic Condition Self-Management in New Zealand (NZ) has been given focus as a useful and appropriate approach for self-management support and improvement of long-term condition management. AIM: To determine the use of the Flinders Program™ in NZ and identify barriers and enablers to its use. METHOD: A web-based survey was undertaken in June 2009 with 355 eligible participants of the 500 who had completed 'Flinders' training in NZ since 2005. RESULTS: 152 (43%) respondents completed the survey over a one-month time frame. Of those who responded, the majority were primary care nurses (80%; 118). Fifty-five percent (82) of survey respondents reported using some or all of the Flinders tools. Of these, 11% (16) reported using all of the tools or processes with 77% (104) of respondents having completed six or fewer client assessments utilising the Flinders tools. This indicates that respondents were relatively inexperienced with use of the Flinders Program™. Barriers to implementation were identified as the time needed for structured appointments (up to one hour), funding, resistance from colleagues, lack of space and insufficient ongoing support. DISCUSSION: Despite the extent of training in the use of the Flinders Program™, there is limited use in clinical practice of the tools and processes associated with the model. Without structured support for quality improvement initiatives and self-management programmes, the ability to implement learned skills and complex interventions is limited.

The feasibility of assessing the Flinders Program™ of patient self-management in New Zealand primary care settings.

INTRODUCTION: The Flinders Program™ has been adopted in New Zealand as a useful and appropriate approach for self-management with primary care clients who have chronic conditions. The Flinders Program™ has not been evaluated in New Zealand settings. AIM: To assess the feasibility of undertaking a substantive long-term trial to gauge the effectiveness of primary care nurses using the Flinders Program™ to improve health outcomes for New Zealand populations. METHODS: A pilot study was undertaken considering four components of feasibility of conducting a long-term trial: practice recruitment, participant recruitment, delivery of the intervention and outcome measures. This included comparing 27 intervention and 30 control patients with long-term health conditions with respect to change in self-management capacity-Partners in Health (PIH) scale-quality of care using the Patient Assessment of Chronic Illness Care (PACIC) scale and self-efficacy across six months. Intervention participants received care planning with practice nurses using the Flinders Program™ in general practices, while control participants received usual care in comparable practices. RESULTS: General practice and participant recruitment was challenging, together with a lack of organisational capacity and resources in general practice for the Flinders Program™. The measures of self-management capacity (PIH), quality of care (PACIC) and self-efficacy were useful and valuable primary outcome measures. DISCUSSION: The overall findings do not support a substantive trial of the Flinders Program™ in primary care. Difficulties associated with participant recruitment and ability of practice nurses to undertake the Flinders Program™ within general practice need to be resolved.

Lessons learnt from attempting to assess the evidence base for a complex intervention introduced into New Zealand general practice.

BACKGROUND AND CONTEXT: Currently, in New Zealand general practice, the introduction of new initiatives is such that interventions may be introduced without an evidence base. A critical role is to respond to the challenges of chronic illness with self-management a key component. The 'Flinders Model' of self-management collaborative care planning developed in Australia has not been evaluated in New Zealand. A study was designed to assess the usefulness of this 'Model' when utilised by nurses in New Zealand general practice. This paper describes the issues and lessons learnt from this study designed to contribute to the evidence base for primary care. Assessment of problems Analysis of interviews with the nurses and the research team allowed documentation of difficulties. These included recruitment of practices and of patients, retention of patients and practice support for the introduction of the 'new' intervention. RESULTS OF ASSESSMENT: A lack of organisational capacity for introduction of the 'new' initiative alongside practice difficulties in understanding their patient population and inadequate disease coding contributed to problems. Undertaking a research study designed to contribute to the evidence base for an initiative not established in general practice resulted in study difficulties. LESSONS LEARNT: The need for phased approaches to evaluation of complex interventions in primary care is imperative with exploratory qualitative work first undertaken to understand barriers to implementation. Collaborative partnerships between researchers and general practice staff are essential if the evidence base for primary care is to develop and for 'new' interventions to lead to improved health outcomes.

Implementation of a Canadian external quality assurance program for breast cancer biomarkers: an initiative of Canadian Quality Control in immunohistochemistry (cIQc) and Canadian Association of Pathologists (CAP) National Standards Committee/Immunohistochemistry.

Immunohistochemistry results for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 are used to guide breast carcinoma patient management and it is essential to monitor these tests in external quality assurance (EQA) programs. Canadian Immunohistochemistry Quality Control is a web-based program with novel approach to EQA. Canadian Immunohistochemistry Quality Control RUN2 included tissue microarray slides with 38 samples tested by 18 immunohistochemical laboratories. Deidentified results were posted for viewing at www.ciqc.ca including all used protocols matched with scanned slides for virtual microscopy and garrattograms. Sensitivity, specificity, Kendall W test (concordance between laboratories), and kappa statistics (agreement with designated reference values) were calculated. Kappa values were within the target range (>0.8, or "near perfect" agreement) for 85% results. Kendall coefficient was 0.942 for estrogen receptor, 0.930 for progesterone receptor, and 0.958 for human epidermal growth factor receptor 2. The anonymous participation, quick feedback, and unrestricted full access in EQA results provides rapid insight into technical or interpretive deficiencies, allowing appropriate corrective action to be taken whereas the use of tissue microarrays enables meaningful statistical analysis.