Staff Focus Research Articles

Experience of e-learning and online assessment during the COVID-19 pandemic at the College of Medicine, Qassim University

ObjectivesDuring the COVID-19 pandemic, academic institutions are promptly shifting all educational activities to the e-learning format. The present work describes concurrent procedures for online teaching and assessment performed at the College of Medicine, Qassim University, KSA. We also explored the impact of e-learning and assessment on the performance of students and faculty, and the challenges to their sustainability. MethodsIn this descriptive cross-sectional study, we recorded the number and duration of different online educational activities during the COVID-19 pandemic. Training sessions for various procedures of virtual classrooms and online assessments were organised for teachers and students. A newly established e-assessment committee arranged different online assessments. A comparison between the mean problem-based learning (PBL) grades of the same students was conducted either face-to-face or online. A student satisfaction survey and online staff focus group about the online learning experiences were conducted, and weekly staff perception reports were prepared. The results obtained were then analysed. ResultsA total of 620 virtual classrooms were successfully implemented over 994 h including theoretical lectures, PBL sessions, seminars, and tutorials. A significant increase in the mean PBL grades was observed for female students during the online sessions. Out of the basic year students and staff, 58.82% reflected their high satisfaction towards virtual classrooms, online assessment, and online workshops. ConclusionThe present study elaborates on the benefits of e-learning and assessment. We observed higher student achievements and promising staff perceptions with obvious improvement in their technological skills. These findings support the shift towards future implementation of more online medical courses.

Strategies used by professional rugby union clubs to manage players for artificial turf exposure.

The use of artificial turf on rugby pitches is increasingly commonplace but there is limited evidence around its effects on injury, recovery, and performance. It is unclear whether this uncertainty influences player management strategies in professional clubs. To understand how professional rugby union clubs in England approach player management for artificial turf, to explore how the beliefs of medical and strength/conditioning staff influence these decisions, and to determine whether differences exist between clubs with different levels of exposure to artificial surfaces. The study was a cross-sectional mixed methods study. Twenty-three medical and strength/conditioning staff members from 12 English Premiership Rugby Union clubs completed two bespoke questionnaires and participated in a semi-structured interview. Two-thirds of the participants described formal club-level approaches to artificial turf. All participants from low-exposure clubs (<50% training and match time on artificial pitches) reported adjusting player recovery strategies following games on artificial turf to mitigate elevated muscle soreness and fatigue. Clubs with artificial surfaces at their home venues were less likely to adapt recovery than clubs with natural turf pitches. Regardless of exposure participants believed switching between surface types was a risk factor for injury. Medics reported that acute injuries associated with artificial turf exposure typically occurred at the foot or ankle, whereas abrasions and overuse injuries were more common and often affected the knees, hips and lower back. Players with compromised joints were less likely to be selected for matches on artificial surfaces. Player management around artificial turf is a focus for staff at professional rugby union clubs. Club practices vary by exposure and may consequently influence injury risk estimates.

Upprepningar och glada utrop – pedagogers och barns agenda under tre bokstunder i språkbad

Denna artikel undersöker pedagogers och barns agenda under tre bokstunder med högläsning av bilderböcker i en språkbads-förskolegrupp. Samtliga barn har en finskspråkig bakgrund och lär sig svenska i förskolan. Analyser av de videofilmade bokstunderna har gjorts med en sociokulturell och diskursanalytisk infallsvinkel. Resultaten visar att pedagogerna fokuserar på barnens språkförståelse och språkutveckling, medan barnen på eget initiativ och genom estetiska förhållningssätt riktar sin uppmärksamhet mot den egna upplevelsen av bokens innehåll. Barnens handlingar visar också att det är centralt för dem att uppfylla vissa förväntningar på hur bokstunder ska gå till. De bidrar därmed till att upprätthålla bokstunden på ett bestämt sätt. Pedagogernas koncentration på språk kan ses som naturlig eftersom språkstödjande handlingar främjar barnens förståelse av boken. Däremot får barnen knapphändigt stöd för sin läslust och få utmaningar när det gäller att utgående från sina egna tankar, föreställningar eller tolkningar förhålla sig till bokens innehåll.

Examining a Child Welfare Parenting Intervention for Parents With Intellectual Disabilities

Purpose: There is scant child welfare research on parenting interventions for parents with intellectual and developmental disabilities (I/DD). This mixed-methods research examined client participation in an in-home parenting intervention, including client characteristics, which clients benefit most from participation, and key aspects of program participation. Method: The sample included participant program records, client satisfaction surveys, stakeholder interviews, and a staff focus group. The quantitative data were analyzed using growth curves and binary logistic regression. The qualitative data were analyzed using thematic analysis. Results: Time spent in Project Improving Parenting Achievements Together was predictive of improvement in parenting skills and the home environment and reduction in the odds of out-of-home placement for children of parents with I/DD. The intensity of services, tailored education, community engagement, and client–worker relationship were the key aspects of program participation. Discussion: With proper supports, parents with I/DD can learn parenting skills, improve the home environment, and keep their family intact.

Qualitative Process Evaluation of Rural Schools: Uptake of Change Processes and Contextual Factors Influencing Implementation Within a Primary Prevention Program for Youth.

Sexual violence (SV), homophobic name-calling, and bullying commonly occur in school settings. As such, comprehensive school-based violence prevention strategies are needed. Recent calls in prevention science argue that investigations of preventive interventions must move beyond simply testing if programs work; rather, they must also examine how interventions work. The purpose of this study was to explore the differential uptake of salient change mechanisms of a school-based primary prevention program, Sources of Strength (Sources) in rural schools, and examine contextual factors that may influence implementation outcomes in rural contexts. As a supplement to a randomized controlled trial of Sources in 20 high schools in Colorado, the present project utilized a rigorous qualitative design to conduct staff focus groups and student interviews within four schools (two intervention and two waitlist schools) that participated in the RCT. Results suggest variability in uptake of Sources key processes (expansion of networks to build connections, school-wide activities, and staff support) in intervention schools. While these were indicated as non-formalized processes in waitlist schools, there was also variability in these reports. Furthermore, results revealed specific contextual factors including cultural norms, degree of rurality, and school-level buy-in/investment that impacted implementation outcomes for intervention and waitlist schools (e.g., pre-implementation readiness). Implications are discussed around alignment of a school's policies, procedures, and values with the preventative intervention in effort to support strong implementation.

Qualitative analysis of latent safety threats uncovered by in situ simulation-based operations testing before moving into a single-family-room neonatal intensive care unit.

ObjectivesWe aimed to identify: (a) latent safety threats (LSTs) in a new neonatal intensive care unit (NICU) through simulation-based pre-occupancy operations testing, and (b) LSTs that remained unresolved 1-year post-occupancy.Study designIn this qualitative study, 111 healthcare professionals participated in patient care simulations and debriefings in a new NICU. Debriefing transcripts were inductively analyzed to characterize LSTs. Unresolved LSTs were identified 1 year after NICU occupancy.ResultsThematic saturation was attained after analysis of nine debriefings. Four major themes affecting staff function and patient safety emerged from 305 threats: relay of information, workplace design, patient care processes, and patient family and staff focus. One-year post occupancy, 29 (9%) LSTs remained unresolved.ConclusionTeam debriefings of simulated patient events uncover LSTs that can largely be resolved before transitioning patient care into a new NICU. Understanding how LSTs interact provides a platform to develop viable strategies to mitigate patient safety risks.

Formal and informal support at Icelandic universities: experiences of staff members and immigrant students

Due to increased migration in recent decades, universities must adapt their practices to meet the needs of a changing student body. Many immigrant students desire to complete their studies at universities, yet factors such as language of communication and cultural traditions limit their possibilities. This paper comes out of a study titled Educational Aspirations, Opportunities and Challenges for Immigrants in University Education in Iceland. The findings are based on individual interviews with immigrant students and university staff members and focus group interviews with immigrant students. The theoretical framework of the study draws from the ideas of culturally competent counselling. This helps to analyse immigrant students’ experiences of formal and informal support during their university studies (Arredondo et al., 1996; Maunonen-Eskelinen, Kaikkonen &amp; Clayton, 2005). Formal support constitutes institutional support provided by the universities, such as orientation programs and social activities of various kinds. Informal support, in contrast, incorporates other means of assistance to immigrant students either through those whom they trust, such as instructors, or community members in the role of cultural brokers. Immigrant students also get support through their present and former friends and through their extended family members. The findings indicate that, despite the challenges that immigrant students face at Icelandic universities, the majority were quite positive about their experiences as they described different types of formal and informal support which they obtained throughout their studies.

Reporting and recording sexual safety incidents in inpatient mental health settings

Concerns have been raised about the sexual safety of people in mental health inpatient settings and it has been identified that the reporting of sexual safety incidents is inconsistent across healthcare services. This article describes the strategy developed by Humber Teaching NHS Foundation Trust (HTFT) to improve sexual safety for people using mental health services and comply with recommendations from the Care Quality Commission.The strategy was informed by a literature review and several reports into sexual safety. The literature review found that staff are often unsure how to identify and categorise sexual safety incidents, while debriefing and support for those who experience such incidents are often lacking. In addition, not all healthcare services have policies and protocols in place to guide staff who experience sexual safety incidents. Based on the findings of the literature review, along with recommendations from various organisations, HTFT developed a strategy to ensure the delivery of safe and accountable care. This strategy included: a review of trust policies and procedures; staff and service user focus groups; and the development of a staff education programme. The aim is to disseminate this learning across other inpatient services in the trust.

Psychological factors and maternal-fetal attachment in relation to epidural choice

IntroductionA woman's first childbirth is an event of great importance to her life, involving her transition to parenthood. Many studies have analyzed the roles of depression, anxiety and fear of childbirth linked to childbirth expectations and the consequent choice of an epidural to avoid pain. Few studies have investigated the predictor role of maternal-fetal attachment on the choice of epidural. ObjectiveExplore, in a sample of low-risk pregnant nulliparous women, differences regarding the preference, or not, of epidural for vaginal childbirth. Design and Setting87 nulliparous women, aged 24 to 44 years of age, were recruited in the maternity ward of a public hospital of the metropolitan area of Tuscany (Italy) during the 3rd trimester of gestation. Participants were asked to complete the Pregnancy Related Anxiety Questionnaire-R, Wijma Delivery Expectancy Questionnaire, Centrality of Events Scale, and Prenatal Attachment Inventory. FindingsMultivariate analyses of variance showed that women who chose delivery without epidural reported lower levels of fear of childbirth and anxiety, and higher levels of centrality of pregnancy and prenatal attachment to unborn child, than women who chose epidural. Key conclusionsOur data highlight the importance that medical staff focus on the maternal bond, to help future mothers have the best possible childbirth experience.

I Am Not Alone: Expanding the Epistemological Framework for Supporting Marginalized Women’s Transformative Learning

Marginalized adults have limited access to learning experiences that prioritize reflection and discourse, both considered preconditions in the Mezirow-informed field of transformative learning (TL). Using narrative analysis of a staff focus group and participant interviews over a 1-year learning journey, this study shows how a literacy program in a women’s homeless shelter created conditions that supported TL for two marginalized women of color. Results show how program learning goals were attuned to issues of positionality for women marginalized by race, class, and gender and were consistent with Africentric womanist epistemological and axiological assumptions. Conditions that fostered connectedness among women in troubling contexts and contributed to qualitative change in ways of knowing included purposeful spaces dedicated to reflection, dialogue, and student-centered pedagogy. The findings have important implications for the theoretical grounding of policy and practice in support of marginalized women’s TL.

Development and impact of an endoscopic non-technical skills (ENTS) behavioural marker system

BackgroundNon-technical skills (NTS) are crucial to effective team working in endoscopy. Training in NTS has been shown to improve team performance and patient outcomes. As such, NTS training and assessment...

Engaging Expectant and Parenting Adolescents: Lessons from the Massachusetts Pregnant and Parenting Teen Initiative

IntroductionPrograms supporting adolescent parents have been shown to increase socio-economic opportunities and promote healthy child development for young families, but retaining young parents is challenging. The Massachusetts Pregnant and Parenting Teen Initiative (MPPTI) offers case management and linkages to community and clinical services to young families. We examine engagement strategies identified by MPPTI participants and staff members in relation to participant retention by program site to identify potential strategies for increasing program engagement.MethodsWe employed a mixed-methods approach incorporating quantitative data on program participant characteristics and program retention by site with qualitative data from staff and participant interviews and focus groups.ResultsKey program engagement strategies identified by both MPPTI staff and youth participants were social-emotional supports, staffing model, and concrete supports. We found significant differences in program retention by site; the two sites with the highest levels of program retention offered all engagement strategies identified.DiscussionQuantitative data on program retention coupled with qualitative data from staff and youth interviews suggests that in our program, there may be an association between the engagement strategies identified and levels of program retention.

Embedding compassionate micro skills of communication in higher education: Implementation with psychology undergraduates

Many students struggle with group-based assessments. The pedagogic approach of the ‘compassionate micro skills of communication’ (CMSC) aims to equip students with the skills necessary to work effectively in group settings. To this end, students studying on a core psychology module involving group-work, received structured CMSC learning in seminars. Following its implementation, analysis of data from four student and one staff focus groups, using thematic analysis, indicated support for the pedagogic approach. Four themes emerged: the use of CMSC for addressing unhelpful group behaviours; employing helpful group behaviours; enhancing inclusivity; and areas for CMSC improvement and roll out. Quantitative data collection is still on-going and will be reported elsewhere. However, our preliminary analysis of the qualitative data provides good support for utilising a CMSC pedagogic approach in Higher Education regarding both its efficacy and potential positive impact.

Creating a toolkit with stakeholders for leveraging tablet computers to support person-centred dementia care in hospitals.

IntroductionPeople with dementia may refuse care because they feel overwhelmed by an unfamiliar environment. Everyday technology such as tablets have the potential to support person-centred dementia care in hospitals.AimsWe aimed to identify barriers and enabling factors in order to develop a toolkit to support the use of tablets in engaging individual and group activities, especially to play family videos, for hospitalized older people with dementia.MethodsA participatory action research approach was employed. We facilitated staff focus groups and conducted interviews with stakeholders. A toolkit was developed based on participants’ perspectives on how to support successful adoption.ResultsOur analysis identified two enabling factors: users’ engagement in developing a toolkit for support and adapting implementation to meet local needs. Barriers included staff and family inexperience, mechanical instability of hardware, issues around privacy and data access, technology use and personalization of messages. The toolkit includes short videos, a brochure for family caregivers, and a pocket card for staff.Discussion and implications: Staff, family and patients start with varying levels of experience with the use of tablets, making education and support vitally important to implementation. Health organizations should involve staff, patients, and families to find practical solutions.

123 Acceptability of the Ambient Intelligent Geriatric Management (AMBIGEM) System: A Technological Solution to Prevent in-Patient Falls

Abstract AmbIGeM is a technological solution to prevent in-patient falls in patients aged &amp;gt;65. It has been evaluated in a 100-week stepped wedge pragmatic design in two geriatric evaluation and management (GEM) wards and a general medical ward in two Australian hospitals (Visvanathan, Ranasinghe, Wilson et al., Injury Prevention, 2017,0:1). Evaluation of acceptability of the AmbIGeM system from the perspectives of patients and staff who experienced it is reported here. 30 patients completed a 24-item survey, 27 patients were interviewed, 22 staff participated in 3 focus groups and 51 staff completed a 39-item survey. Survey data were descriptively analysed, and focus group and interview data were thematically analysed. In patient surveys, patients were overall strongly positive, with means 8+ (on 11-point scale) on most items. In patient interviews, the AmbIGeM system was considered a good idea to prevent falls. Most patients thought the singlets comfortable and had no concerns for their privacy nor impact on normal activity. Patients and families felt reassured, although sometimes they misunderstood the purpose of AmbIGeM. In staff focus groups, staff perceived AmbIGeM beneficial in that it can detect and alert movement in patients who require supervision. In both GEM wards, AmbIGeM was considered particularly beneficial,practical and valuable to use on night shift. Factors such as perceived technical limitations (false and delayed alerts) and felt staff burden impacted on acceptability. In staff surveys, 56% agreed/strongly agreed that AmbIGeM has the capability to prevent falls while 16% disagreed/strongly disagreed, 62% thought AmbIGeM would be more user friendly if it was consistently accurate and 76% believed that AmbIGeM takes a moderate/lot of extra work. Conclusion AmbIGeM is largely acceptable to patients and requires further refinement for staff. Feedback is valuable to further refine the system.

Bed Moves, Ward Environment, Staff Perspectives and Falls for Older People with High Falls Risk in an Acute Hospital: A Mixed Methods Study.

BackgroundFalls remain an important problem for older people in hospital, particularly those with high falls risk. This mixed methods study investigated the association between multiple bed moves and falls during hospitalisation of older patients identified as a fall risk, as well as safety of ward environments, and staff person-centredness and level of inter-professional collaboration.MethodsPatients aged ≥70 years, admitted through the Emergency Department (ED) and identified at high fall risk, who were admitted to four target medical wards, were followed until discharge or transfer to a non-study ward. Hospital administrative data (falls, length of stay [LoS], and bed moves) were collected. Ward environmental safety audits were conducted on the four wards, and staff completed person-centredness of care, and interprofessional collaboration surveys. Staff focus groups and patient interviews provided additional qualitative data about bed moves.ResultsFrom 486 ED tracked admissions, 397 patient records were included in comparisons between those who fell and those who did not [27 fallers/370 non-fallers (mean 84.8 years, SD 7.2; 57.4% female)]. During hospitalisation, patients experienced one to eight bed moves (mean 2.0, SD 1.2). After adjusting for LoS, the number of bed moves after the move to the initial admitting ward was significantly associated with experiencing a fall (OR 1.56, 95% CI 1.11–2.18). Ward environments had relatively few falls hazards identified, and staff surveys indicated components of person-centredness of care and interprofessional collaboration were rated as good overall, and comparable to other reported hospital data. Staff focus groups identified poor communication between discharging and admitting wards, and staff time pressures around bed moves as factors potentially increasing falls risk for involved patients. Patients reported bed moves increased their stress during an already challenging time.ConclusionPatients who are at high risk for falls admitted to hospital have an increased risk of falling associated with every additional bed move. Strategies are needed to minimise bed moves for patients who are at high risk for falls.

Smoke-free prison policy development, implementation, and impact across the entire national prison service in Scotland (TIPs study): a three-phase, mixed methods natural experimental evaluation

BackgroundPrisons had partial exemption from UK 2006–07 policies banning smoking in enclosed public spaces, becoming one of few workplaces with continued exposure to second-hand smoke (SHS). Although bans have been introduced elsewhere, evidence of the process and impact of implementing smoke-free prisons is sparse. We aimed to provide evidence on the process and impact of implementation of smoke-free policy across the national prison service in Scotland. MethodsThe Tobacco in Prisons study (TIPs) is a three-phase, mixed-methods study exploring the periods before policy formulation (phase 1; September 2016–July 2017), during preparation for implementation (phase 2; August 2017–November 2018), and after implementation (phase 3; December 2018–May 2020). Data on SHS, health, smoking, beliefs (eg, smoking or e-cigarettes, desirability, benefits, and challenges of smoke-free policy) were gathered across all 15 Scottish prisons through: (1) staff and prisoner surveys, staff focus groups (phases 1 and 3), and cessation provider interviews; (2) SHS measures (fine particulate matter, PM2·5, using Dylos DC1700 monitors) before, during (week commencing Nov 28, 2018), and 6 months after (week commencing May 27, 2019) implementation on Nov 30, 2018. In six case-study prisons, in-depth interviews were carried out with prisoners, staff, and smoking cessation providers. We also accessed routine data (eg, sickness absence, “canteen” purchases of tobacco and other products) to assess policy impacts. Ethics approval was granted by SPS Research Access and Ethics Committee and University of Glasgow. Participants provided written informed consent. FindingsPhase 1 data showed high prisoner smoking rates (1858 [74%] of 2505 responders), confirmed by SHS measures (128 431 min of PM2.5 data, median 31·7 μg/m3), and concerns about the challenges of smoke-free policy (eg, 1954 [81%] of 2407 prisoners and 737 [58%] of 1269 staff thought smoking bans caused “trouble”). Compared with 2016, air quality improved in all prisons in 2018 (114 303 min of PM2.5 data) with an overall median reduction on the first full working weekday after implementation (Dec 3, 2018) of –81% (IQR –76 to –91). SHS measures collected 6 months after implementation (126 777 min of PM2·5 data) showed sustained improvement (median 3·1 μg/m3, overall median reduction –91% (IQR –88 to –93%)). Reasons for success and continuing challenges of smoke-free prison policy will be discussed. InterpretationThis evaluation of the development, planning, implementation, and impact of smoke-free prison policy demonstrates the importance of research evidence during policy implementation and, as a study of an entire national prison service, provides new evidence for other jurisdictions contemplating bans on smoking in prisons. FundingNational Institute for Health Research.

Use of excessive supplemental oxygen in mechanically ventilated patients is based on unit culture. A multiple-methods study in a regional intensive care unit

BackgroundAdministration of supplemental oxygen is widely used in the management of critically ill patients; however, there is evidence that excessive supplemental oxygen exposure is associated with increased mortality. There is limited research evaluating what factors clinicians take into consideration when managing oxygenation in critically ill adults. ObjectivesThe purpose of this study was to explore intensive care unit (ICU) clinicians’ experience and decision-making when managing supplemental oxygen therapy in mechanically ventilated patients in a regional intensive care unit. MethodsA multiple-methods observational study that included (i) a cross-sectional ICU staff survey and (ii) focus group discussions with critical care nurses was conducted. Descriptive statistics were used to summarise the key outcomes of the staff survey. Thematic analysis was used to analyse the focus group discussions and open-ended questions on the staff survey. The staff survey was completed by 49 ICU clinicians, and 11 critical care nurses participated in the two focus group discussions. ResultsSurvey data showed that staff acknowledged the problem of excessive oxygen exposure; 79.6% (n = 39) reported that the minimum acceptable fraction of inspired oxygen for mechanically ventilated patients was 0.3. The majority (89.8%, n = 44) reported that there was an interdisciplinary approach to decision-making in the unit. Two major themes were chosen from the focus group discussions and staff survey data: (i) Decision-making is based on unit culture rather than evidence and (ii) the process of weaning is driven by interdisciplinary team collaboration. Participants acknowledged that there needed to be a culture change from a liberal approach to oxygen therapy. ConclusionsAlthough participants acknowledged the adverse consequences of excessive oxygen use, achieving oxygenation targets with the minimum level of supplemental oxygen was not a key focus of care. The findings highlight the need to develop and evaluate evidence-based protocols to support a conservative approach to supplemental oxygen management.

Changing Culture to Drive Nurse Engagement and Superior Patient Experience

Brandon "Kit" Bredimus was the recipient of AONL's 2018 Pamela Austin Thompson Early Careerist Award. He helped to develop and implement the program detailed below, which improved nurse engagement and patient experience scores.

Do Canadians Leave No Trace? Understanding Leave No Trace attitudes of frontcountry and backcountry overnight visitors to Canadian provincial parks

Both Ontario and Alberta's provincial park systems receive more than 8 million visitors on an annual basis. Park managers must employ direct (e.g., rules and regulations) and indirect (e.g., education and interpretation programs) strategies to minimize negative environmental impacts caused by these visitors. Leave No Trace (LNT) is a widely accepted educational program that aims to reduce environmentally-depreciative behaviours and promote responsible outdoor recreation through low-impact camping practices. The purpose of this study was to understand the level of perceived LNT knowledge of Canadian provincial parks users as well as determine park visitors' attitudes towards LNT practices. Park visitors' knowledge of and attitudes towards LNT practices were measured to determine if there was a difference between (a) those who camped in the backcountry and frontcountry and (b) between those who camped in Alberta and Ontario provincial parks. Results suggest there are in fact statistical and substantive differences between frontcountry and backcountry over-night visitors as well as those who visited parks in Alberta and Ontario. While those who camped in the backcountry had higher self-reported levels of LNT knowledge, those who camped in the frontcountry expressed pro-environment behavioural attitudes that more closely aligned with LNT practices. Additionally, Alberta park visitors reported higher levels of LNT knowledge and consistently demonstrated pro-environment behavioural attitudes more in line with LNT practices than those of park visitors in Ontario. Management implicationsUnderstanding differences between park users’ knowledge and attitudes, will help park managers develop more effective education programs designed to foster pro-environmental behaviours and attitudes with the goal of reducing the negative impacts associated with camping. There has been controversy in recent years related to the appropriateness and effectiveness of LNT, however, this research suggests that park visitors do in fact know what LNT is and hold attitudes largely in line with the principles, therefore suggesting it is still highly relevant. Significant differences in LNT attitudes and knowledge can be observed between users (i.e., backcountry and frontcountry), which may be explained by social demographics; education efforts should target the most common depreciative behaviours (e.g., dogs off leash) and be tailored to context and user group. Finally, this study suggests that perhaps the LNT brand is not enough, but rather consistent and tailored communication from park staff focusing on consequences of inappropriate behaviours and benefits to the park may be more effective at changing knowledge and attitudes than campaigns officially associated with the LNT brand.