Results to date are promising and this relatively young field is now close to a point where these kinds of cognitive interventions can be recommended to educators. Further research with refined methodology and more diverse samples is required before firm recommendations may be made for medical education and policy; however, these results suggest that such interventions hold promise, with much current enthusiasm for new research.

Objectives: To synthesize the literature describing compliance with WHO hand hygiene (HH) guidelines in Intensive Care Units (ICUs), to evaluate the quality of extant research, and to examine differences in compliance rates across geographical regions, ICU types, and healthcare worker groups, observation methods, and Moments (indications) of HH. Data sources: Electronic searches were conducted in August 2018 using Medline, CINAHL, PsycInfo, Embase, and Web of Science. Reference lists of included studies and related review articles were also screened. Study selection: English-language, peer-reviewed studies measuring HH compliance by healthcare workers in an ICU setting using direct observation guided by the WHO's 'Five Moments of Hand Hygiene', published since 2009, were included. Data extraction: Information was extracted on study location, research design, type of ICU, healthcare workers, measurement procedures, and compliance rates. Data synthesis: Sixty-one studies were included. Most were conducted in high-income countries (60.7%) and in adult ICUs (85.2%). Mean HH compliance was 59.6%. Compliance rates appeared to differ by geographic region (high-income countries 64.5%, low-income countries 9.1%), type of ICU (neonatal 67.0%, pediatric 41.2%, adult 58.2%), and type of healthcare worker (nursing staff 43.4%, physicians 32.6%, other staff 53.8%). Conclusions: Mean HH compliance appears notably lower than international targets. The data collated may offer useful benchmarks for those evaluating, and seeking to improve, hand hygiene compliance in ICUs internationally.

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Psychometric Evaluation of a Measure of Factors Influencing Hand Hygiene Behaviour to Inform Intervention Background. Although the hand hygiene (HH) procedure is simple, the related behaviour is complex and is not readily understood, explained, or changed. There is a need for practical tools to provide data that can guide healthcare managers and practitioners not only on the 'what' (the standards that must be met), but also the 'how' (guidance on how to achieve the standards). Aim. To develop a valid questionnaire to evaluate attitudes to the factors that influence engagement in HH behaviour that can be readily completed, administered, and analysed by healthcare professionals to identify appropriate intervention strategies. Construct validity was assessed using confirmatory factor analysis, predictive validity through comparison with selfreported HH behaviour, and convergent validity through direct unit-level observation of HH behaviour. Methods. The Capability, Opportunity, Motivation-Behaviour (COM-B) model was used to design a 25-item questionnaire that was distributed to Intensive Care Unit (ICU) personnel in Ireland. Direct observation of HH behaviour was carried out at two ICUs. Findings. A total of 292 responses to the survey (response rate 41.0%) were included in the analysis. Confirmatory factor analysis resulted in a 17-item questionnaire. Multiple regression revealed that a model including Capability, Opportunity, and Motivation, was a significant predictor of self-reported Behavioural intention (F(3,209) =22.58, p<0.001). However, the Opportunity factor was not found to make a significant contribution to the regression model. Conclusion. The COMB HH questionnaire is reliable and valid and provides data to support the development, and evaluation, of HH interventions that meet the needs of specific healthcare units.

Background: Improving hand hygiene (HH) compliance is one of the most important, but elusive, goals of infection control. The purpose of this study was to use the capability (C), opportunity (O), motivation (M), and behaviour (B; COMB) model and the theoretical domains framework (TDF) to gain an understanding of the barriers and enablers of HH behaviours in an intensive care unit (ICU) in order to identify specific interventions to improve HH compliance. Methods: A semi-structured interview schedule was developed based upon the COMB model. This schedule was used to interview a total of 26 ICU staff: 12 ICU nurses, 11 anaesthetic specialist registrars, and three anaesthetic senior house officers. Results: Participants were confident in their capabilities to carry out appropriate HH behaviours. The vast majority of participants reported having the necessary knowledge and skills, and believed they were capable of carrying out appropriate HH behaviours. Social influence was regarded as being important in encouraging HH compliance by the interviewees-particularly by nurses. The participants were motivated to carry out HH behaviours, and it was recognised that HH was an important part of their job and is important in preventing infection. It is recommended that staff are provided with targeted HH training, in which individuals receive direct and individualised feedback on actual performance and are provided guidance on how to address deficiencies in HH compliance at the bedside at the time at which the HH behaviour is performed. Modelling of appropriate HH behaviours by senior leaders is also suggested, particularly by senior doctors. Finally, appropriate levels of staffing are a factor that must be considered if HH compliance is to be improved. Conclusions: This study has demonstrated that short interviews with ICU staff, founded on appropriate behavioural change frameworks, can provide an understanding of HH behaviour. This understanding can then be applied to design interventions appropriately tailored to the needs of a specific unit, which will have an increased likelihood of improving HH compliance.

Background Prehospital care is potentially hazardous with the possibility for patients to experience an adverse event. However, as compared to secondary care, little is known about how patient safety is managed in prehospital care settings. Objectives The objectives of this systematic review were to identify and classify the methods of measuring and monitoring patient safety that have been used in prehospital care using the five dimensions of the Measuring and Monitoring Safety (MMS) framework and use this classification to identify where there are safety ‘blind spots’ and make recommendations for how these deficits could be addressed. Methods Searches were conducted in January 2020, with no limit on publication year, using Medline, PsycInfo, CINAHL, Web of Science and Academic Search. Reference lists of included studies and existing related reviews were also screened. English-language, peer-reviewed studies concerned with measuring and monitoring safety in prehospital care were included. Two researchers independently extracted data from studies and applied a quality appraisal tool (the Quality Assessment Tool for Studies with Diverse Designs). Results A total of 5301 studies were screened, with 52 included in the review. A total of 73% (38/52) of the studies assessed past harm, 25% (13/52) the reliability of safety critical processes, 1.9% (1/52) sensitivity to operations, 38.5% (20/52) anticipation and preparedness and 5.8% (3/52) integration and learning. A total of 67 methods for measuring and monitoring safety were used across the included studies. Of these methods, 38.8% (26/67) were surveys, 29.9% (20/67) were patient records reviews, 14.9% (10/67) were incident reporting systems, 11.9% (8/67) were interviews or focus groups and 4.5% (3/67) were checklists. Conclusions There is no single method of measuring and monitoring safety in prehospital care. Arguably, most safety monitoring systems have evolved, rather than been designed. This leads to safety blind spots in which information is lacking, as well as to redundancy and duplication of effort. It is suggested that the findings from this systematic review, informed by the MMS framework, can provide a structure for critically thinking about how safety is being measured and monitored in prehospital care. This will support the design of a safety surveillance system that provides a comprehensive understanding of what is being done well, where improvements should be made and whether safety interventions have had the desired effect.

Fatigue is a debilitating and common condition in cancer patients. This study examined pretreatment predictors of fatigue before chemotherapy and also assessed whether these could prospectively predict fatigue posttreatment. A total of 100 patients completed questionnaires assessing psychological factors, physical activity and sleep. A subsample of 26 participants wore actigraphs to objectively assess sleep/wake and activity/rest. Fatigue was measured pretreatment and posttreatment and at follow-up several months later. Greater pretreatment pain, depression, stress and sleep disruption significantly predicted greater fatigue before chemotherapy, explaining 55 percent of the variance. Pretreatment fatigue significantly predicted post-treatment fatigue. No other significant prospective predictors of posttreatment fatigue emerged.

Background: Guided reflection interventions, in an effort to reduce diagnostic error, encourage diagnosticians to generate alternative diagnostic hypotheses and gather confirming and disconfirming evidence before making a final diagnosis. This method has been found to significantly improve diagnostic accuracy in recent studies; however, it requires a significant investment of time, and psychological theory suggests the possibility for unintended consequences owing to cognitive bias. This study compared a short and long version of a guided reflection task on improvements in diagnostic accuracy, change in diagnostic confidence, and rates of corrected diagnoses.Methods: One hundred and eighty-six fourth- and fifth-year medical students diagnosed a series of fictional clinical cases, by first impressions (control condition) or by using a short or long guided reflection process, and rated their confidence in their initial diagnostic hypothesis at intervals throughout the process. In the “short” condition, participants were asked to generate two alternatives to their initial diagnostic hypothesis; in the “long” condition, six alternatives were required.Results: The reflective intervention did not elicit more accurate final diagnoses than diagnosis based on first impressions only. Participants who completed a short version of the task performed similarly to those who completed a long version. Neither the short nor long form elicited significant changes in diagnostic confidence from the beginning to the end of the diagnostic process, nor did the conditions differ on the rate of corrected diagnoses.Conclusions: This study finds no evidence to support the use of the guided reflection method as a diagnostic aid for novice diagnosticians, who may already use an analytical approach to diagnosis and therefore derive less benefit from this intervention than their more experienced colleagues. The results indicate some support for a shorter, less demanding version of the process, and further study is now required to identify the most efficient process to recommend to doctors.