Resident hesitation in the operating room: does uncertainty equal incompetence?

Context

In postgraduate medical programmes, the progressive development of autonomy places residents in situations in which they must cope with uncertainty. We explored the phenomenon of hesitation, triggered by uncertainty, in the context of the operating room in order to understand the social behaviours surrounding supervision and progressive autonomy.

Methods

Nine surgical residents and their supervising surgeons at a Canadian medical school were selected. Each resident–supervisor pair was observed during a surgical procedure and subsequently participated in separate post‐observation, semi‐structured interviews. Constructivist grounded theory was used to guide the collection and analysis of data.

Results

Three hesitation‐related themes were identified: the principle of progress; the meaning of hesitation, and the judgement of competence. Supervisors and residents understood hesitation in the context of a core surgical principle we termed the ‘principle of progress’. This principle reflects the supervisors’ and residents’ shared norm that maintaining progress throughout a surgical procedure is of utmost importance. Resident hesitation was perceived as the first indication of a disruption to this principle and was therefore interpreted by supervisors and residents alike as a sign of incompetence. This interpretation influenced the teaching–learning process during these moments when residents were working at the edge of their abilities.

Conclusions

The principle of progress influences the meaning of hesitation which, in turn, shapes judgements of competence. This has important implications for teaching and learning in direct supervision settings such as surgery. Without efforts to change the perception that hesitation represents incompetence, these potential teaching–learning moments will not fully support progressive autonomy.

     

Junior staffing changes and the temporal ecology of adverse incidents in acute psychiatric wards

AIM: This paper reports an examination of the relationship between adverse incident rates, the arrival of new junior staff on wards, and days of the week on acute psychiatric wards. BACKGROUND: Incidents of violence, absconding and self-harm in acute inpatient services pose risks to patients and staff. Previous research suggests that the arrival of inexperienced new staff may trigger more adverse incidents. Findings on the relationship between incidents and the weekly routine are inconsistent. METHOD: A retrospective analysis was conducted of formally reported incident rates, records of nursing student allocations and junior doctor rotation patterns, using Poisson Regression. Variance between days of the week was explored using contingency table analysis. The data covered 30 months on 17 psychiatric wards, and were collected in 2002-2004. FINDINGS: The arrival of new and inexperienced staff on the wards was not associated with increases in adverse incident rates. Most types of incidents were less frequent at weekends and midweek. Incident rates were unchanged on ward-round days, but increased rates were found on the days before and after ward rounds. CONCLUSION: Increased patient tension is associated with raised incident rates. It may be possible to reduce incident rates by moderating stimulation in the environment and by mobilizing support for patients during critical periods.     

Interventions in healthcare-associated infection: researchers urged to CONSORT with ORION

The ORION (Outbreak Reports and Intervention studies Of Nosocomial infection) statement has been prepared by a group of investigators with the expressed purpose of increasing the quality of research and reporting in the area of nosocomial infection. It is hoped that publication of the ORION statement will aid investigators in the design, performance and reporting of studies in this area, and will encourage journals and research councils to incorporate it into their submission and reviewing processes.     

The impact of team processes on psychiatric case management

Title. The impact of team processes on psychiatric case management Aim. This paper is a report of a study to identify the structures and interactions within community mental health teams that facilitate or impede effective teamwork and psychiatric case management. Background. Effective case management requires close collaboration between case managers or care co‐ordinators and other members of the multidisciplinary mental health team, yet there has been little research into this relationship. Method. A multiple case study of seven United Kingdom community mental health teams was conducted between 1999 and 2001, using qualitative methods of participant observation, semi‐structured interviews and document review. Findings. Factors were identified that impacted on the ability of care co‐ordinators to act effectively: ‘structure and procedures’; ‘disrespect and withdrawal’; ‘humour and undermining’; ‘safety and disclosure’. Care co‐ordination was enhanced when team structures and policies were in place and where team interactions were respectful. Where members felt disrespected or undermined, communication, information sharing and collaboration were impaired, with a negative impact on the care provided to service users. Conclusions. Teams require clear operating procedures alongside interprofessional trust and respect to ensure that there is open, safe and reflective participation. Further research is required to identify how best to bring about collaborative, effective teamwork in mental healthcare.     

Physicomechanical evaluation of low-shrinkage dental nanocomposites based on silsesquioxane cores

This study aimed to determine the modulus, hardness, and polymerization shrinkage of novel silsesquioxane (SSQ)-based nanocomposites synthesized for dental applications. Four novel SSQ materials were developed and mixed with control monomers in 5, 10, 20, and 50 wt% SSQ nanocomposite ratios and were evaluated for use as potential low-shrinkage composite restoratives. The postgel polymerization shrinkage of the hybrid materials was then investigated and compared with unfilled 1:1 (control) bisphenol A glycerolate (1 glycerol/phenol) dimethacrylate/tri(ethylene glycol) dimethacrylate (Bis-GMA/TEGDMA) materials using a strain-monitoring device and test configuration. Mechanical properties, such as hardness and modulus, were determined using the depth-sensing microindentation approach. All samples investigated were polymerized using a dental light-curing unit (BISCO VIP) at 500 mW cm(-2) for 40 s. The results obtained were analyzed using analysis of variance/Scheffe's posthoc test at a significance level of 0.05. At 60 min postlight polymerization, postgel shrinkage associated with the control was found to be significantly higher than for all control/SSQ mixtures. Hardness and modulus were found to decrease with increased amount of SSQ monomers added, indicating that the incorporation of SSQ monomers into the control generally helps to reduce both the rigidity and the polymerization shrinkage. Therefore, in the correct formulation, SSQ materials have great potential to be used as low-shrinkage composite restoratives.