Examining healthcare staff views and experiences with equity, diversity, and inclusion (EDI) in a multi-disciplinary healthcare setting: A mixed methods needs assessment to advance inclusive excellence.

Psychological safety is essential for effective learning, communication, and professional development in nursing and midwifery education. Environments lacking psychological safety hinder student engagement, reduce confidence, and negatively affect learning outcomes. Despite its importance, the concept remains underexplored in African educational and clinical contexts. This study examined trainee nurses' and midwives' perceptions and experiences of psychological safety and interactive communication in classroom and clinical settings in Ghana. An embedded mixed-methods cross-sectional design guided by Good Reporting of a Mixed-Method Study (GRAMMS) checklist and Edmondson's Psychological Safety Theory was employed. A total of 169 students were recruited using purposive and convenience sampling. Data were collected using a structured questionnaire adapted from Edmondson's psychological safety scale (α = 0.79) with embedded open-ended questions. Quantitative data were analyzed using SPSS version 27, while qualitative data were analyzed using Braun and Clarke's Thematic Analysis. Psychological safety levels were categorized as low (1.0-2.9), moderate (3.0-3.9), and high (≥ 4.0). Students reported moderate psychological safety in classroom settings (mean = 3.42, SD = 0.79) and lower psychological safety in clinical settings (mean = 3.05, SD = 0.86). Approximately 70% felt comfortable asking questions in class, while 49% reported fear of public reprimand during clinical training. Respectful communication, supportive supervision, and peer collaboration enhanced psychological safety, whereas hierarchical relationships, negative feedback practices, and fear of embarrassment hindered it. Psychological safety varies across learning environments, with clinical settings presenting greater challenges. Institutional strategies should prioritize mentorship, supportive supervision, and communication training to improve learning outcomes and professional development.

BackgroundHospital managers are responsible for the delivery of organisational strategy, development of clinical services and maintaining quality standards. There is limited research on hospital managers, in particular how stress manifests and impacts managers and the presence of individual resilience. Managers must work closely with clinical colleagues, however these relationships can be hindered by the perception of stereotyping and differing priorities. This study aimed to explore the working environment of hospital managers, focusing upon the unique stresses faced, psychological safety and the presence of resilience.MethodsThis study utilised mixed methodology using an embedded approach. Participants were purposively recruited from all levels of hospital management within one National Health Service Trust in London, United Kingdom. An exploration of managers experiences was undertaken using semi-structured qualitative interviews. Psychological safety and individual resilience were additionally assessed using validated surveys. Qualitative data were analysed iteratively using inductive thematic analysis, and triangulated with quantitative data. Kruskal-Wallis statistical analysis was performed to evaluate differences in resilience and psychological safety according to seniority and background experience.ResultsTwenty-two managers were recruited and interviewed, with 20 returning completed surveys. Key findings from the thematic analysis included the importance of good working relationships with clinical colleagues, the persistence of some stereotyping, and feeling unsupported in times of challenge. Stresses described included the bureaucracy involved when delivering change, conflict with colleagues and target driven expectations.Participants described their own psychological safety as lower than desired, supported by quantitative data; but recognised its importance and strived to create it within their own teams. Sixteen participants had ‘normal’ scores for resilience, with senior managers more likely to have higher scores than those more junior (p=0.011).ConclusionPositive working relationships, high psychological safety and individual resilience are important for organisational safety and individual wellbeing. Our data illustrate unique stressors faced by hospital managers, provide detail on sometimes challenging working relationships, and demonstrate scope to improve both the psychological safety and resilience of those in managerial positions. A map for senior healthcare leaders was constructed, facilitating the identification of modifiable areas within their organisation to promote good working relationships and improve the working environment of hospital managers.

Inequities in health are increasingly recognized across the country and globe.1,2 These inequities in morbidity and mortality stratify on demographic attributes, including race, ethnicity, gender identity, sexual orientation, ability, language status, and other factors individually and intersectionally.3–7 Anesthesiologists witness these health inequities across a broad range of practice areas and health care services.8–11 The root causes of healthcare inequities are multifactorial and operate at systemic and individual levels. At the systemic or structural level, biases built into policies, procedures, and practices influence the equity of healthcare delivery. These structural biases are often rooted in historical and sociopolitical discrimination, via varied mechanisms including differential access to healthcare;12,13 discriminatory policies and practices;9,14,15 and biased clinical reference standards.16–20 Implicit bias, in contrast, occurs at the individual level while also collectively influencing outcomes. Implicit bias may be linked to differential response to patient concerns, including time to evaluation,21,22 degree of diagnostic workup,21–24 clinical communication,25 access to referral,26 and/or access to treatment options,27 all ultimately influencing care outcomes. A diverse workforce is a necessary component in mitigating bias and inequity. The distribution of race, gender, and other demographics in the current healthcare workforce does not correspond to the overall patient population distribution.28–30 In academic anesthesiology, only 3% of the anesthesiologist workforce comprises Black or African-American physicians (versus 13% of the general population), and only 6% are from all races underrepresented in medicine (versus 34% of the general population).31–33 Women constitute 35% of academic anesthesiology faculty (compared to 50% of the general population).34 From 2009 to 2019, the number of ACGME-accredited pain fellowship programs increased by 14%; however, data reveals persistent gender and race disparities in the demographics of pain fellows.35,36 The root causes for workforce inequities mirror the causes of health inequities: structural and individual bias and microaggressions in the secondary and medical education pathways,37 as well as remnants of more explicit discriminatory policies and practices, such as sociopolitical segregation, educational segregation, and the residual impact of reports and legislation, e.g. the Flexner Report, which led to widespread closure of historically Black medical schools and strained the pathways for individuals of color to enter physician careers, with lasting impact.38–41 Not only is there prima facie value in a diverse, inclusive, and equitable workforce, there are also many reasons why workforce diversity positively influences healthcare outcomes, and conversely why lack of diversity contributes to healthcare outcomes disparities.33 Countless evidence-supported correlations have been identified regarding the benefits of workforce diversity on physician development and patient experience and outcomes. For physicians, some of these benefits include increased productivity and innovation,42 improved cognitive and affective development,43,44 and expanded breadth and depth of educational and research agendas.33,45 For patients, these benefits include improved clinician-patient communication,46–48 improved patient satisfaction and knowledge,49–53 increased academic focus on addressing disparities,33,45,54 improved access,50–52,55 and better quality of care and outcomes.46–48,55–61 The leak Even the apparent recent increases in healthcare workforce diversity obscure the magnitude of the current workforce disparity problem. While there have been modest increases in diversity in the healthcare workforce in aggregate, the proportion of individuals from backgrounds underrepresented in medicine ("URiM") consistently decreases at each level of advancement in medicine.31,62–66 In 2021, 1% of matriculants to United States medical schools identified as Native American or Alaskan Native, 11% identified as Black or African American, and 13% identified as Hispanic, Latine, or of Spanish origin.67 Women represented 55% of matriculants.67 In contrast, among 2021 anesthesiology residents, 0.1% identified as Native American or Alaskan Native, 5% identified as Black or African American, and 5% identified as Hispanic, Latine, or of Spanish origin. Only 33% identified as female and only one student identified as gender non-binary.68 A change in the proportions of race and gender representation from one level to the next reflects inequity, highlighting the "leak," so to speak. This gap further stratifies at the faculty level, where most URiM physicians in academic medicine, including anesthesiology, are at the instructor or assistant professor rank, and are underrepresented at higher ranks, including associate professor, professor, chair, associate dean, or dean.31,66,69–71 As stated previously, the driving factors for workforce and advancement inequities are historical injustices as well as ongoing systemic barriers to the success of URiM individuals, which may be modifiable or mitigated. These challenges include implicit biases in the advancement process,31,72–74 micro- and macroaggressions,37,75–77 deficiency of optimal mentors,31,78,79 disparate access and information regarding opportunities for advancement,74,79 disparate expectations (e.g., the "minority tax," the "glass ceiling," and the "glass cliff"),45,74,80–82 and other insidious factors. Herein, we will describe strategies for improving diversity and equitable representation in the anesthesiologist workforce, specifically by improving pathways and environments to enter and advance in anesthesiology. Although each individual whose identity includes one or more URiM demographic categories (e.g., race, gender identity, sexual orientation, et al) faces unique challenges, we will collectively explore common challenges and themes for any URiM individuals or groups. We will also describe examples from our experience implementing a strategic plan for this mission. Strategies range from readily accessible options for individuals committed to this cause, up to complex, resource-intensive program-building initiatives. Programmatic interventions Departmental, divisional, and training program leaders have numerous opportunities and imperatives to promote diversity, equity, and inclusion (DEI) in our field, particularly through focused recruitment and retention (fulfillment and advancement). Recruitment in this context means both the recruitment of anesthesia-bound URiM individuals to a particular institution and the recruitment of URiM individuals to pursue a career in duplicate the specialty of anesthesiology. "Retention" in this context goes beyond simply retaining individuals to stay in this field or at the institution; ensuring their development, fulfillment, advancement, and thriving is also crucial. Furthermore, this yields self-sustaining benefits, as a diverse, equitable, inclusive environment is one of the strongest tools for recruiting and retaining URiM individuals in an institution, department, or program. Advancement of any or all of the recommendations outlined throughout this work contributes to recruitment and retention, enhancing the more explicit guidelines mentioned below.29,83,84 Recruitment Equitable recruitment entails an equitable approach to all aspects of workforce recruitment – for all roles. In this section, we will discuss recommendations for the recruitment framework for any role, though many examples are most salient for the physician workforce. In graduate medical education, the recruitment process begins long before the application cycle, and we will discuss those seminal elements subsequently in the Pathways section. These recommendations include prioritizing outreach to URiM candidates, addressing systemic and implicit bias challenges at all stages of the recruitment process, diversifying the recruitment leadership, and fostering a data responsive environment. URiM-focused recruitment outreach Demonstrate valuing of URiM candidates through directed outreach – at Historically Black Colleges and Universities, through URiM-focused national societies and their conferences (e.g., Student National Medical Association, National Hispanic Medical Association, American Medical Women's Association, Medical Student Pride Alliance, Association of Native American Medical Students, National First Generation to Medicine Association (FGLIMed)), and via formal or informal networks and affinity groups. For faculty, consider engaging in cohort or cluster recruitment – recruitment of faculty in cohorts can promote a collective morale, with benefits in productivity, retention, and thriving.85 URiM-curated recruitment experiences Provide curated opportunities for URiM candidates to gain experience, exposure, and insights on the program, department, or institution. Dedicating rotation spots or scholarships for visiting electives in anesthesiology may be particularly valuable for individuals at medical schools not offering anesthesiology rotations for medical students and also for individuals with financial constraints. Faculty or resident ambassadors – who represent the program or institution and offer another insight into the institutional DEI culture – may be crucial in connecting URiM candidates with potential opportunities. URiM recruitment and "Second Look" events provide candid settings to learn about the environment, strengths, and challenges at the program or institution. However, these events should be designed with equitable access in mind and not create further disparity due to financial or other burdens. Publicizing DEI policies and mission statements explicitly may be helpful for prospective and current trainees, faculty, and staff because it implies institutional commitment and promotes culture and psychological safety. In order to hold weight, these stated policies must be matched by actual practice. Equitable and holistic candidate selection practices Approach candidate selection for interviews and candidate scoring and ranking equitably and holistically. In clerkships, disparities in clerkship grades and Medical Student Performance Evaluation summary words were found to favor white students over URiM or non-URiM minority students.86 One study found that most fourth-year medical student participants recalled being asked at least one potentially discriminatory interview question about their marital status, children, pregnancy plans, place of birth or national origin, religion, or ethnicity.87 Another study of resident selection found that Asian applicants had their personality less often discussed.88 Strategies to mitigate bias in the interview process might be including life-performance questions (e.g., leadership, community service, overcoming adversity, realistic self-appraisal, ability to recognize and navigate one's own bias, and ability to set goals and self-responsibility) and consistently asking the same questions to all participants.89 Addressing biased evaluation approaches and implementing alternative criteria may improve fairness and equity in assessment of candidate qualifications, and increase trainee diversity.90 Anti-bias training and awareness Everyone involved in the candidate recruitment and selection process must understand the value of the perspectives that URiM candidates bring to patient care and health equity, and the risks of those candidates being undervalued due to bias in the selection process. Not only have URiM candidates likely experienced systemic bias upstream that may influence their candidacy, they are also at risk of experiencing implicit bias during the application process. URiM candidates are at a higher risk of being subjected to interviewer bias, conscious or unconscious.83,91 Even the demographics conveyed (or presumed) in their written application can influence how their candidacy is perceived during interviewee selection and the eventual evaluation and ranking process. For example, a Harvard Business School research trial demonstrated that applications that had been "whitened" (i.e. revised by the researchers to exclude race-revealing data) were more than twice as likely to receive interview invitations than the same applications which preserved the data indicating that the applicant was Black or African-American.92 Implement specialized anti-bias training for those involved in the recruitment, interviewing, evaluation, and selection processes, in addition to the general anti-bias and cultural humility education that should exist at any institution.93 These training sessions should ideally be interactive, practical, expert-led, and tailored for the specific context or practice; simple click-through, self-study modules are not enough.94 Recruitment team diversity Diversify recruitment teams, and be mindful of the "minority tax,"80 i.e. the disproportionate utilization of URiM faculty without compensation to "represent" the institution in recruitment, mentorship, administrative, and other DEI-related positions in order to promote the appearance of a diverse institution. A diverse recruitment team can recruit a diverse workforce and is an accepted best practice for prioritizing diversity.95–97 However, URiM faculty career advancement can be hindered by expectations that they serve as diversity representatives in disproportion to non-URiM faculty. This disproportionate administrative burden on URiM, individuals though often well intentioned by leadership, comes at the cost of opportunities that lead to true career development and advancement activities.23 Time spent serving the DEI mission of the department, through recruitment or other avenues, should be appropriately recognized and built into a time-based or financial compensation structure.80,98,99 Data responsive environment Promoting a data-responsive environment requires that leadership identify, collect, evaluate, and respond to quantitative and qualitative data regarding the recruitment and selection processes, as well as the overall DEI environment at the program, department, or institution. For example, the influence of bias may be suggested by comparing the proportions of URiM to non-URiM individuals at each stage of the process: applicants, interview invitees, interviewees, new hires, promotions, and appointments to leadership roles. Metrics specific to graduate medical education recruitment may include the proportions of URiM to non-URiM individuals ranked to match, matched, advancing yearly, passing examinations, completing training, and ultimately achieving board certification if practicing. If there is a decrease in the proportion of URiM individuals from one stage to the next, systemic factors are likely contributory and should be explored in depth. This may include a more in-depth evaluation of, for example, how specific interviewers are rating individuals from different backgrounds, whether subtly biased language may be marked on URiM evaluations, and what events or metrics are cited in individual cases of promotion or advancement denial or delay.92,100,101 Collect qualitative data by engaging with individuals regarding the outcomes: find out why individuals chose to join the institution, but make equal effort to find out why others chose not to accept an interview invitation, chose not to rank to match, or chose not to accept a professional or academic position. Retention/thriving climate In addition to the recruitment-specific approaches, some needs must be addressed at a departmental or institutional level to promote the necessary characteristics of a thriving environment. As mentioned previously, "retention" goes beyond simply retaining individuals to stay in this field or at a particular institution, and requires ensuring their development, fulfillment, advancement, and thriving. Recommendations for promoting a diverse, equitable, and inclusive environment include explicit and compensated DEI leadership roles, committees, and departmental missions; high-quality anti-bias training; robust mentorship and sponsorship; directed, deliberate support; and fostering a data-responsive environment and safe culture. DEI leadership roles and committees Create leadership positions and DEI councils. Some institutions, such as the Mount Sinai School of Medicine, have reported success after a dedicated council was created to oversee early pipelines, outreach, and recruitment of URiM physicians, with representatives institution-wide.102 While a study in 2022 found that many anesthesiology departments had diversity and inclusion initiatives, only a few reported clearly defined leadership roles, which may hinder departmental success in promoting diversity.103 DEI leadership roles and activities should be compensated in a time-based or financial structure in order to recognize the value they provide to the institution, and ensure available time for the success of the efforts. DEI mission Define a departmental DEI mission that clearly prioritizes diversity, equity, and inclusion in patient care, research, education, innovation, and any other divisions of the department. While it is crucial to prioritize DEI in professional development as detailed here, there must be a parallel commitment to demonstrating this as a priority in these other domains for a comprehensively safe and positive environment. For example, perceiving an increased minority tax,99 witnessing microaggressions against patients of certain demographics,104 or noticing that health equity research is less valued in a department105 may undermine the morale of URiM faculty. Anti-bias training and health equity education Anti-bias training for all faculty and administrative leadership roles is imperative for creating an inclusive culture. As stated previously, this training must go beyond the ubiquitous and rote modules that accommodate learner multi-tasking.94 Intensive anti-bias training should be interactive and practically tailored to the audience. Anti-bias culture emanates from the examples set by leadership. Institutions benefit when key leaders are willing to interrogate their own biases and acknowledge the pervasive nature of bias and inequities even among progressive, well-intentioned individuals and institutions.106 In addition, developing a robust health equity education program may play a valuable role in increasing workforce diversity and promoting an inclusive culture – by serving as a recruitment tool, by elevating candidates from underrepresented backgrounds, and by broadcasting an institutional commitment to health equity.94,107,108 In our institution, several initiatives have been started, including sponsored electives in anesthesiology and health equity for visiting students, a health equity in anesthesiology and critical care curriculum for medical students, a longitudinal case-based health equity curriculum for anesthesiology residents, and a health equity seminar series for critical care fellows. Mentorship and sponsorship Mentorship and sponsorship are paramount. Early and direct access to invested mentors can elevate individuals in their careers and help achieve a more representative number of URiM anesthesiologists, particularly in leadership positions.109–113 Pairing junior URiM team members with qualified mentors and can to a to in their careers, through informal or direct to and other career development opportunities. is a at many of available URiM mentors for URiM and there will likely to be a workforce equity is While many individuals may a this may not be a realistic at most In many it may better serve to be with qualified even without demographic URiM faculty in promotion or Women and other URiM underrepresented in leadership and academic in academic anesthesiology, in professor, chair, and may influence the promotion and process who have experienced bias throughout their careers may be over for or be less likely to be for leadership positions or due to not to the same demographic or as those in positions of the value of URiM team members and ensure that the work of all is recognized appropriately the and institution. for and needs URiM by time and financial for these and a culture of can promote innovation, and increase Create and for and health care, financial and One is and programs for URiM fellows. A of 1% of for these initiatives had URiM and faculty promotion and increased programs and recruitment can inequities and for and URiM environment As for the recruitment process, program and departmental may provide opportunities to and mitigate bias and inequity. data may include demographics with evaluations, time to and other more of academic and/or clinical must be when these in order to at any or as opportunities for in program or departmental than further and by gender are and must to be data should be with invested the of on the potential for and of and potential In healthcare where is individuals may to about from team physicians or administrative because out can their professional tools the with of can be with to from individuals on domains of in and from URiM individuals at the institution to learn about barriers and challenges that may be the institutional culture. A study by the School of Medicine found that URiM faculty were less likely to that faculty recruitment was that and that they be at their current institution in resident events and of can the of any URiM trainee should be a and explored for opportunities to and prioritizing a data-responsive environment, leadership can to URiM team members that their is their are and leadership is willing to make necessary to improve the institutional environment and promote While the of URiM representation in academic anesthesiology in some with some metrics have to change (e.g., the distribution of and faculty appointments and been that diversity will at least to professional equity to the population achieve these individuals at level in the or institution must recognize the of the candidate and academic institutions, URiM can benefit from and at stages of their faculty recruitment, retention, and career advancement longitudinal at the work and levels. these strategies for increasing access to research, and URiM faculty can experience increased and through barriers and programs In a environment, DEI leaders may to new programs dedicated to improving pathways for URiM individuals to pursue careers in anesthesiology. to as are specialized initiatives designed to and students from underrepresented backgrounds to pursue and healthcare and and other unique In programs engaging students in and programs have positive outcomes for URiM students in several key including academic and into health medical these the at each stage of advancement, as detailed URiM representation at more junior at more levels. In order to promote and ensure diversity at all of a approach to programs may be at each advancing educational Although these programs have demonstrated impact at other educational and have the potential to elevate URiM success at the institutional level and at a national or At our institution, we the Pathways in in with the of and is a program to recruit and URiM medical students to pursue academic component of the program is designed to evidence-supported factors in URiM academic success and career Although there are many for a program, we this experience as a potential for other to or The program is of of and other on at for time and to on to medical student (e.g., and to correspond with key of the medical student The longitudinal nature students to with the program throughout their own advancement in medical training and to find to their The to of application and structural barriers and implicit and These sessions URiM students to the breadth of available to pursue in URiM individuals are underrepresented in more This may be due to including differential exposure, differential access to mentorship on application and implicit and structural bias in the application While the is less modifiable via a program, the program the other factors in the sessions of each the program all of the strategies for candidacy, and participants with potential mentors in these are interactive and sessions to in developing and their academic medical program includes sessions for each of medical such as time in medical for and and rotation for The are throughout the to for each medical student stage (e.g., in the and interview in the The overall includes as well as areas identified by in research on barriers to academic further the program are in advance of the program to any particular of is to program for their in for by numerous a may be specifically on this A of on rotation includes for mentorship, time a on the interview research, an match, and for fellowship or next In addition to the informal by the specialty and the of each program is dedicated to direct opportunities through the which or potential mentors and or selection invitations for valued with invitations for of the is while being mindful of the "minority program leaders for to be recognized and compensated on a time-based academic by the department. of the success of this program is the institutional and direct administrative from the of and the of Medical and the School of program with and and and implicit bias healthcare workforce and can impact health outcomes and success and workforce equity in anesthesiology must be a priority for healthcare program and individual and must be directed DEI that ensure more equitable access for URiM individuals to pursue anesthesiology training, in their careers, and into leadership in and these on race, gender, and other can be but these are critical for bias and While many of the interventions may be opportunities are available at level to the and make a positive impact on workforce We our recommendations can serve as a for anesthesiology leaders to DEI at their programs and and to URiM representation and success in the field of anesthesiology. an individual level, this means and to a more inclusive work environment. For anesthesiology training programs and advancing healthcare workforce equity requires comprehensively DEI data and addressing such as bias in recruitment and advancement, workforce education, and dedicated for and programs are a approach to elevate healthcare workforce equity in a an impact at the level may robust and and of the educational have an increased to promote about race, ethnicity, gender, orientation, ability status, and other factors. also have a professional and to systemic inequities and of bias in anesthesiology and medicine we recognize the of fostering diversity and equity in we to a for our our patients, and of that they have of

AAIM Recommendations to Promote Equity in the Clerkship Clinical Learning Environment

The issue of prevention and treatment of healthcare-associated infections (HCI), and in particular intravascular catheter-related infections associated with (ICRI), still remains unresolved. The purpose of the work was to determine the shortcomings in the epidemiological surveillance (ES) for ICRI and the ways to correct them, with the further development of an effective system of ES for ICRI in multidisciplinary healthcare settings. In 2019‒2020, a comprehensive epidemiological study was conducted. It was conducted on the basis of the surgical and intensive care units in multidisciplinary healthcare settings. The study included a retrospective epidemiological analysis of 160 medical records of inpatients on the use of intravascular catheters, a cross-sectional epidemiological study of the use of intravascular catheters, prospective epidemiological observation of 94 patients with intravascular catheters (n=149), a cross-sectional epidemiological study of the level of knowledge, attitude and practice of using intravascular catheters and adherence to infection control rules of 123 healthcare workers (HCW). No cases of catheter-related phlebitis or other ICRI were documented in the medical records of inpatients. An analysis of the completeness of the documentation of the catheterization procedure revealed that in 100% of cases, the probable duration of catheterization, the results of daily observation of the catheterization site, information about the change of dressings and washing of the vascular catheter were not routinely recorded. HCW have an insufficient level of knowledge about epidemiological features, infection control and prevention of ICRI. The majority of HCW (80.0±3.65%) feel the need to receive additional information regarding possible complications of vascular catheterization, infection control, and prevention of ICRI. Taking into account the mentioned shortcomings, a system of ES for ICRI in the multidisciplinary healthcare setting was developed. It includes three structural modules: informational, diagnostic and management. The developed ES system according to the ICRI is suitable for use in multidisciplinary healthcare settings and can be adapted according to the material and technical capacity of the healthcare settings. Keywords: infection control, catheter-related phlebitis, catheter-related bloodstream infections, epidemic situation.

The international mobility of nurses is a significant component of healthcare systems worldwide, resulting in the global recruitment and adaptation of culturally and linguistically diverse nurses into diverse work environments. CALD nurses face integration challenges, which can potentially compromise their well-being and adjustment to the new setting. Psychological safety is a key component to promoting individual well-being and effective organisational integration. This systematic review aimed to identify the current evidence on the psychological safety of culturally and linguistically diverse nurses in healthcare work environments and the factors associated with it. This systematic review was conducted using JBI guidelines. PiCo/PEO format was utilised for inclusion and exclusion criteria, including English/Finnish, without time limitations. The screening process was conducted by two independent researchers, with a third researcher resolving the conflicts. The PRISMA checklist was utilised in reporting. Data were analysed using content analysis for qualitative and data synthesis for quantitative. CINAHL, PubMed, ProQuest, Scopus and Medic. 24.10.2024-23.1.2025. The systematic review yielded 15 qualitative, one mixed-methods and one quantitative article. The content analysis produced 270 codes, 67 subcategories, seven categories and two main categories. Professional growth and acceptance captured inclusion, professional competence and support from colleagues and managers in creating job satisfaction. Marginalised disempowerment reflected factors linked to low psychological safety, contributing to reduced job satisfaction in the workplace. Healthcare organisations should confront existing inequities on psychological safety in culturally diverse healthcare environments that are structured around professional inequalities to create equitable spaces for CALD nurses. More research is needed to understand psychological safety experiences from the CALD nurse perspective, exploring the equitability of facilitating factors amid systemic disadvantages in the healthcare workplace. No patient or public involvement. Prospero registration: CRD42024581860.

The dual effect of board gender diversity on R&D investments

The study aimed to examine the influence of leadership openness and accessibility on resilience to violent extremism among boys’ secondary schools in the north eastern counties of Kenya. The study utilized a cross-sectional approach that collated both qualitative and quantitative data to meet the purposes of the study. The large study sample included 5,870 male secondary school learners, 18 Directors of Education, 18 Deputy County Commissioners (DCCs), and 108 school administrators spread across Garissa, Wajir, and Mandera counties. To obtain 375 study subjects, stratification and simple random methods were used on the entire population. A pre-test study was conducted in Lamu County. SPSS version 26.0 was used for purposes of analysis. The quantitative data were examined through statistical description methods incorporating frequencies, percentages, and table representation. Moreover, correlation analysis examined the cross-relationships between study variables. On the other hand, qualitative data was examined through thematic analysis, thus ensuring its alignment with research objectives. The findings of this study underscore the significant role that leadership openness and accessibility play in enhancing resilience to violent extremism among boys' secondary schools in North Eastern Kenya. The study reveals that school leaders who foster transparent communication and maintain an open-door policy contribute significantly to creating an environment of trust and psychological safety. Such an environment is conducive to identifying and addressing early warning signs of radicalization, allowing for timely interventions. The study concludes that leadership openness and accessibility play a crucial role in enhancing resilience to violent extremism among boys’ secondary schools in North Eastern Kenya. Open leadership that encourages transparent communication and accessibility builds trust among teachers, students, and the broader school community. It is recommended that school leaders in the North Eastern counties of Kenya actively cultivate openness and accessibility as key leadership practices.

BackgroundEffective teamwork in interdisciplinary healthcare teams is necessary for patient safety. Psychological safety is a key component of effective teamwork. The baseline psychological safety on pediatric inpatient healthcare teams is unknown. The purpose of this study is to determine the baseline psychological safety between pediatric nurses and residents and examine the impact of an interdisciplinary nighttime simulation curriculum.MethodsA convergent, multistage mixed methods approach was used. An interprofessional simulation curriculum was implemented fall 2020 to spring 2021. Qualitative focus group data and quantitative survey data on team psychological safety were collected and compared, both pre- and post-intervention and across nurses and residents. Thematic analysis of the qualitative data was conducted, and themes integrated with survey findings.ResultsData were collected from 30 nurses and 37 residents pre-intervention and 32 and 38 post-intervention, respectively. Residents and nurses negatively rated psychological safety (pre-intervention mean = 3.40 [SD = 0.72]; post-intervention mean = 3.35 [SD = 0.81]). At both times psychological safety was rated significantly lower for residents (pre-intervention mean = 3.11 [SD = 0.76], post-intervention mean = 2.98 [SD = 0.84]) than nurses (pre-intervention mean = 3.76 [SD = 0.45], post-intervention mean = 3.79 [SD = 0.50]), all P < .001. Qualitative analysis identified six integrated themes: (1) influence of existing relationships on future interactions, (2) unsatisfactory manner and frequency of communication, (3) unsatisfactory resolution of disagreements (4) overwhelming resident workload impairs collaboration, (5) interpersonal disrespect disrupts teamwork, and (6) interprofessional simulation was useful but not sufficient for culture improvement.ConclusionResident-nurse team psychological safety ratings were not positive. While interprofessional simulation curriculum shows promise, additional efforts are needed to improve psychological safety among residents and nurses.

INTRODUCTION Postgraduate Year 1 (PGY1) doctors face various challenges transiting from medical students to doctors. This period of steep learning curves and increased stress[1] can affect clinical performance and patient safety,[2] and lead to mental health issues.[3] Mindfulness and reflective practices have been shown to help equip junior doctors with coping mechanisms to reduce burnout and improve resilience.[4] Mindfulness involves paying attention to purpose, being in the present moment and doing so non-judgementally,[5] aiming to develop a greater understanding of oneself and the situation. Reflection is a meta-cognitive process that occurs before, during or after situations, similar to mindfulness in its purpose of developing a greater understanding of internal and external factors to gain new insight and learning for future improved practice.[6,7] Mindfulness practices have been associated with positive outcomes among doctors, including improved well-being,[8] reduced stress[9] and enhanced resilience.[4,10] Reflective practice is also well established in professional development.[11] As advocates for junior doctor well-being, we implemented a mindfulness and reflective practice pilot programme (MRPP) for our PGY1 doctors. We aimed to explore the impact of the MRPP using an outcomes-logic model. Recognising that the dynamic and stressful work environment with limited time and resources may be a barrier for successful implementation of this programme,[12] we also aimed to explore the barriers to and factors in sustaining our programme for future cohorts. METHODS This was a mixed-methods study with qualitative data obtained via group interviews and validated surveys completed by the participants. We adopted an exploratory research design as a broad-ranging, purposive, systematic, prearranged undertaking designed to maximise the discovery of generalisations leading to description and understanding of an area.[13] Group interviews were conducted to obtain and understand opinions in a natural setting.[14] Group interview was chosen over individual interview, as the nature of the topic was suited for discussion in a group setting (since all participants had undergone the same MRPP) and it saves time. This was a single-site study conducted from May 2019 to December 2019. The MRPP included elements from a validated programme, Mindfulness-Based Stress Reduction (MBSR) developed by Jon Kabat-Zinn.[5] The MRPP was led by a clinical psychologist trained in MBSR and reflection. Over each 4-month posting for PGY1 doctors, seven out of 12 weekly protected housemen teaching sessions were allocated for the MRPP. Sessions began with a short didactic teaching component (15 min), followed by interactive games or hands-on activities for concept demonstration (15 min). Significant time was allocated for in-depth reflection and exploration of real-life work scenarios facilitated by the psychologist (30 min). Senior doctors were invited to certain sessions to provide additional perspectives. The sessions were centred around a specific learning theme [see Supplemental Digital Appendix 1 at https://links.lww.com/SGMJ/A66].[15] Participants also learnt and applied different mindfulness techniques during the MRPP sessions. Ethics approval was obtained from National Healthcare Group Domain Specific Review Board (DSRB: 2020/00170). Group interviews were conducted by the same interviewer via the ZOOM video-conferencing platform. The authors jointly developed the interview guide [see Supplemental Digital Appendix 2 at https://links.lww.com/SGMJ/A67]. Interviews were audio-recorded. Discussion notes were jointly summarised by the interviewer after each interview. An independent party transcribed the recordings, after which any omissions or transcription errors were corrected. Maslach Burnout Inventory (MBI) and 25-item Connor–Davidson Resilience Scale (CD-RISC 25) were the validated scales used to measure burnout and resilience, respectively. An outcomes-logic model was utilised in this study, as this model pays critical attention to the relationships between programme components and the components’ relationships to the programme’s context.[16] Outcomes-logic model works best when the programme is a dynamic system; it allows the implementers to study the intended and unintended outcomes emerging from the programme.[17] There are four components in an outcomes-logic model: input, activities, outputs and outcomes [see Supplemental Digital Appendix 3 at https://links.lww.com/SGMJ/A68]. The input component comprises all relevant resources such as funding resources, facilities, faculty skills, staff time and relevant institutional culture. The second component, activity, is the set of ‘treatments’, strategies, innovations or changes planned for the educational programme. In our context, it will be the MRPP. This activity will require proper planning and underpinned educational theories for successful implementation. The third component, output, is defined as the indicator that one of the programme’s activities or parts of an activity is underway or completed, and that something (a ‘product’) had happened. This may include the number of participants attending, number of modules created or the number of experts produced. Lastly, the outcomes component consists of short-, medium- and long-term changes intended as a result of the programme’s activities. The outcomes that we anticipated after the participants went through the MRPP include demonstration of awareness in their own coping and wellness, implementation of reflection in their daily life, and reduction in burnout. In addition to these four components, context, such as social and cultural features, is crucial and will influence the success of the implementation.[17] Based on this model, we implemented the MRPP and explored whether the outcomes have been achieved. Data analysis was performed by two of the authors (SSL and YLL), who read each transcript thoroughly before thematic analysis.[18] Given the exploratory nature of this research, we used inductive coding, interpreting the raw data towards generating codes. The two authors coded the data independently before gathering to obtain a consensus. Potential themes were then generated for similar codes, and the codes were clustered to form categories and eventually themes. The researchers came together again for discussion on the process of generation of themes to check if there was a good ‘fit’ between the themes and the coded data. This process was carried out until a definite set of themes were decided. Quantitative data was analysed using IBM SPSS Statistics version 23.0 (IBM Corp, Armonk, NY, USA). Comparative statistics were done using chi-square test for categorical data and t-test for continuous data. RESULTS Of the 18 participants who attended the MRPP over the study period, ten agreed to the interviews (55.6% response rate). Four themes emerged from the thematic analysis. The themes were integrated into the outcomes-logic model [Figure 1]. A summary of the themes and sub-themes is presented in Table 1.Figure 1: Diagram shows the overview of themes from qualitative data assessing our mindfulness and reflective practice pilot programme.Table 1: Themes and subthemes with selected quotes of interviewees from group interviews.Theme 1: Techniques applicable to learners In general, PGY1 doctors were able to learn and apply the techniques taught to them. The top three techniques included breathing exercises (40 coded phrases), reflection (20 coded words/phrases) and mindfulness practices (11 coded words/phrases). The mention of reflection related to in-session sharing activities and self-initiated reflections. Mindfulness was a term that encapsulated all the techniques taught in the programme. Other specific techniques such as body scan and relaxation exercises were also brought up. Another subtheme was the relational aspect where ‘specific stories’ allowed the participants to relate to the scenarios shared. Theme 2: Conditions for successful implementation Participants commented on tangible issues for implementation: practicality of the techniques, resources, timing, topics, duration and frequency of the sessions. Participants felt that they might not have energy left after work to practise what was taught, especially during busy workdays, and that it can be time consuming to practise. Participants also felt that more frequent and longer sessions would be useful in solidifying concepts and application. Regarding topics, participants felt that ‘personal life, relationships and spiritual’ topics were not ideal topics for discussion. The timing of the session was sometimes stressful due to workload in the mornings, when these sessions were scheduled. The ‘psychological atmosphere’ was another subtheme raised; some positive points highlighted included good support from peers and seniors, which was appreciated by the participants. The presence of seniors in some sessions made some feel less ‘open’ to share experiences; however, there were also those who felt confident in doing so in a psychologically safe environment. The role of attendees was the next subtheme; participants highlighted the role of the facilitator (psychologist) facilitating the session, particularly in picking up on issues and directing the discussions. The role of seniors was helpful, as their perspectives reassured the participants that their seniors also had similar experiences. Participants also aspired to be like their seniors. The department culture of allowing protected time for these sessions was well received by the participants. Theme 3: Short-term effects A major theme was the short-term effects of the MRPP. These included the ability for cognitive regulation, which helped participants in ‘thought process(ing)’ and thus, in decision-making. The MRPP also taught participants emotional awareness and ways to regulate emotion. Other positive short-term effects included nurturing values such as ‘patience’, ‘being kind’ and ‘empathy’. Additionally, participants reported being able to do reflections more proactively and share them more readily with other participants during the sessions. Theme 4: Potential long-term effects Long-term effects of the MRRP included participants having their own psychological strategy as part of their coping mechanism. Subthemes included the application of the MRPP in both clinical practice and daily life. Another subtheme was the challenges in continuation of practice after the programme ended, with heavy workload and difficulty in retention cited as the main factors. These main factors stemmed from the same reason, i.e., the participants felt less competent to practise techniques after having changed their clinical posting from the initial paediatric posting. This shift in posting resulted in a faster-paced environment with a heavier workload, which in turn reduced their free time and mental capacity to continue the practice of mindfulness and reflection. Significantly, the change in posting also meant cessation of the MRPP, which had acted as an efficient and constant reminder and an outlet for practice. Other innate factors cited included individual choice or personality traits. All 18 participants completed the study questionnaires. After the MRPP, the, prevalence of burnout on the MBI was significantly reduced (from 61.1% to 16.7%, P = 0.02). This improvement was most marked in the emotional exhaustion domain of the MBI (from 66.7% to 27.8%, P = 0.04). Mean resilience scores on CD-RISC 25 showed improvement from 66.2 to 70.8, although this was not statistically significant (P = 0.15) [Table 2].Table 2: Pre and post-intervention MBI outcomes and CDRISC 25 scores for participants of the MRPP.DISCUSSION We used the outcomes-logic model to evaluate the impact of the MRPP. While some outcomes we would like to achieve in the model (such as increased reflection process, staff wellness and reduced burnout) were put forward, we found that the participants gained more than the anticipated outcome. We found that PGY1 doctors were able to retain the key techniques taught (such as cognitive and emotional regulation, and reflection), allowing them to access these techniques even beyond the sessions. The ability to practise these in their daily lives translated to positive effects both in the short and long term. Our findings of the positive impact experienced are consistent with studies reporting that such programmes improved emotional stability, awareness and regulation[19] and also confirmed greater improvements in burnout with increased self-reflection and resilience.[4,10] We believe that our programme can help with cognitive regulation and equip PGY1 doctors with the ability to manage the risk of burnout and improve resilience as they continue to negotiate challenges throughout their career. In addition, they were able to bond better with their colleagues through these sessions, which improved their peer relationships even outside of work. While the short-term benefits accrued from attending the MRPP are apparent from our interviews, we believe the ability to change practice — in which mindfulness and reflective thinking become a natural part of coping — would be a true reflection of the success of this programme. To ensure better retention of the skills learnt in the sessions, we recognise that seven sessions may not be sufficient to allow for adequate application. Increasing the frequency of sessions and continuing these throughout the PGY1 year may lead to more opportunities for practical application (duration of the sessions was also brought up by the participants). The curriculum for the programme, including specific topics for discussion, needs to be planned carefully. Participants preferred to discuss matters confined to work and professional relationships instead of their personal life, relationships and spiritual topics. In addition, while there was openness in sharing about work-related topics, the people present in the sessions made a difference; the presence of seniors may pose a challenge to more open sharing. This finding is not surprising and echoes sentiments from published literature.[20] We believe that a fine balance is needed in this aspect; while confidentiality and psychological safety are important in sharing, there are benefits to having certain faculty members in the sessions to receive feedback and clarify any issues pertaining to the workplace that the participants may have. Another benefit of seniors’ participation is that the sharing of their personal journeys and challenges may promote solidarity, empathy and inter-rank collegiality, which may in turn enhance workplace well-being.[21] Our results have also highlighted aspects that educators and administrators can improve on when planning and continuing such programmes, particularly to ensure sustainability in supporting junior doctor well-being. Tangible issues such as practicality of techniques and timings should be addressed. We recognise that PGY1 doctors are busy with the stressful demands of clinical work and must balance work schedules with attendance at these sessions. Work commitments have been cited as a significant barrier to attending such programmes.[22] Protected time and a culture that prioritises junior doctor well-being are helpful in enabling PGY1 doctors to attend sessions without feeling that they are compromising clinical work. Support from leadership and seniors is thus essential and has been shown to enhance the effectiveness of such courses.[23] Importantly, our experience highlights that the structured delivery of a mindfulness and reflection-based curriculum for junior doctors can be feasible and potentially beneficial for participants. A particular strength of our MRPP is that the programme had been curated specifically to cater to the needs of our PGY1 participants locally, with topics and practices that are applicable and culturally relevant for the local context. We hope that our positive experience with the MRPP will be a catalyst that initiates conversations about the potential implementation of similar programmes locally or in the wider community. We recognise several limitations of our study, which may prevent a wider adoption of the MRPP. The programme was conducted during a paediatric posting that has different clinical demands from other postings, potentially affecting the participants’ mindset. However, PGY1 duties tend to be similar regardless of discipline. Our pilot programme was conducted in a small group, which may limit the overall perspectives shared. Nonetheless, the three group interviews achieved data saturation from the thematic analysis. As the interview was voluntary, those who agreed to participate may be a self-selected group who might have positive inherent traits and thus, higher positive perceptions of the programme. As we wanted to ensure anonymity, we did not collate reasons for those not willing to participate in the study. We recognise the use of interviews is subject to recall bias, and the responses may be affected by their current situation at work or in their personal lives. While there were potential ‘long-term’ effects gathered from the participants, the interviews were conducted within 4 months after completion of the posting. This and the lack of repeat of the objective validated measures (MBI and CD-RISC 25) after a longer period since leaving the posting precluded confirmatory findings on sustained benefits of the MRPP. Overall, our PGY1 doctors had positive perceptions of the impact of the MRPP and were able to adopt techniques that benefitted them, at least in the short term. Our exploratory research identified tangible issues in the implementation of this programme. These issues need to be taken into consideration when implementing the MRPP on a wider scale, for the benefit of junior doctors. Financial support and sponsorship This research received funding from the National University Hospital Education Fund. Conflicts of interest There are no conflicts of interest.

Issues to address in burn care for ethnic minority children: A qualitative study of the experiences of health care staff

The study specifically examined the effects of gender diversity, personality diversity, generational diversity, and ethnicity diversity on organizational development goals at The Nairobi Hospital [TNH]. Two theories were employed: Social Identity Theory and Critical Race Theory. The study adopted a descriptive survey research design that utilized both qualitative and quantitative data. The study's target population was employees of TNH, comprising 50 in top management, 80 medical doctors, 137 nurses, and 250 support staff. Stratified sampling was employed to select a sample of the population for participation in the research. Subsequently, simple random sampling was used to obtain a sample from each stratum, consisting of 5 top management, 12 doctors, 36 nurses, and 120 support staff. Structured questionnaires and interviews were used to collect information from the selected respondents, with questionnaires providing quantitative data and interviews collecting qualitative data. Upon data collection, quantitative data was cleaned and entered into SPSS Software Version 28.0, where it was coded and prepared for analysis. The data was analyzed using statistical software for social science, generating descriptive and inferential statistics. Descriptive statistics entailed frequencies and percentages. A pilot study was conducted at Nairobi Women's Hospital, and face-to-face and content validity were used to ensure the validity and reliability of the study. The study found that diversity management is crucial in organizational development, as the data showed that employees believed that diversity in gender, ethnicity, generations, and personality plays a significant role in organizational development in terms of client satisfaction, financial growth, and employee satisfaction and retention. From the results, the study established that there exists a strong positive and significant relationship (r = .641, P=0.000) between gender diversity on organizational development at TNH, Kenya. The study concluded that a significant majority of respondents believe that age diversity is considered during recruitment and hiring and that retention strategies are effective across age groups. The study recommends that TNH should continue to enhance its focus on age diversity in recruitment and hiring while addressing the concerns of those who are undecided or disagree.

66. A NOVEL MILESTONE-BASED SHIFT ASSESSMENT TOOL OF PEDIATRIC EMERGENCY MEDICINE (PEM) FELLOWS

The current COVID-19 pandemic greatly affected many global activities, including teaching and learning. This research investigated teachers’ perceived challenges and coping strategies to craft localized school-based support mechanisms. This study followed a mixed methods convergent parallel design where quantitative and qualitative data were collected during the same phase of the data-gathering process. This design was followed to enrich quantitative data with qualitative data. This study utilized two research instruments to gather quantitative data for the following variable – perceived challenges and coping strategies. To collect qualitative data, interviews were conducted using the sub-questions aligned with the study's central question. The data were derived from randomly selected public school teachers of an educational institution in Makati City. Three of those teachers who answered were chosen at random to be interviewed. During analysis, Shapiro-Wilk’s normality test was done for the quantitative data to determine the statistical analysis to be employed. Both quantitative and qualitative data were analyzed through Pearson r coefficient and thematic analysis, respectively. Results showed that perceived challenges have no significant relationship with overall coping strategies. However, by analyzing the subcomponents of coping strategies, perceived challenges positively correlate with problem-focused coping. This result revealed that when teachers experience a high intensity of challenges in their teaching practices during the pandemic, they tend to do active coping strategies indicative of grit and a more practical approach to solving the problem. Moreover, qualitative data supported that teachers must also be given mental and emotional support besides physical, technological, and financial support. Furthermore, parallel studies must be conducted with a more diverse and large sample to serve as a guide in crafting a nationwide support mechanism for teachers during a challenging situation

The current COVID-19 pandemic greatly affected many global activities, including teaching and learning. This research investigated teachers’ perceived challenges and coping strategies to craft localized school-based support mechanisms. This study followed a mixed methods convergent parallel design where quantitative and qualitative data were collected during the same phase of the data-gathering process. This design was followed to enrich quantitative data with qualitative data. This study utilized two research instruments to gather quantitative data for the following variable – perceived challenges and coping strategies. To collect qualitative data, interviews were conducted using the sub-questions aligned with the study's central question. The data were derived from randomly selected public school teachers of an educational institution in Makati City. Three of those teachers who answered were chosen at random to be interviewed. During analysis, Shapiro-Wilk’s normality test was done for the quantitative data to determine the statistical analysis to be employed. Both quantitative and qualitative data were analyzed through Pearson r coefficient and thematic analysis, respectively. Results showed that perceived challenges have no significant relationship with overall coping strategies. However, by analyzing the subcomponents of coping strategies, perceived challenges positively correlate with problem-focused coping. This result revealed that when teachers experience a high intensity of challenges in their teaching practices during the pandemic, they tend to do active coping strategies indicative of grit and a more practical approach to solving the problem. Moreover, qualitative data supported that teachers must also be given mental and emotional support besides physical, technological, and financial support. Furthermore, parallel studies must be conducted with a more diverse and large sample to serve as a guide in crafting a nationwide support mechanism for teachers during a challenging situation