High-stress Situations Research Articles

Burnout and Post-traumatic Stress Disorders in Police Officers: Systematic Review and Meta-analysis

AbstractThe occupational environment of law enforcement officers, characterised by high-stress situations and critical societal roles, necessitates continuous monitoring of their mental health. This systematic review and meta-analysis aims to explore the associations and impacts of burnout and PTSD among police officers, shedding light on how these conditions are influenced by evolving job demands and societal expectations. Adhering to PRISMA guidelines, we searched four databases PubMed, PsycINFO, and CINAHL from January 2000 to January 2024. Studies involving active-duty police officers that assessed burnout and PTSD using validated tools were included. A risk of bias was assessed using an eight-criteria scale, focusing on methodological strengths and weaknesses across studies. We analysed data from 10 studies comprising 4572 officers worldwide. The results indicated variable relationships between burnout, PTSD, and their impacts on occupational functioning, with significant heterogeneity across studies (I2 > 75%). Despite the variability, there was a consistent trend showing that occupational stressors are linked to both burnout and PTSD, suggesting a pervasive influence of job-related demands on officer mental health. The findings reveal a complex interaction between burnout and PTSD in police officers, influenced by both individual and occupational factors. This interplay highlights the need for interventions that are sensitive to cultural and contextual nuances of policing. Future strategies should prioritise individual, organisational, and societal dimensions to reduce the psychological burden and enhance resilience among officers.

Active armed offender: A novel clinical practice guideline for pre-hospital care in Ireland

Incidents involving pre-hospital clinicians responding, or being caught in, active situations of those armed with knives and guns are rising in Ireland. These high-profile and high-stress situations require prior planning to minimise loss of life and maintain the safety of paramedic staff. Better situational awareness has been identified by veteran paramedics involved in active armed offender incidents as a key priority in preventing assault of staff. This novel proposed Clinical Practice Guideline (CPG) for the Pre Hospital Emergency Council (PHEC) Ireland is based on existing similar guidelines in Australia. This CPG combines pre-hospital emergency guidelines with established tactical medicine principles from the military and police services worldwide. This CPG seeks to minimise harm to clinicians as well as inform them of appropriate clinical priorities while operating in an unsafe situation

The Urgent Need for Disaster Education as a Core Competency in Accredited Schools and Colleges of Public Health by the Council on Education for Public Health.

Public Health is essential to disaster preparedness, mitigation, response, and recovery. This has never been more evident than during the COVID-19 pandemic when public health was the disaster response lead. However, students are graduating from accredited schools and colleges of public health with limited or no education in disaster management. This is a crisis unto itself, and it is incumbent upon The Council on Education for Public Health (CEPH) to take immediate action. Public health preparedness should be recognized as a core element in public health curricula, and practical experiences, such as drills and simulations, are necessary to equip students with the confidence and competencies needed in high-stress situations. The need for such preparedness education extends beyond the COVID-19 pandemic. It is a crucial step for creating a resilient and competent public health workforce capable of safeguarding community health in the face of complex and emerging challenges.

Work of Breathing for Aviators: A Missing Link in Human Performance

In this study, we explore the work of breathing (WoB) experienced by aviators during the Anti-G Straining Maneuver (AGSM) to improve pilot safety and performance. Traditional airflow models of WoB fail to adequately distinguish between breathing rate and inspiratory frequency, leading to potentially inaccurate assessments. This mismatch can have serious implications, particularly in critical flight situations where understanding the true respiratory workload is essential for maintaining performance. To address these limitations, we used a non-sinusoidal model that captures the complexities of WoB under high inspiratory frequencies and varying dead space conditions. Our findings indicate that the classical airflow model tends to underestimate WoB, particularly at elevated inspiratory frequencies ranging from 0.5 to 2 Hz, where resistive forces play a significant role and elastic forces become negligible. Additionally, we show that an increase in dead space, coupled with high-frequency breathing, elevates WoB, heightening the risk of dyspnea among pilots. Interestingly, our analysis reveals that higher breathing rates lead to a decrease in total WoB, an unexpected finding suggesting that refining breathing patterns could help pilots optimize their energy expenditure. This research highlights the importance of examining the relationship between alveolar ventilation, breathing rate, and inspiratory frequency in greater depth within realistic flight scenarios. These insights indicate the need for targeted training programs and adaptive life-support systems to better equip pilots for managing respiratory challenges in high-stress situations. Ultimately, our research lays the groundwork for enhancing respiratory support for aviators, contributing to safer and more efficient flight operations.

The Impact of Emotional Intelligence on Nurses' Professional Quality of Life in Pre-Hospital Emergency Settings: A Multicentre Mixed-Method Study.

Pre-hospital emergency nurses, frequently exposed to high-stress situations, are at risk for burnout and stress-related issues, affecting their overall well-being. The Professional Quality of Life (ProQoL) scale, widely used among hospital nurses, remains untested in pre-hospital emergency settings. To adapt and validate the ProQoL scale for pre-hospital emergency contexts and explore the protective role of emotional intelligence in professional well-being. A mixed-method study was conducted. The qualitative approach involved semi-structured interviews to inform the modification of items for adapting the ProQoL to the pre-hospital emergency setting. A quantitative method was applied to assess the relationship between emotional intelligence and professional well-being through content and face validity measures. Qualitative interviews suggested refining the ProQoL for pre-hospital emergency settings, emphasising factors such as job satisfaction and professional conduct. The revised 21-item Pre-Hospital Emergency-Professional Quality of Life (PHE-ProQoL) scale demonstrated strong content validity (I-CVI: 0.86-1, S-CVI: 0.9) and face validity. Significant correlations were observed between emotional intelligence and professional well-being, with negative correlations between emotional intelligence and both burnout (Pearson's r = -0.859) and post-traumatic stress (Pearson's r = -0.792), and a positive correlation with compassion satisfaction (Pearson's r = +0.917). Pre-hospital nurses displayed moderate levels of compassion satisfaction (27.3 ± 9.81), high emotional intelligence (28.0 ± 9.58), especially in empathy, and substantial levels of burnout (22.5 ± 6.09) and stress (21.2 ± 4.3). The study found that pre-hospital emergency nurses exhibit moderate compassion satisfaction and above-average emotional intelligence, particularly in perceiving and managing others' emotions. However, they also experience significant levels of burnout and post-traumatic stress. Burnout and post-traumatic stress significantly affect pre-hospital emergency nurses. Enhancing emotional intelligence is crucial for their well-being. Nursing managers now have access to a validated and reliable tool to assess this.

Coping Flexibility: Match Between Coping Strategy and Perceived Stressor Controllability Predicts Depressed Mood

AbstractIndividual differences in coping responses can predict psychological distress, anxiety, and depression; therefore, it is vital to explore adaptive coping strategies. Recent research suggests that an individual’s ability to choose strategies based on the context may be more important than the ability to use any one strategy, an ability termed coping flexibility. For example, problem-focused coping is adaptive for situations of high control, while emotion-focused coping is adaptive for situations of low control. This conceptualization of coping flexibility, termed strategy-situation fit, consists of the match of strategy to situation. The purpose of the present study was to evaluate if daily fluctuations in strategy-situation fit for daily stressors would be associated with daily levels of depressed mood. A seven-day diary study in a sample of undergraduate students (n = 75) was completed. The results of generalized linear mixed models demonstrated that in situations of high stress and high control, more use of emotion-focused coping was related to higher levels of depressed mood. Additionally, in situations of high stress and low control, more use of emotion-focused coping was related to lower levels of depressed mood. These findings suggest that the match between emotion-focused coping and perceived stressor controllability can be a predictor of daily experiences of depressed mood when faced with high-level stressors.

Blue Space: Extracting the Sensory Characteristics of Waterscapes as a Potential Tool for Anxiety Mitigation.

Objective: The purpose of this study is to investigate if there is a physiological stress response to the visual and auditory characteristics of waterscapes. Background: Biophilic research suggests that the presence of water can reduce stress, reduce blood pressure, and increase circulation. However, water has largely been omitted from healthcare design due to concerns of cost, maintenance, waterborne pathogens, and contamination. Existing research has not yet provided a design methodology to incorporate the healing effects of water without the potential diseases, contamination, and maintenance issues associated with physical water. Given the current technological capabilities, the isolation of the auditory and visual sensory stimuli has potential to re-introduce the healing benefits of water into healthcare design. Methods: Participants were either exposed to a slow-moving or fast-moving waterscape for 20 minutes. Pre- and post-anxiety were measured using the State Trait Anxiety Scale in an online Qualtrics survey (118 participants) and through a salivary cortisol biomarker (in which 26 participants also partook). Results: The overall results demonstrate that the utilization of digital blue space was effective in reducing stress. There was no significant difference between the lake or waterfall environment in both salivary cortisol and state-trait anxiety measures. However, it is suggested that the slow and fast-moving waterscapes may be beneficial in different settings. Conclusion: Design recommendations are made regarding potential biophilic design in healthcare facilities. The utilization of sensory waterscapes can also provide a cost affordable, non-pharmacological, alternative for anxiety mitigation for patients and staff undergoing high-stress situations.

An experimental study on lithium-ion electric vehicles battery packs behavior under extreme conditions for prevention of thermal runaway

The need for efficient and dependable lithium-ion battery packs has significantly increased as a result of the progressively rising sales of electric vehicles (EVs). Thermal management is one of the key factors in battery performance and durability. To avoid thermal deterioration, improve safety, and maximize system effectiveness, the battery pack's temperature must be carefully managed. These battery systems' potential for thermal runaway has raised concerns about how safely they can be operated in harsh environments. Environmental considerations, governmental laws, and developments in battery technology are driving the switch from internal combustion engines to electric automobiles. Lithium-ion batteries are sensitive to temperature variations and operating them outside the optimal temperature range can lead to accelerated degradation, reduced capacity, and compromised safety. Key performance indicators used to assess battery thermal management system effectiveness include temperature uniformity, cooling effectiveness, energy usage, and effect on battery life. This paper describes an experimental investigation that looked at how lithium-ion EV battery packs behaved in harsh environments. It also suggests a unique strategy to prevent thermal runaway by using materials like Transformer Oil (TO) and Phase Change Materials (PCM). A specially built experimental setup was created to undertake this inquiry in order to imitate several extreme situations, including high ambient temperatures. A lithium-ion (NMC) battery pack (7S3P) was put through the experimental phase's predicted harsh circumstances to see how it would react thermally. In order to obtain insight into the underlying mechanisms causing thermal runaway, the data acquired were evaluated, and crucial thermal metrics like temperature distribution, heat dissipation, and thermal gradients were studied. The experiment's findings showed that under extreme circumstances, conventional cooling techniques were ineffective in preventing thermal runaway, which resulted in serious safety risks and a reduction in battery performance. The suggested strategy, which incorporates PCM and TO, was then put into practice to fix these flaws and improve battery safety. Due to their ability to self-regulate, they served as components that prevented thermal runaway by limiting the rise in temperature under high-stress situations.

A comparison of recall methods for high-stress critical incidents in police training

Police officers often face critical incidents involving armed offenders, requiring the use of force to ensure safety. Eyewitness accounts, including those from officers, are crucial in the justice system but can be unreliable. Techniques such as self-authored statements and structured interviews are used to gather information, but their efficacy in high-stress situations is unclear. Previous research suggests that heightened arousal during memory encoding enhances recall, particularly for central details. This study compares recall methods (statements vs. interviews) for police officers in high-stress versus no-stress situations, focusing on central and peripheral event details. Officers participated in a simulated high-stress incident, providing memory data through both methods. Overall, no significant difference was found in memory scores between the techniques. However, analysis revealed significant differences favoring structured interviews for peripheral information. Recall that central information remained consistent across methods. These findings highlight the need for careful methodology when examining memories formed in stressful contexts.

Coaching workshops for managing communication challenges perceived by emergency nurses in Morocco: a pilot experiment

PurposeIn emergency departments, effective communication is of utmost importance to ensure the safety of patients. However, communicating can be quite challenging when dealing with high-stress situations. This study aims to assess the efficacy of coaching workshops, informed by a transtheoretical coaching model, in managing communication challenges perceived by emergency nurses and enhancing their communication skills.Design/methodology/approachThe study involved seven emergency room nurses working at a public hospital in Morocco. The data were gathered through various instruments, including observation grids, interviews and pre- and post-test questionnaires.FindingsThe study identified prevalent challenges in communication among nurses, notably difficulties in accurately interpreting messages when faced with confrontational attitudes from colleagues or superiors. Additionally, some nurses exhibited asymmetrical communication patterns, prioritizing their own perspectives over others' during interactions. The findings revealed a statistically significant disparity between pre- and post-test scores (P = 0.017). The nurses’ mean score has improved by 5.14 after attending the four workshop coaching experience, passing from 5.71 in the pre-test to 10.85 in the post-test.Originality/valueThis is the first study in Morocco to evaluate the effectiveness of coaching workshops guided by a transtheoretical coaching model in improving communication skills and overcoming communication barriers among working emergency nurses.

Protecting Frontline Workers: Strategies for Preventing and Mitigating Violence in the Emergency Department

Violence in the emergency department (ED) has been escalating for decades worldwide. High-stress situations are commonplace in the ED and can lead to intentional and unintentional aggression from patients. Staff must be educated on the signs of violence and escalation to recognize potentially dangerous situations early. Staff must also identify underlying medical conditions as the source of unintentional violence. Both situations would require different approaches to management. ED violence negatively affects patient care and leads to long-term harmful outcomes for staff. Multiple strategies for mitigation and prevention have been explored in the literature. Among those, weapon detection systems, de-escalation training, and violence prevention programs have demonstrated improved staff outcomes and decreased violence. Formalized procedures and policies should clearly assign roles for each staff member in the event of a violent patient. Training programs should be instituted and may include self-defense classes or crisis intervention courses. Emergency medicine residency programs and EDs around the country must address the rising incidence of violence within EDs through interdisciplinary policy, procedure development, and prevention and mitigation programs.

The Differential Diagnosis between Cushing's Disease and Pseudocushing Syndrome in a Pre-agonic Patient.

The pseudo-Cushing's encompass several disorders that can occur in high-stress situations and that show biochemical features like those of Cushing's syndrome. We present a case with difficult differential diagnosis for overlapping laboratory findings. A 74-year-old man was admitted to our hospital for worsening dyspnoea for a month, 15 kilograms of weight loss in the previous months, asthenia, hypotonia, and muscle hypotrophy. Moreover, due to the onset of acute hypoxic-hypercapnic respiratory failure, the patient was treated with non-invasive ventilation and then admitted to the intensive care unit, for pneumonia and respiratory failure due to Meticillin-sensitive Staphylococcus aureus and Klebsiella Aerogenes. Antibiotic therapy was started. During the treatment in the ICU, the patient underwent endotracheal intubation for the worsening of respiratory function, and inotropic drug therapy was introduced for the development of septic shock. Hormones were tested, showing an ACTH-dependent hypercortisolism. The results of Nugent, Liddle, and the dexamethasone- suppressed CRH stimulation tests suggested a not-neoplastic ACTH-dependent hypercortisolism. The pituitary contrasted magnetic resonance image showed gland hypertrophy, and the abdominal computed tomography ruled out adrenal lesions. Unfortunately, the patient developed a multi-organ failure and died. The autopsy finding confirmed the absence of pituitary and other neuroendocrine tumors and showed bilateral adrenal hypotrophy. Our clinical case described a patient with pseudo-Cushing's syndrome during sepsis and pre-agonist phase, with a difficult differential diagnosis, in which the combination of the low-dose dexamethasone suppression test and the CRH test allowed a conclusive and correct diagnostic orientation.

Internet-Based Trauma Recovery Intervention for Nurses: A Randomized Controlled Trial

Introduction: Nurses, who care for patients with various traumas, may also experience post-traumatic stress disorder due to indirect or direct exposure to traumatic situations. This study examined the effectiveness of an Internet-based trauma recovery intervention for Korean nurses. Methods: This randomized controlled trial was conducted with 112 nurses aged 23–40 years who were randomly assigned to the intervention (n = 56) or control group (n = 56) from May 7 to December 20, 2020. Nurses in the intervention group attended eight sessions, and the same intervention was administered to the control group. Repeated measures were collected at pre-test, post-test 1 (immediately after the intervention), and post-test 2 (4 weeks after the intervention). A total of 102 nurses (intervention group: n = 49; control group: n = 53) were completed because 10 nurses dropped out before the first session. Data were analyzed using the χ2 test, Fisher’s exact test, t-test, Mann-Whitney U test, and repeated measures ANOVA (intention-to-treat and per protocol). Results: There were significant changes in functional health, resilience, post-traumatic stress, depressive symptoms, state anxiety, and trait anxiety over time and in the group-by-time interactions (intention-to-treat and per protocol). There was a significant difference in social support in the group-by-time interactions, but there were no significant changes between the two groups or over time (intention-to-treat and per protocol). Conclusion: The Internet-based trauma recovery nursing intervention is effective in clinical and community settings for nurses who cannot participate in fixed-schedule programs due to shift work. This study’s findings are relevant for implementing Internet-based trauma recovery programs for nurses and the general population, including survivors and relatives of patients who suffered from COVID-19. This program will also be very useful for people in other high-stress situations. Nurse leaders should consider different populations and situations when offering effective coping strategies suitable for changing environments.

The Relationship Between Stress, Training, and Performance in a Highly Realistic Lethal Force Scenario

To determine whether an officer’s use of force is reasonable, courts consider the totality of the circumstances known at the time of the incident by the officer and consider whether other reasonably prudent officers would have responded in a similar way. The results of the source article suggest it is unreasonable to expect officers to perform perfectly in high-stress situations. Regardless of their training and experience, officers often make errors in such situations and experience a range of performance problems. Training standards need to be set in an attempt to minimize poor officer performance. Realistic scenario-based training should be used, which elicits stress responses and focuses on the development of skills that have been shown to improve performance under stress.

Implementation of a vascular acute care surgery model is associated with improved surgeon efficiency and 2-year mortality after lower extremity intervention

ObjectiveVascular surgeons work long, unpredictable hours with repeated exposure to high-stress situations. Inspired by general surgery acute care surgery models, we sought to organize the care of vascular emergencies with the implementation of a vascular acute care surgery (VACS) model. Within this model, a surgeon is in-house without elective cases and assigned for consultations and urgent operative cases on a weekly basis. This study examined the impact of a VACS model on postoperative mortality and surgeon efficiency. MethodsThis was a retrospective cohort analysis of institutional Vascular Quality Initiative data from July 2014 to July 2023. Patients undergoing lower extremity bypass, peripheral vascular intervention, or amputation were included. There was a washout period from January 2020 to January 2022 to account for COVID-19 pandemic practice abnormalities. Patients were separated into pre- or post-VACS groups. The primary clinical outcomes were 30-day and 2-year mortality. Secondary clinical outcomes included 30-day complications and 30-day and 1-year major adverse limb events (MALE). Separate analyses of operating room data from July 2017 to February 2024 and fiscal data from fiscal year 2019 to fiscal year 2024 were conducted. A washout period from January 2020 to January 2022 was applied. Efficiency outcomes included monthly relative value units (RVUs) per clinical fraction full-time equivalent (cFTE) and daytime (0730-1700, Monday-Friday) operating room minutes. Patient factors and operative efficiency were compared using appropriate statistical tests. Regression modeling was performed for the primary outcomes. ResultsThere were 972 and 257 patients in the pre- and post-VACS groups, respectively. Pre-VACS patients were younger (66.8 ± 12.0 vs 68.7 ± 12.7 years; P = .03) with higher rates of coronary artery disease (34.6% vs 14.8%; P < .01), hypertension (88.4% vs 82.2%; P = .01), and tobacco history (84.4% vs 78.2%; P = .02). Thirty-day mortality (2.4% pre-vs 0.8% post-VACS; P = .18) and Kaplan-Meier estimation of 2-year mortality remained stable after VACS (P = .07). VACS implementation was not associated with 30-day mortality but was associated with lower 2-year mortality hazard on multivariable Cox regression (hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.3-0.9; P = .01). Operative efficiency improved post-VACS (median, 850.0; interquartile range [IQR], 765.7-916.3 vs median, 918.0; IQR, 881.0-951.1 RVU/cFTE-month; P = .03). Daytime operating minutes increased (469.1 ± 287.5 vs 908.2 ± 386.2 minutes; P < .01), whereas non-daytime minutes (420.0; IQR, 266.0-654.0 vs 469.5; IQR, 242.0-738.3 minutes; P = .40) and weekend minutes (129.0; IQR, 0.0-298.0 vs 113.5; IQR, 0.0-279.5 minutes; P = .59) remained stable. ConclusionsA VACS model leads to improvement in surgeon operative efficiency while maintaining patient safety. The adoption of a vascular acute care model has a positive impact on the delivery of comprehensive vascular care.

Virtual Reality Adaptive Training for Personalized Stress Inoculation.

To evaluate a personalized adaptive training program designed for stress prevention using graduated stress exposure. Astronauts in the high-risk space mission environment are prone to performance-impairing stress responses, making preemptive stress inoculation essential for their training. This work developed an adaptive virtual reality-based system that adjusts environmental stressors based on real-time stress indicators to optimize training stress levels. Sixty-five healthy subjects underwent task training in one of three groups: skill-only (no stressors), fixed-graduated (prescheduled stressor changes), and adaptive. Psychological (subjective stress, task engagement, distress, worry, anxiety, and workload) and physiological (heart rate, heart rate variability, blood pressure, and electrodermal activity) responses were measured. The adaptive condition showed a significant decrease in heart rate and a decreasing trend in heart rate variability ratio, with no changes in the other training conditions. Distress showed a decreasing trend for the graduated and adaptive conditions. Task engagement showed a significant increase for adaptive and a significant decrease for the graduated condition. All training conditions showed a significant decrease in worry and anxiety and a significant increase in the other heart rate variability metrics. Although all training conditions mitigated some stress, the preponderance of trial effects for the adaptive condition supports that it is more successful at decreasing stress. The integration of real-time personalized stress exposure within a VR-based training program not only prepares individuals for high-stress situations by preemptively mitigating stress but also customizes stressor levels to the crew member's current state, potentially enhancing resilience to future stressors.

Policy Brief 13: Catalysing the private sector for disaster response and resilience – Case study of the Philippine Disaster Resilience Foundation

Extreme weather events, earthquakes, volcanic eruptions and epidemics cause the loss of countless lives and bring disruption to many countries. Governments and humanitarian aid agencies are expected to be at the forefront of preparing for and responding to such disasters.&#x0D; However, occasionally the scale and impact of some natural disasters are so large that additional resources beyond what governments can provide become necessary. In such cases, efforts may be perceived as insufficient and slow. Resources and efforts need to be augmented in order to provide relief and support to those who need it most.&#x0D; Could the private sector take a more leading role in pre- and post-disaster efforts? How could a structured, long-term engagement reduce the inevitable integrity risks in high-stress disaster situations involving numerous government, business and international actors?&#x0D; This Policy Brief looks at how the Philippines Disaster Resilience Foundation (PDRF) has emerged as a leading private-sector coordinator for disaster risk reduction and management.&#x0D; It illustrates the important role that the private sector can play in responding to – and building resilience to – natural disasters and other humanitarian emergencies. It also showcases how vital it is for good governance, integrity and transparent collaboration to be at the heart of those efforts.

HUBUNGAN TINGKAT SPIRITUALITAS DENGAN PSYCHOLOGICAL DISTRESS PADA KELUARGA PASIEN DI UNIT PERAWATAN INTENSIF

Intensive care units often become stressful environments where families of patients experience emotional impacts due to serious health conditions, and spirituality serves as an effort to cope with psychological discomfort. The research aims to examine the correlation between the level of spirituality and psychological distress in the families of patients. This is a non-experimental quantitative study using a correlational approach with a cross-sectional method. The research was conducted at Arifin Achmad Hospital in Pekanbaru. Sample selection was done using accidental sampling, considering inclusion and exclusion criteria, resulting in 40 respondents. The measurement tools used were the Daily Spiritual Experience Scale (DSES) questionnaire and the Hospital Anxiety and Depression Scale (HADS) questionnaire. Data analysis employed the Chi-Square test with α = 0.05. The research results indicate a description of a high level of spirituality in 67.5% of the respondents. The description of psychological distress is moderate in 40% of the cases. The Chi-Square statistical test yielded a p-value of 0.000 (p &lt; 0.05). In conclusion, there is a relationship between the level of spirituality and psychological distress in the families of patients in the intensive care unit, indicating that families with lower levels of spirituality are more susceptible to experiencing severe psychological distress when facing high-stress situations.

Effect of Rapid Response Order Panels on Resident and Nurse Satisfaction.

Hospitals are required to have rapid response (RR) systems in place to respond to acute changes in a patient's condition. In high-stress situations like RR, medical residents face decision-making challenges due to time constraints and perceived pressure. Instituting order panels (OPs) can facilitate clinical decision making and improve residents' and nurses' satisfaction and patient safety. This quality improvement (QI) project aimed to create and institute standardized OPs for common RR clinical scenarios to improve satisfaction of internal medicine residents and nurses with the RR process. This was a single tertiary care center QI project that developed OPs for 10 common RR scenarios. Resident and nursing satisfaction with RR was assessed before and after OP implementation via survey and qualitative data collection. Residents and nurses expressed high levels of satisfaction across various aspects of the RR process before and after OP implementation in both quantitative and qualitative analysis. Increased satisfaction was observed among residents regarding time spent placing orders (94%; P = 0.02) and time spent correcting wrong orders (87%; P = 0.03) after OP implementation. The nurses' survey revealed no statistically significant differences in satisfaction before and after the implementation of OPs regarding communication, collaboration, efficiency, and organization of the team. The introduction of standardized OPs for RRs resulted in increased satisfaction among internal medicine residents in terms of order placement and correcting wrong orders. Nurse satisfaction based on survey responses remained neutral. Qualitative data from both groups demonstrated a positive impact on communication, efficiency, and teamwork.

Compliance or confusion? The usefulness of blindfolding horses as a handling technique

Blindfolds have commonly been suggested to make horses more tractable in emergency or high-stress situations such as barn fire evacuations or trailer loading. However, little research has been done on the veracity of this claim. Two studies were conducted to examine the impact of blindfolds on ease of handling. In Study 1, 33 riding lesson horses were led from a familiar stall both blindfolded and unblindfolded. In Study 2, 27 of these horses were then led through an obstacle course both blindfolded and unblindfolded that required them to weave through cones, back up through a chute, walk across a tarp and pass through a gate made of pool noodles that brushed their flanks. For both studies, time taken to complete each phase of the test (Study 1: haltering, blindfolding, exiting stall; Study 2: each of the four obstacles) was recorded, as well as heart rate difference from baseline, lead rope pressure and frequency of avoidant or resistant behaviours. Results were analyzed using a mixed model with post-hoc Tukey-Kramer comparisons to investigate the relationship between variables. Generally, blindfolded horses required more time and greater lead rope pressure for handling and displayed higher frequencies of avoidant (p < 0.05) and active refusal behaviour (p < 0.04) in Study 1 and for the cones and backing up obstacles in Study 2. Conversely, when navigating the visually frightening “gate” obstacle in Study 2, blindfolded horses required less time (p = 0.0053) and lead rope pressure (p = 0.0049) and demonstrated fewer avoidant (p < 0.0001) or refusal behaviours (p = 0.0009) than unblindfolded horses. Blindfolded horses showed a greater heart rate increase from baseline while being led in Study 1 (p = 0.0226). Blindfolding did not have an effect on heart rate in Study 2 (p = 0.1672), but horses demonstrated reduced heart rate difference from baseline during their second attempt at the obstacle course regardless of blindfolding status (p < 0.0001). These findings suggest that blindfolding may be a beneficial tool when navigating visually frightening stimuli and time is not a concern. However, in emergency scenarios such as barn fire evacuations, blindfolding is likely to increase lead time and difficulty of handling, which could negatively impact the success of a rescue and put human and animal lives at risk. Future research is required to test the efficacy of blindfolds in a more realistically simulated emergency environment.