Publications by authors named "Nicole Etherington"

23 Publications

  • Page 1 of 1

Barriers and enablers to effective interprofessional teamwork in the operating room: A qualitative study using the Theoretical Domains Framework.

PLoS One 2021 22;16(4):e0249576. Epub 2021 Apr 22.

Department of Anaesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada.

Background: Effective teamwork is critical for safe, high-quality care in the operating room (OR); however, teamwork interventions have not consistently resulted in the expected gains for patient safety or surgical culture. In order to optimize OR teamwork in a targeted and evidence-based manner, it is first necessary to conduct a comprehensive, theory-informed assessment of barriers and enablers from an interprofessional perspective.

Methods: This qualitative study was informed by the Theoretical Domains Framework (TDF). Volunteer, purposive and snowball sampling were conducted primarily across four sites in Ontario, Canada and continued until saturation was reached. Interviews were recorded, transcribed, and de-identified. Directed content analysis was conducted in duplicate using the TDF as the initial coding framework. Codes were then refined whereby similar codes were grouped into larger categories of meaning within each TDF domain, resulting in a list of domain-specific barriers and enablers.

Results: A total of 66 OR healthcare professionals participated in the study (19 Registered Nurses, two Registered Practical Nurses, 17 anaesthesiologists, 26 surgeons, two perfusionists). The most frequently identified teamwork enablers included people management, shared definition of teamwork, communication strategies, positive emotions, familiarity with team members, and alignment of teamwork with professional role. The most frequently identified teamwork barriers included others' personalities, gender, hierarchies, resource issues, lack of knowledge of best practices for teamwork, negative emotions, conflicting norms and perceptions across professions, being unfamiliar with team members, and on-call/night shifts.

Conclusions: We identified key factors influencing OR teamwork from an interprofessional perspective using a theoretically informed and systematic approach. Our findings reveal important targets for future interventions and may ultimately increase their effectiveness. Specifically, achieving optimal teamwork in the OR may require a multi-level intervention that addresses individual, team and systems-level factors with particular attention to complex social and professional hierarchies.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249576PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061974PMC
April 2021

Implementation of the Operating Room Black Box Research Program at the Ottawa Hospital Through Patient, Clinical, and Organizational Engagement: Case Study.

J Med Internet Res 2021 Mar 16;23(3):e15443. Epub 2021 Mar 16.

Department of Obstetrics, Gynecology, and Newborn Care, University of Ottawa, Ottawa, ON, Canada.

Background: A large proportion of surgical patient harm is preventable; yet, our ability to systematically learn from these incidents and improve clinical practice remains limited. The Operating Room Black Box was developed to address the need for comprehensive assessments of clinical performance in the operating room. It captures synchronized audio, video, patient, and environmental clinical data in real time, which are subsequently analyzed by a combination of expert raters and software-based algorithms. Despite its significant potential to facilitate research and practice improvement, there are many potential implementation challenges at the institutional, clinician, and patient level. This paper summarizes our approach to implementation of the Operating Room Black Box at a large academic Canadian center.

Objective: We aimed to contribute to the development of evidence-based best practices for implementing innovative technology in the operating room for direct observation of the clinical performance by using the case of the Operating Room Black Box. Specifically, we outline the systematic approach to the Operating Room Black Box implementation undertaken at our center.

Methods: Our implementation approach included seeking support from hospital leadership; building frontline support and a team of champions among patients, nurses, anesthesiologists, and surgeons; accounting for stakeholder perceptions using theory-informed qualitative interviews; engaging patients; and documenting the implementation process, including barriers and facilitators, using the consolidated framework for implementation research.

Results: During the 12-month implementation period, we conducted 23 stakeholder engagement activities with over 200 participants. We recruited 10 clinician champions representing nursing, anesthesia, and surgery. We formally interviewed 15 patients and 17 perioperative clinicians and identified key themes to include in an information campaign run as part of the implementation process. Two patient partners were engaged and advised on communications as well as grant and protocol development. Many anticipated and unanticipated challenges were encountered at all levels. Implementation was ultimately successful, with the Operating Room Black Box installed in August 2018, and data collection beginning shortly thereafter.

Conclusions: This paper represents the first step toward evidence-guided implementation of technologies for direct observation of performance for research and quality improvement in surgery. With technology increasingly being used in health care settings, the health care community should aim to optimize implementation processes in the best interest of health care professionals and patients.
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http://dx.doi.org/10.2196/15443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8074833PMC
March 2021

Impact of physician's sex/gender on processes of care, and clinical outcomes in cardiac operative care: a systematic review.

BMJ Open 2020 09 29;10(9):e037139. Epub 2020 Sep 29.

Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

Objectives: This systematic review aimed to assess the role of physician's sex and gender in relation to processes of care and/or clinical outcomes within the context of cardiac operative care.

Design: A systematic review.

Data Sources: Searches were conducted in PsycINFO, Embase and Medline from inception to 6 September 2018. The reference lists of relevant systematic reviews and included studies were also searched.

Eligibility Criteria For Selecting Studies: Quantitative studies of any design were included if they were published in English or French, involved patients of any age undergoing a cardiac surgical procedure and specifically assessed differences in processes of care or clinical patient outcomes by physician's sex or gender. Studies were screened in duplicate by two pairs of independent reviewers.

Outcome Measures: Processes of care, patient morbidity and patient mortality.

Results: The search yielded 2095 publications after duplicate removal, of which two were ultimately included. These studies involved various types of surgery, including cardiac. One study found that patients treated by female surgeons compared with male surgeons had a lower 30-day mortality. The other study, however, found no differences in patient outcomes by surgeon's sex. There were no studies that investigated anaesthesiologist's sex/gender. There were also no studies investing physician's sex or gender exclusively in the cardiac operating room.

Conclusions: The limited data surrounding the impact of physician's sex/gender on the outcomes of cardiac surgery inhibits drawing a robust conclusion at this time. Results highlight the need for primary research to determine how these factors may influence cardiac operative practice, in order to optimise provider's performance and improve outcomes in this high-risk patient group.
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http://dx.doi.org/10.1136/bmjopen-2020-037139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526284PMC
September 2020

Sex and gender analysis in knowledge translation interventions: challenges and solutions.

Health Res Policy Syst 2020 Sep 23;18(1):108. Epub 2020 Sep 23.

Vitam - Centre de recherche en santé durable, Pavillon Landry-Poulin, 2525, Chemin de la Canardière, Québec, G1J 0A4, Canada.

Sex and gender considerations are understood as essential components of knowledge translation in the design, implementation and reporting of interventions. Integrating sex and gender ensures more relevant evidence for translating into the real world. Canada offers specific funding opportunities for knowledge translation projects that integrate sex and gender. This Commentary reflects on the challenges and solutions for integrating sex and gender encountered in six funded knowledge translation projects. In 2018, six research teams funded by the Canadian Institutes of Health Research's Institute of Gender and Health met in Ottawa to discuss these challenges and solutions. Eighteen participants, including researchers, healthcare professionals, trainees and members of the Institute of Gender and Health, were divided into two groups. Two authors conducted qualitative coding and thematic analysis of the material discussed. Six themes emerged, namely Consensus building, Guidance, Design and outcomes effectiveness, Searches and recruitment, Data access and collection, and Intersection with other determinants of health. Solutions included educating stakeholders on the use of sex and gender concepts, triangulating perspectives of researchers and end-users, and participating in organisations and committees to influence policies and practices. Unresolved challenges included difficulty integrating sex and gender considerations with principles of patient-oriented research, a lack of validated measurement tools for gender, and a paucity of experts in intersectionality. We discuss our findings in the light of observations of similar initiatives elsewhere to inform the further progress of integrating sex and gender into the knowledge translation of health services research findings.
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http://dx.doi.org/10.1186/s12961-020-00625-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509920PMC
September 2020

Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis.

Br J Anaesth 2020 10 16;125(4):605-613. Epub 2020 Jul 16.

Department of Anaesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada.

Background: Handover of anaesthesia patient care during surgery is common; however, its association with patient outcome is unclear. This systematic review aimed to assess the impact of anaesthesia handover during surgery on patient outcome.

Methods: All prospective and retrospective clinical studies specifically investigating the association of intraoperative transfer of anaesthesia care between anaesthesia providers in the operating room with patient morbidity and mortality were included. Searches were conducted from inception to April 24, 2019 in Medline, Medline in Process, CINAHL, and Embase. Reference lists of included studies were searched. Studies were assessed for eligibility and data were extracted by independent reviewers in duplicate with disagreements resolved by consensus or a third reviewer. Risk of bias was assessed in duplicate using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data were summarised narratively given substantial heterogeneity. An exploratory meta-analysis was conducted using a random-effects model for a subset of comparable studies.

Results: Eight studies met the inclusion criteria. Six studies focused on patients as the unit of analysis (n=605 678) and two focused on anaesthesia providers as the unit of analysis (n=307). Seven studies identified a relationship between anaesthesia handovers and adverse patient outcomes, whereas one suggested that handover may be beneficial to error detection or rectification. Included studies were of fair or good quality. Meta-analysis of four studies found a 40% increased risk of patients experiencing an adverse event when an anaesthesia handover occurs during the procedure (pooled risk ratio=1.40; 95% confidence interval, 1.19 to 1.65; P<0.001; I=98%).

Conclusions: Intraoperative anaesthesia handovers generally increase morbidity and mortality for surgical patients but could have the potential to improve safety in certain contexts. Future research should determine the specific handover characteristics that impact safety.
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http://dx.doi.org/10.1016/j.bja.2020.05.062DOI Listing
October 2020

Applying an intersectionality lens to the theoretical domains framework: a tool for thinking about how intersecting social identities and structures of power influence behaviour.

BMC Med Res Methodol 2020 06 26;20(1):169. Epub 2020 Jun 26.

Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.

Background: A key component of the implementation process is identifying potential barriers and facilitators that need to be addressed. The Theoretical Domains Framework (TDF) is one of the most commonly used frameworks for this purpose. When applying the TDF, it is critical to understand the context in which behaviours occur. Intersectionality, which accounts for the interface between social identity factors (e.g. age, gender) and structures of power (e.g. ageism, sexism), offers a novel approach to understanding how context shapes individual decision-making and behaviour. We aimed to develop a tool to be used alongside applications of the TDF to incorporate an intersectionality lens when identifying implementation barriers and enablers.

Methods: An interdisciplinary Framework Committee (n = 17) prioritized the TDF as one of three models, theories, and frameworks (MTFs) to enhance with an intersectional lens through a modified Delphi approach. In collaboration with the wider Framework Committee, a subgroup considered all 14 TDF domains and iteratively developed recommendations for incorporating intersectionality considerations within the TDF and its domains. An iterative approach aimed at building consensus was used to finalize recommendations.

Results: Consensus on how to apply an intersectionality lens to the TDF was achieved after 12 rounds of revision. Two overarching considerations for using the intersectionality alongside the TDF were developed by the group as well as two to four prompts for each TDF domain to guide interview topic guides. Considerations and prompts were designed to assist users to reflect on how individual identities and structures of power may play a role in barriers and facilitators to behaviour change and subsequent intervention implementation.

Conclusions: Through an expert-consensus approach, we developed a tool for applying an intersectionality lens alongside the TDF. Considering the role of intersecting social factors when identifying barriers and facilitators to implementing research evidence may result in more targeted and effective interventions that better reflect the realities of those involved.
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http://dx.doi.org/10.1186/s12874-020-01056-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7318508PMC
June 2020

La définition des moments critiques et non critiques en salle d'opération : une étude de consensus Delphi modifiée.

Can J Anaesth 2020 08 6;67(8):949-958. Epub 2020 May 6.

Department of Surgery, University of Toronto, Toronto, ON, Canada.

Background: While the operating room (OR) has significantly benefited from aviation strategies to improve safety, the rate of avoidable human errors remains relatively high. One key aviation strategy that has yet to be formally established in the OR is the "sterile cockpit" rule, which prohibits all non-essential behaviours during critical moments of a flight. Applying this rule to the OR may enhance patient safety, but the critical moments of surgery need to be defined first.

Methods: This study used a modified Delphi methodology to determine critical moments during surgery according to OR team members across institutions, professions, and specialties. Analysis occurred after each round. The stopping criterion was consensus on 80% of survey items or no change in the mean score for any individual item between two consecutive rounds.

Results: The first round included 304 respondents. Of these, 115 completed the second-round survey, and 75 completed all three rounds (27 nurses, 29 anesthesiologists, 19 surgeons). Critical moments obtained by consensus were: induction of anesthesia; emergence from anesthesia; preoperative briefing; final counts at the end of the procedure; anesthesiologist- or surgeon-relevant intraoperative event; handovers; procedure-specific high-risk surgical moments; crisis resource management situations; medication and equipment preparation; and key medication administration.

Conclusions: By defining the most critical moments of surgery, future research can determine the relative importance of behaviour and actions at each stage and target interventions to these stages.
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http://dx.doi.org/10.1007/s12630-020-01688-3DOI Listing
August 2020

Can preventive hyperbaric oxygen therapy optimise surgical outcome?: A systematic review of randomised controlled trials.

Eur J Anaesthesiol 2020 Aug;37(8):636-648

From the Department of Anaesthesiology and Pain Medicine, The Ottawa Hospital (SB), Clinical Epidemiology Program, The Ottawa Hospital Research Institute (SB, ME, NE), Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (LM, OCB), Department of Diving and Hyperbaric Medicine, Sainte Anne's Military Hospital, Toulon, France (PL), Diving and hyperbaric Unit, University hospitals of Geneva, Geneva, Switzerland (PL, RP, MP, MAM), Department of Anaesthesiology and Acute Medicine, University Hospitals of Geneva, Geneva, Switzerland (MP), Department of Diving and Hyperbaric Medicine, Prince of Wales Hospital and the University of New South Wales, Randwick, New South Wales, Australia (MB).

Background: A primary underlying cause of postoperative complications is related to the surgical stress response, which may be mitigated by hyperbaric oxygen therapy (HBOT), the intermittent administration of oxygen at a pressure higher than the atmospheric pressure at sea level. Promising clinical studies have emerged suggesting HBOT's efficacy for reducing some postoperative complications. Notwithstanding, the effectiveness (if any) of HBOT across a range of procedures and postoperative outcomes has yet to be clearly quantified.

Objective: This systematic review aimed to summarise the existing literature on peri-operative HBOT to investigate its potential to optimise surgical patient outcome.

Design: A systematic review of randomised controlled trials (RCTs) with narrative summary of results.

Data Sources: MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials were searched without language restrictions through to 19 June 2018.

Eligibility Criteria: Studies were included if they involved patients of any age undergoing any surgical procedure and provided with at least one HBOT session in the peri-operative period. Two independent reviewers screened the initial identified trials and determined those to be included. Risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs.

Results: The search retrieved 775 references, of which 13 RCTs were included (627 patients). Ten RCTs (546 patients) reported treatment was effective for improving at least one of the patient outcomes assessed, while two studies (55 patients) did not find any benefit and one study (26 patients) found a negative effect. A wide range of patient outcomes were reported, and several other methodological limitations were observed among the included studies, such as limited use of sham comparator and lack of blinding.

Conclusion: Peri-operative preventive HBOT may be a promising intervention to improve surgical patient outcome. However, future work should consider addressing the methodological weaknesses identified in this review.

Trial Registration: The protocol (CRD42018102737) was registered with the International ProspectiveRegister of Systematic Reviews (PROSPERO).
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http://dx.doi.org/10.1097/EJA.0000000000001219DOI Listing
August 2020

Sex/gender and additional equity characteristics of providers and patients in perioperative anesthesia trials: a cross-sectional analysis of the literature.

Korean J Anesthesiol 2021 02 13;74(1):6-14. Epub 2020 Mar 13.

Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.

Sex and gender, among other equity-related characteristics, influence the process of care and patients' outcomes. Currently, the extent to which these characteristics are considered in the anesthesia literature remains unknown. This study assesses their incorporation in randomized controlled trials (RCTs) on anesthesia-related interventions, for both patients and healthcare providers. This is a cross-sectional analysis using an existing dataset derived from the anesthesia literature. The dataset originated from a scoping review searching MEDLINE, Embase, CINAHL, CENTRAL, and the Cochrane Database of Systematic reviews. RCTs investigating the effect of anesthesia-related interventions on mortality for adults undergoing surgery were included. Equity outcome measures were recorded for both patients and providers and assessed for inclusion in the study design, reporting of results, and analysis of intervention effects. Three-hundred sixty-one RCTs (n = 144,674) were included. Most RCTs (91%) reported patient sex/gender, with 58% of patients identified as male. There were 139 studies (39%), where 70% or more of the sample was male, compared to just 14 studies (4%), where 70% or more of the sample was female. Only 10 studies (3%) analyzed results by patient sex/gender, with one reporting a significant effect. There was substantial variation in how age was reported, although nearly all studies (98%) reported some measure of age. For healthcare providers, equity-related information was never available. Better consideration of sex/gender and additional health equity parameters for both patients and providers in RCTs is needed to improve evidence quality, and ultimately, patient care and outcome.
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http://dx.doi.org/10.4097/kja.19484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7862933PMC
February 2021

Measuring the teamwork performance of operating room teams: a systematic review of assessment tools and their measurement properties.

J Interprof Care 2021 Jan-Feb;35(1):37-45. Epub 2019 Dec 22.

Clinical Epidemiology Program, The Ottawa Hospital Research Institute.

Teamwork is fundamental to surgical patient safety but is inconsistently measured. While many tools have been developed for elective intraoperative situations, it is unclear which is the most robust. This systematic review aimed to identify tools to measure the teamwork of operating room teams. Studies were included if they examined the measurement properties of these tools. PsycINFO, Embase (via OVID), CINAHL, ERIC, Medline and Medline in Process (via OVID) were searched through to May 3, 2019, as were reference lists of included studies and previously published relevant reviews. Retrieved articles were screened and data extracted in duplicate by two independent reviewers. Quality was assessed using the COSMIN checklist. Of the 2121 references identified, 14 studies of six assessment tools were included. Tools were validated across various specialties, mostly in clinical rather than simulated settings. The Observational Teamwork Assessment for Surgery (OTAS) and Operating Theater Team Non-Technical Skills Assessment Tool (NOTECHS) were the most frequently investigated tools. Though acceptable for assessing teamwork, both NOTECHS and OTAS rely on the questionable assumption that the teamwork of a team is equivalent to the sum of individual performances. Future studies may investigate other assessment tools that assess the whole team as the unit of analysis along with the potential of these tools to provide healthcare providers with meaningful feedback in clinical practice.
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http://dx.doi.org/10.1080/13561820.2019.1702931DOI Listing
December 2019

Interventions for improving teamwork in intrapartem care: a systematic review of randomised controlled trials.

BMJ Qual Saf 2020 01 10;29(1):77-85. Epub 2019 Oct 10.

Department of Anesthesiology and Pain Medicine, Ottawa Hospital, Ottawa, Ontario, Canada

Background: The labour and delivery environment relies heavily on interdisciplinary collaboration from anaesthesiologists, obstetricians and nurses or midwives to deliver optimal patient care. A large number of adverse events in obstetrics are associated with failure in communication and teamwork among team members, with substantive consequences. The objective of this study is to perform a systematic review of interventions aimed at improving teamwork in obstetrics.

Methods: This systematic review identified and assessed randomised controlled trials (RCTs) of interventions aimed at improving teamwork among interdisciplinary teams in obstetrical care. Medline, CENTRAL, CINAHL and Embase were searched for studies evaluating one of: patient outcomes, team performance or processes of clinical efficiency. Identified citations were reviewed in duplicate for eligibility.

Results: Nine RCTs met the inclusion criteria; five of these RCTs were conducted under simulated clinical environments. Simulation-based teamwork training interventions were the most represented (n=7 studies, 3047 healthcare providers (HCPs), 107 782 births), followed by checklists (n=1 study, 136 HCPs) and an electronic-based decision support tool (n=1 study, 296 HCPs). Simulation-based teamwork training was found to improve team performance in 100% of relevant studies (3 of 3 studies assessing team performance) and patient morbidity in 75% of relevant studies (3 of 4 studies assessing patient morbidity). However, no direct mortality benefit was identified among all the studies reviewed. Studies were assessed to be of low-moderate quality and had significant limitations in their study designs.

Conclusion: While the evidence is still limited and from low to moderate quality RCTs, simulation-based teamwork interventions appear to improve team performance and patient morbidity in labour and delivery care.

Prospero Trial Registration Number: CRD42018090452.
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http://dx.doi.org/10.1136/bmjqs-2019-009689DOI Listing
January 2020

Evidence for simulation-based education in hyperbaric medicine: A systematic review.

Diving Hyperb Med 2019 Sep;49(3):209-215

Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.

Introduction: Evidence from many areas of healthcare suggests that skills learned during simulation transfer to clinical settings; however, this has not yet been investigated in hyperbaric medicine. This systematic review aimed to identify, summarize, and assess the impact of simulation-based education in hyperbaric medicine.

Methods: Eligible studies investigated the effect of simulation-based education for learning in hyperbaric medicine, used any design, and were published in English in a peer-reviewed journal. Learning outcomes across all Kirkpatrick levels were included. MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched. Pairs of independent reviewers assessed references for study eligibility.

Results: We found no article assessing the impact of simulation-based education in hyperbaric medicine published in English. Only one potentially relevant paper published in German was found.

Conclusions: More research is needed to determine how the hyperbaric medicine community and their patients may benefit from simulation-based education to optimize both practice and patient care.
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http://dx.doi.org/10.28920/dhm49.3.209-215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6884102PMC
September 2019

Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework.

BMJ Open Qual 2019 1;8(3):e000686. Epub 2019 Aug 1.

Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.

Background: Systematically observing clinical performance in the operating room (OR) to support patient safety initiatives faces numerous logistical and methodological challenges. These may be solved by new audio-video recording technologies like the OR Black Box, which is a tool similar to black boxes in aviation. This study aimed to identify barriers and enablers that may influence patients', clinicians' and senior leadership team members' support of the OR Black Box in order to guide its future implementation.

Methods: Patients, clinicians and senior leadership team members were recruited to participate in semistructured interviews informed by the theoretical domains framework (TDF) to identify factors relevant to planning OR Black Box implementation. Deidentified interview transcripts were analysed in duplicate following a TDF coding structure.

Results: Data saturation was achieved at 15 patients, 17 clinicians and 9 senior leadership team members. Seven domains were relevant for patients, nine for clinicians and four for senior leadership. Knowledge and Beliefs about consequences were barriers and enablers for all three groups. Memory, attention and decision processes and Social influences were enablers for both clinicians and senior leadership. Environmental context and resources, Emotion and Behavioural regulation were found to be barriers and enablers for both clinicians and patients. Social/professional role and identity and Reinforcement were enablers for patients only and Optimism and Intentions were barriers and enablers to clinicians.

Conclusions: While most stakeholders were supportive of the OR Black Box, we identified many key areas that need to be addressed during its implementation. It is critical to ensure all stakeholders have adequate and accurate information about the OR Black Box system and research goals, and that the OR Black Box is positioned as a patient safety initiative for learning from and improving practice.
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http://dx.doi.org/10.1136/bmjoq-2019-000686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683111PMC
August 2019

Interprofessional communication in the operating room: a narrative review to advance research and practice.

Can J Anaesth 2019 Oct 28;66(10):1251-1260. Epub 2019 May 28.

Department of Anaesthesiology & Pain Medicine, The Ottawa Hospital, Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.

Purpose: Communication failures are often at the root of adverse events for surgical patients; however, evidence to inform best communication practice in the operating room is relatively limited. This narrative review outlines the importance of interprofessional communication for surgical patient safety, maps its barriers and facilitators, and highlights key strategies for enhancing communication quality in the operating room. Based on this review, a research agenda to inform best practices in interprofessional operating room communication is suggested.

Source: The non-systematic literature search included searches of relevant databases (Medline (via OVID), PubMed, Scopus, and EMBASE, PsycINFO, CINAHL), relevant grey literature sources (e.g., patient safety institute websites), and reference lists of selected articles.

Principal Findings: Effective interprofessional communication plays a critical role in the operating room, but faces many challenges at the individual, team, environmental, and organizational level. Factors that support effective communication are less documented than barriers, but include team integration, flattened hierarchies, and structure/standardization. Checklists, safety briefings, and teamwork/communication training are the most common techniques used to improve communication in the operating room. Of all communication techniques, closed-loop communication may be the most practical and inexpensive strategy.

Conclusion: The perioperative community should be encouraged to implement existing effective solutions to improve communication and investigate creative solutions to identified barriers. Improved methods of data collection are needed to enhance evidence quality, increase understanding of communication barriers and facilitators, and identify the best strategy to advance practice.
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http://dx.doi.org/10.1007/s12630-019-01413-9DOI Listing
October 2019

Anesthesia interventions that alter perioperative mortality: a scoping review.

Syst Rev 2018 11 30;7(1):218. Epub 2018 Nov 30.

Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Rd, Critical Care Wing 1401, Ottawa, Ontario, K1H 8L6, Canada.

Background: With over 230 million surgical procedures performed annually worldwide, better application of evidence in anesthesia and perioperative medicine may reduce widespread variation in clinical practice and improve patient care. However, a comprehensive summary of the complete available evidence has yet to be conducted. This scoping review aims to map the existing literature investigating perioperative anesthesia interventions and their potential impact on patient mortality, to inform future knowledge translation and ultimately improve perioperative clinical practice.

Methods: Searches were conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library databases from inception to March 2015. Study inclusion criteria were adult patients, surgical procedures requiring anesthesia, perioperative intervention conducted/organized by a professional with training in anesthesia, randomized controlled trials (RCTs), and patient mortality as an outcome. Studies were screened for inclusion, and data was extracted in duplicate by pairs of independent reviewers. Data were extracted, tabulated, and reported thematically.

Results: Among the 10,505 publications identified, 369 RCTs (n = 147,326 patients) met the eligibility criteria. While 15 intervention themes were identified, only 7 themes (39 studies) had a significant impact on mortality: pharmacotherapy (n = 23), nutritional (n = 3), transfusion (n = 4), ventilation (n = 5), glucose control (n = 1), medical device (n = 2), and dialysis (n = 1).

Conclusions: By mapping intervention themes, this scoping review has identified areas requiring further systematic investigation given their potential value for reducing patient mortality as well as areas where continued investment may not be cost-effective given limited evidence for improving survival. This is a key starting point for future knowledge translation to optimize anesthesia practice.
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http://dx.doi.org/10.1186/s13643-018-0863-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6267894PMC
November 2018

Measuring the teamwork performance of teams in crisis situations: a systematic review of assessment tools and their measurement properties.

BMJ Qual Saf 2019 04 11;28(4):327-337. Epub 2018 Oct 11.

Division of General Surgery, St Michael's Hospital, Toronto, Canada.

Background: Educational interventions to improve teamwork in crisis situations have proliferated in recent years with substantial variation in teamwork measurement. This systematic review aimed to synthesise available tools and their measurement properties in order to identify the most robust tool for measuring the teamwork performance of in crisis situations.

Methods: Searches were conducted in Embase (via OVID), PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Education Resources Information Center, Medline and Medline In-Process (via OVID) (through 12 January 2017). Studies evaluating the measurement properties of teamwork assessment tools for in clinical or simulated crisis situations were included. Two independent reviewers screened studies based on predetermined criteria and completed data extraction. Risk of bias was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

Results: The search yielded 1822 references. Twenty studies were included, representing 13 assessment tools. Tools were primarily assessed in simulated resuscitation scenarios for emergency department teams. The Team Emergency Assessment Measure (TEAM) had the most validation studies (n=5), which demonstrated three sources of validity (content, construct and concurrent) and three sources of reliability (internal consistency, inter-rater reliability and test-retest reliability). Most studies of TEAM's measurement properties were at no risk of bias.

Conclusions: A number of tools are available for assessing teamwork performance of teams in crisis situations. Although selection will ultimately depend on the user's context, TEAM may be the most promising tool given its measurement evidence. Currently, there is a lack of tools to assess teamwork performance during intraoperative crisis situations. Additional research is needed in this regard.
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http://dx.doi.org/10.1136/bmjqs-2018-008260DOI Listing
April 2019

Exploring experiences with compulsory psychiatric community treatment: A qualitative multi-perspective pilot study in an urban Canadian context.

Int J Law Psychiatry 2018 Mar - Apr;57:122-130. Epub 2018 Mar 2.

Mental Health Services, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Faculty of Medicine, University of Toronto, 250 College Street, 8th Floor, Toronto, Ontario M5T 1R8, Canada. Electronic address:

As medical, ethical and clinical effectiveness debates about the use of compulsory psychiatric treatment continues, it is important to further explore the actual experiences and perspectives of all relevant stakeholders in community treatment orders (CTOs). This qualitative pilot study engaged a total of twenty-seven clients, their family members, and care providers in Toronto, Canada. Semi-structured, one-on-one interviews were conducted between February and July 2013 and analyzed using thematic analysis. Top key themes from all the participants identified include, among others: 1) clients' experiences of coercion while treated under CTO, but a preference for CTOs compared to involuntary hospitalization, nevertheless; 2) limited real opportunities for collaboration in treatment decisions expressed by clients and family members; 3) acceptance of the potential for clinical recovery on CTOs while debating the role of CTO in a broader recovery journey by all stakeholders; 4) general preservation of therapeutic relationships between clients and care providers, while acknowledging the tension of taking on an "enforcer" role by providers; and 5) existence of different avenues for asserting agency by clients. The findings of this research illuminate the nuanced, complex, and adaptive perspectives held by different stakeholders, point to the importance of preserving and enhancing procedural justice in their use, and alert the field to incorporate recovery-based approaches in this controversial practice that is a widely and commonly used clinical tool across many jurisdictions.
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http://dx.doi.org/10.1016/j.ijlp.2018.02.007DOI Listing
March 2019

Evaluating the Effectiveness of Online Training for a Comprehensive Violence Against Women Program: A Pilot Study.

J Interpers Violence 2021 01 24;36(1-2):160-183. Epub 2017 Aug 24.

Ontario Association of Interval & Transition Houses, Toronto, Canada.

Evaluating violence against women (VAW) training is essential to moving the field forward with proven approaches that can improve service provision for survivors of violence. Given existing resource constraints involved in VAW work, online training represents an economical and flexible option; however, existing evaluations of online programs in the VAW field are scant and face a variety of limitations. This study aimed to fill this gap by using a pre-/posttest design, comparison group, and mixed-method analysis to assess the effectiveness and value of an online training program. The program was intended to provide foundational knowledge in feminist antiviolence principles and values to a range of individuals working with survivors of intimate partner violence (IPV). Program participants ( = 108) included volunteers, students, and professionals from various sectors, allowing for the application of the results to a broader field of VAW support services. This is important as individuals who work with IPV survivors may do so in a range of settings outside of the shelter context. Results demonstrate the potential for online VAW training to improve participants' knowledge of and attitudes about VAW, which can positively inform their work with survivors. Qualitative responses provide further insight into course impact and highlight positive and negative aspects of the course. Although preliminary, these results provide justification for continued development and evaluation of online VAW training programs.
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http://dx.doi.org/10.1177/0886260517725734DOI Listing
January 2021

Re-evaluating gender differences in self-rated health: The importance of cohort.

J Women Aging 2017 Mar-Apr;29(2):150-162. Epub 2016 Jul 21.

a Department of Sociology , University of Western Ontario , London , Ontario , Canada.

Research examining gender differences in self-rated health (SRH) has typically not distinguished between age and cohort-related changes in the health of men and women over time. Using longitudinal data from the Panel Study of Income Dynamics, this study finds gender diffegrences in SRH may actually be an artifact of cohort. Prior to examining health across cohorts, women reported worse health than men. With the introduction of cohort to the models, no gender difference was found except in the earliest cohort (born 1924-1933). Historical context is therefore critical to understanding the health trajectories of women and men, which are not uniform across cohorts.
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http://dx.doi.org/10.1080/08952841.2016.1108737DOI Listing
June 2017

Quality of Life and Self-Determination: Youth with Chronic Health Conditions Make the Connection.

Appl Res Qual Life 2016;11:571-599. Epub 2015 Jan 7.

Bloorview Research Institute, 150 Kilgour Road, Toronto, ON Canada M4G 1R8.

While optimizing quality of life (QOL) is a key goal of rehabilitation care, no previous study has reported on what 'QOL' means to youth with chronic health conditions. In addition, no qualitative studies have explored the relationship between QOL and self-determination (SD). Objectives of this qualitative study were to examine: what the terms 'quality of life' and 'self-determination' mean to youth with chronic conditions; the factors these youth think are linked with these concepts; the relationship they see between concepts, the types of future goals youth have and how they view the connection between their SD and these goals. A descriptive methodology was used. A purposive sample of 15 youth aged 15 to 20 years was obtained. Youth had cerebral palsy, a central nervous system disorder, or autism spectrum disorder. Semi-structured interviews were conducted first, followed by a focus group. Line-by-line coding of transcripts was completed, codes were collapsed into categories, and themes identified. Participants viewed QOL as an overarching personal evaluation of their life, and used terms such as satisfaction and happiness to describe the concept. Factors related to QOL included: 'relationships', 'supportive environments', 'doing things', 'personal growth and moving forward', and 'understanding of self/acceptance of disability'. Participants described SD in such terms as confidence and motivation. Contributors to SD were: 'personal strengths', 'interdependence', and 'functional independence'. SD was considered important to QOL. Youth goals were reflective of the goals of most adolescents. They identified the importance of having key goals that were of personal interest to them. This study adds consumer-based information to the debate over the meaning of QOL. Service providers and decision makers should be aware of the factors that youth feel impact their QOL and SD, the importance of SD to youth QOL, and of SD to future goals, and consider this information when tailoring therapeutic interventions.
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http://dx.doi.org/10.1007/s11482-014-9382-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4917566PMC
January 2015

From "Buzzword" to Best Practice: Applying Intersectionality to Children Exposed to Intimate Partner Violence.

Trauma Violence Abuse 2018 01 7;19(1):58-75. Epub 2016 Mar 7.

1 Centre for Research & Education on Violence Against Women & Children, Faculty of Education, Western University, London, Ontario, Canada.

Empirical studies on the impact of intimate partner violence (IPV) on children have burgeoned over the last three decades. Notably absent from existing approaches to studying children exposed to IPV, however, is attention to how various positionalities intersect to impact the experiences of children and their families. In fact, while the importance of an intersectional framework for understanding IPV has been discussed for over two decades, little or no attention has been given to issues of children's exposure to IPV. In this article, we examine the current state of the literature on children exposed to IPV through an exploratory meta-analysis, finding limited application of intersectionality and a focus on discrete categories of difference. We then demonstrate why and how an intersectional framework should be applied to children exposed to IPV, with specific strategies for research and policy. We suggest a child-centered approach that recognizes diversity among children exposed to IPV, extending the challenge to traditional "one-size-fits-all" models to include an intersectionality-informed stance.
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http://dx.doi.org/10.1177/1524838016631128DOI Listing
January 2018

Maternal factors and the emotional and behavioural functioning of adolescents with chronic health conditions.

Disabil Rehabil 2016 07 27;38(14):1359-69. Epub 2015 Oct 27.

d Centre for Child Development, Bloorview Research Institute , Toronto , Ontario , Canada.

Purpose: This study investigated the association between mothers' mental health and education and the emotional and behavioural functioning of adolescents with chronic health conditions over time.

Methods: Data were drawn from an ongoing study. Study participants (N = 363) were recruited through eight children's rehabilitation centres. Logistic regression models were estimated.

Results: There were significantly reduced odds that girls would display clinical signs of hyperactivity/inattention one year later compared to boys when a maternal mental health condition was present (OR = 0.10; p < 0.01). Where low maternal education was present, girls were more likely to display peer relationship problems one year later (OR = 3.72; p < 0.01). For both genders, having a mother with less than a high school education was also associated with conduct problems one year later (OR = 2.89; p < 0.01).

Conclusions: Findings support a link between maternal factors and emotional and behavioural functioning in adolescents with chronic conditions. A holistic and family-centred approach to assessment and service delivery is indicated. Implications for Rehabilitation When conducting clinical assessments, service providers should consider associations between maternal education and mental health and the emotional and behavioural functioning of adolescents with chronic health conditions. A holistic and family-centred approach to assessment and service delivery is indicated to ensure adolescents with chronic conditions and their families receive support for interrelated needs.
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http://dx.doi.org/10.3109/09638288.2015.1099055DOI Listing
July 2016

Race, Gender, and the Resources That Matter: An Investigation of Intersectionality and Health.

Women Health 2015 29;55(7):754-77. Epub 2015 May 29.

a Department of Sociology, Social Science Centre , The University of Western Ontario , London , Ontario , Canada.

This study examined racial disparities in health among women, in particular, the relationship between social status and both the development of psychosocial resources and good health. These relationships were investigated using a sample of 869 women from the 2007 wave of the U.S. Panel Study of Income Dynamics, Child Development Supplement. While Black women developed the intrapersonal rewards of self-efficacy and self-esteem through socioeconomic status, they did not experience the same degree of health benefits with these advantages as White women. Models relating both self-rated health and chronic conditions suggested that, instead, highly educated Black women were at a persistent health disadvantage relative to Whites, even at the same levels of psychosocial resources. That being said, Black women with higher self-efficacy, and particularly, higher self-esteem, were more likely than Black women with lower levels of these resources to report being in better health. Thus, resources may improve health within a disadvantaged group while still not bringing them up to the level of health experienced by their advantaged counterparts. Overall, the findings demonstrated that research should not treat women as a homogenous group, assuming that mechanisms affecting health operate the same for women regardless of their race.
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http://dx.doi.org/10.1080/03630242.2015.1050544DOI Listing
January 2016
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