Health system resilience is increasingly central to health policy, yet comparative assessments often rely on absolute resource volumes that favour larger economies. This study evaluates post-pandemic health system resilience across 37 OECD countries using exclusively per-capita indicators, removing population-scale bias. Indicators are referenced to the 2021-2023 pandemic period, most at their 2021 values. Seven criteria spanning structural capacity, human resources, and population health and crisis outcomes were weighted objectively with the CRITIC method, and countries were ranked with the VIKOR compromise method; robustness was tested through Entropy weighting, TOPSIS ranking, strategy-parameter sensitivity analysis, leave-one-out criterion analysis, and resampling-based rank intervals. Physician density, hospital-bed capacity, and COVID-19 mortality per million were the most informative criteria; per-capita health expenditure was the least discriminating. Japan ranked first and satisfied both VIKOR acceptability conditions, followed by Austria, Switzerland, France, and Luxembourg. The United States-the highest per-capita spender-ranked 32nd of 37, an expenditure-outcomes paradox reflecting VIKOR's penalisation of the weakest criterion; the country rises to mid-table under compensatory TOPSIS. Findings are consistent with resilience-related performance being associated with the conversion of per-capita resources into outcomes rather than with spending volume, supporting outcome-oriented performance frameworks for future public health crises.
Prolonged mechanical ventilation can impair diaphragmatic function and hinder weaning. This study evaluated the effect of nurse-led graded diaphragmatic functional training in mechanically ventilated ICU patients. In this single-center randomized controlled trial, 120 adult patients receiving mechanical ventilation in the intensive care unit of a tertiary hospital in Hefei from February to December 2024 were randomly assigned to either the intervention group (n = 60) or the control group (n = 60). The control group received routine rehabilitation care and early mobilization, while the intervention group received nurse-led graded diaphragmatic training in addition to standard care. Ultrasound was used to evaluate end-inspiratory diaphragm thickness, end-expiratory diaphragm thickness, diaphragm thickening fraction, diaphragmatic excursion, incidence of ventilator-associated pneumonia (VAP), and successful weaning rates before and 7 days after intervention. A total of 54 patients in the intervention group and 56 in the control group completed the study. After 7 days of intervention, the intervention group had significantly higher end-inspiratory diaphragm thickness, end-expiratory diaphragm thickness, diaphragm thickening fraction, diaphragmatic excursion, and weaning success rate, and a significantly lower incidence of VAP compared to the control group (p < 0.05). Nurse-led graded diaphragmatic functional training improves diaphragmatic function, enhances weaning success, reduces ventilator-associated pneumonia, and promotes recovery in mechanically ventilated ICU patients.
Aim of this study was to develop and evaluate the validity and reliability of the ReTos (Regione Toscana) scale for identifying older inpatients at risk of falls. 15,159 inpatients aged ≥65 years from 41 Italian hospitals were enrolled with six-month follow-up. Items were generated through literature review and expert consensus. Content validity was assessed by a multidisciplinary panel. Exploratory factor analysis (EFA) examined dimensionality. Internal consistency was estimated using McDonald's Omega. Criterion-related validity was tested through logistic regression, and discriminative performance assessed using the area under the ROC curve. Mean age was 79 years (52.7% female). During follow-up, 278 patients experienced at least one fall (incidence 0.59 per 1,000 patient-days). EFA reduced the original 22 items to 11 items across five factors: motor disorders, mental state, diseases/medications, anamnesis and sensory impairment. Several items were significantly associated with fall occurrence. Internal consistency was acceptable (Ω = 0.79). Discriminative performance was modest (AUC = 0.62; 95% CI 0.58-0.66), with sensitivity 0.70 and specificity 0.52 at a cut-off ≥7; positive predictive value was low (0.03), reflecting low event incidence. The ReTos scale demonstrated satisfactory psychometric properties but modest discriminative performance, supporting its use as an adjunct to clinical judgment rather than a stand-alone tool.
This 18-month longitudinal mixed-methods study employed an explanatory sequential design QUAN→qual examining 412 healthcare workers (nurses and physicians) from four tertiary hospitals in China to explore the bidirectional relationships between organizational climate, individual resilience, and career compromise. Quantitative data were collected at baseline, 9 months, and 18 months using validated instruments: Practice Environment Scale-Nursing Work Index, Connor-Davidson Resilience Scale-10, and Career Compromise Scale. Random-intercept cross-lagged panel models (RI-CLPM) examined bidirectional relationships. Semi-structured interviews (n = 45) conducted at the third timepoint explored mechanisms underlying quantitative patterns, analyzed via thematic analysis. RI-CLPM revealed significant bidirectional effects. Organizational climate at baseline predicted increased resilience at 9 months and reduced career compromise at 18 months. Resilience predicted improved perceptions of organizational climate and lower career compromise. Career compromise predicted decreased resilience and more negative climate perceptions. Qualitative themes highlighted support mechanisms, resilience adaptation, and decision-making dynamics, showing that positive organizational climates enhance resilience through psychological safety and development opportunities, reducing career compromise. Organizational climate, resilience, and career compromise demonstrate reciprocal relationships over time, supporting a dynamic systems perspective. Interventions should simultaneously target organizational factors and individual capacities to optimize healthcare workforce retention. Findings inform evidence-based policies for tertiary hospital management.
De Beer (2026) argues that burnout's ICD-11 classification as an "occupational phenomenon" necessitates a stricter separation between organizational screening and clinical diagnosis. This commentary challenges that "dual approach" as a false dichotomy that underestimates the biological reality of chronic stress. Drawing on biomarker research from 2024 and 2025 and the validation logic of the Burnout Assessment Tool that De Beer published on extensively in the past, I argue that the occupational-clinical split risks functioning as a liability shield rather than a care pathway. When we deny the diagnostic validity of workplace screening, we create a "Twilight Zone" where employees with severe symptoms can be given organizational "risk" labels without corresponding clinical recognition or care. I propose an Integrated Continuum Model where workplace screening functions as valid Stage 1 assessment within a coordinated care pathway, ensuring that high-risk scores trigger immediate clinical triage rather than administrative limbo. The failure to integrate these approaches does not protect employees. It leaves them without a clear path to appropriate care.
Evaluating agreement between AI-generated functional assessment metrics and clinician judgment in stroke rehabilitation is important for understanding how AI-supported evaluation tools may complement clinical practice. This cross-sectional study examined agreement between AI-generated functional performance metrics and clinician-rated judgments in adults with chronic stroke and explored clinician- and patient-level predictors of discrepancies. A total of 186 participants, including 90 adults with chronic stroke and 96 rehabilitation clinicians, completed standardized functional assessments. AI-generated metrics derived from wearable inertial sensors and computer vision algorithms were compared with clinician-rated judgments across multiple functional domains. Agreement was evaluated using intraclass correlation coefficients, and multivariable linear regression identified predictors of AI-clinician discrepancy scores. Agreement between AI metrics and clinician judgment was moderate to good across domains (ICC range = 0.68-0.79), with the highest agreement observed for task execution speed. Greater clinician experience and physical therapy discipline were associated with higher agreement, while regression analysis showed that older age and longer time since stroke were associated with larger discrepancies, and greater motor impairment severity was associated with smaller discrepancies. Overall, AI-generated functional metrics demonstrated meaningful concordance with clinician judgment and appear most useful as complementary evaluative tools that require contextualized clinical interpretation.
The PROMIS Sleep Disturbance Short Form 8b (PROMIS SD-SF-8b) is an 8-item self-report measure evaluating two dimensions of sleep disturbance: Insomnia symptoms and dissatisfaction with sleep. This study aims to validate the PROMIS SD-SF-8b for use among Arab nurses. A cross-sectional, descriptive, correlational design was employed. The instrument underwent a rigorous five-step cross-cultural adaptation process. Psychometric testing included descriptive statistics, internal consistency analysis, test-retest reliability, exploratory and confirmatory factor analyses (EFA, CFA), and evaluation of convergent and discriminant validity. The Ar-PROMIS SD-SF-8b demonstrated excellent internal consistency (Cronbach's alpha = 0.81; McDonald's omega = 0.82) and test-retest reliability (ICC = 0.90). EFA revealed a two-factor structure explaining 57.44% of the total variance. CFA supported the two-factor model (CFI = 0.96, RMSEA = 0.07, CMIN/df = 2.03). Composite reliability exceeded average variance extracted, indicating strong convergent validity. The AVE values surpassed the MSV values, further supporting the discriminant validity of the Ar-PROMIS SD-SF-8b. No significant floor or ceiling effects were observed, indirectly suggesting the instrument's robustness and sensitivity to detect variations in sleep disturbance among Arab nurses. The Ar-PROMIS SD-SF-8b is a valid and reliable instrument for assessing sleep disturbance among Arab nurses. By providing precise measurement of sleep-related impairments, this instrument can aid healthcare organizations and researchers in identifying nurses at risk and effectively monitoring sleep-related outcomes, thereby facilitating the implementation of targeted occupational health and well-being interventions. Its application may inform targeted interventions and broader evaluations in culturally comparable healthcare settings.
This study aimed to analyse the application characteristics of patient-reported outcomes (PROs) in traditional Chinese medicine (TCM) clinical trials for musculoskeletal disorders in China. This study included TCM clinical trials for musculoskeletal diseases conducted in China between January 1, 2010, and August 1, 2023. Data were extracted from ClinicalTrials.gov, the Chinese Clinical Registry, and the International Traditional Medicine Clinical Trial Registry. Eligible trials were categorized as (1) explicitly specified PROs, (2) implicitly specified PROs (generic outcome concepts [e.g., pain] without naming a specific instrument), and (3) PROs not mentioned. Of 494 eligible trials, 446 (90.3%) used PROs as endpoints. Of 67,839 participants, 58,093 (85.6%) were in trials with specific PRO tools, 4,400 (6.5%) in trials with ambiguous PRO descriptions, and 5,346 (7.9%) in trials without PROs. Arthropathies (43.0%) were the most common condition among PRO-inclusive trials, and the Visual Analogue Scale was the most frequently used PRO tool. Primary sponsors showed significant regional imbalance, with most concentrated in eastern China. This study demonstrated a significant emphasis on PRO application in TCM clinical trials for musculoskeletal diseases in China, while also identifying gaps in standardization and regional distribution that require addressing.
Standard health evaluations often treat gender as a mere covariate, masking distinct socioeconomic pathways to disease. We applied a gender-stratified Bayesian framework to evaluate how socioeconomic indicators relate to biologically uncontrolled diabetes risk in the volatile post-pandemic context. Using NHANES 2021-2023 data (N = 5,995), we conducted a Bayesian multilevel logistic regression utilizing targeted prior regularization and partial pooling to stabilize estimates for underrepresented subgroups. This approach provides a rigorous assessment of structural factors including income, education, employment, and health insurance. Our analysis identified a sharp gender divide. While educational attainment serves as a universal buffer, structural drivers differ fundamentally by gender. For men, labor market status acts as a high-fidelity signal of functional reserve; active job seekers show significantly lower odds of uncontrolled diabetes (OR = 0.26, 95% CrI: 0.07-0.70), reflecting health selection at re-entry. Conversely, uninsured women show a lower diagnostic likelihood (OR = 0.47, 95% CrI: 0.24-0.87), reflecting structural invisibility rather than metabolic protection. Gender-blind models miss critical structural vulnerabilities. Translating these findings into actionable guidance requires a paradigm shift in screening design.
This study translated, adapted, and evaluated the psychometric properties of the Illness Management and Recovery (IMR) Scale for Spanish-speaking populations, including both clinician and client versions. The translation followed the International Test Commission's 2018 guidelines to ensure cultural and linguistic appropriateness. A total of 172 mental health service users completed the client version, while their reference professionals provided the corresponding responses to the clinician version and Health Nation Outcome Scale. Users also completed the Recovery Assessment Scale, the Functional Social Support Questionnaire, and the Dispositional Hope Scale. The Spanish versions demonstrated good adequacy, revealing a three-dimensional structure-goals and connectedness, management, and medication/substance use-consistent across both versions and aligned with prior studies. The management dimension showed adequate internal consistency, whereas the other two dimensions had lower reliability. Correlations with established recovery measures supported the IMR scale's external validity. Findings support the Spanish IMR scale as a valuable tool for assessing mental health recovery, capturing both clinician and user perspectives. This research contributes significantly to the evaluation of illness management and recovery among Spanish-speaking individuals with severe mental disorders, offering a culturally adapted and psychometrically sound measure.
This study assessed patient safety culture across selected public hospitals in Sierra Leone and explored how perceptions vary by hospital characteristics, including size, location and resource availability, with the aim of identifying practical strategies to strengthen safety culture and improve care quality. A sequential cross-sectional mixed-methods design was employed. Quantitative data were collected from 404 healthcare workers using the Hospital Survey on Patient Safety Culture and analysed using descriptive statistics and logistic regression. Qualitative data from ten key informant interviews were thematically analysed in NVivo-14 to provide contextual insights. The overall patient safety culture score was low at 40.5% (95% CI: 37.4-43.6). Teamwork within units and organizational learning emerged as relative strengths, while incident reporting and management support were identified as major weakness. Most respondents rated patient safety as acceptable, although underreporting of incidents was widely acknowledged, driven by fear of blame, time constraints and unclear reporting procedures. Qualitative findings highlighted leadership gaps, staffing shortages, resource limitations and marked disparities between urban and rural hospitals. Overall, patient safety culture in Sierra Leone hospitals remains underdeveloped, highlighting the need for strengthened leadership accountability, non-punitive reporting systems, improved communication, training, and broader systemic investments to enhance safe and high-quality care.
Currently there is little guidance on the power considerations for the multiple-group (controlled) interrupted time series design (MG-ITSA). In this study, simulations estimated power based on the number of time periods, the number of control units, when the treatment is introduced, and the degree of autocorrelation. The measures of effect were the difference in differences (DID) in level and the DID in trend. Power was evaluated at three different effect sizes. Higher power was generally associated with longer studies, more control units, larger effect sizes, and decreasing autocorrelation. Introducing the treatment at the halfway point in the study typically produced higher power than elsewhere for DID in trend. DID in level required fewer time periods to achieve the desired power than the DID in trend. The results show that to increase power, a researcher can increase the number of control units, increase the number of time periods, utilize the DID in level as the measure of effect, and maximize the effect size. Autocorrelation cannot be readily manipulated, and therefore must be accounted for in the time series regression model. Health researchers must consider the many factors highlighted here that uniquely affect power when determining the most efficient way to conduct an MG-ITSA study.
The interaction of multidimensional person, environment, task, and performance factors requires advanced analytic approaches to understand livability among older adults. This study examined the predictive value of the Livability Scale (LS) for residential satisfaction using multiple machine learning algorithms in adults aged 65 and above. Six models-logistic regression, decision tree, random forest, gradient boosting, support vector machine, and an ensemble model-were compared to determine which best captured the LS complex structure. The random forest demonstrated the strongest performance (F1 = 0.74, AUC = 0.78) with consistent generalization in k-fold cross-validation (M = 0.68), providing balanced sensitivity (0.60) and specificity (0.90). Model comparison also revealed meaningful differences: SVM showed heightened sensitivity to satisfaction, correctly detecting a larger number of satisfied cases but with increased false positives, whereas GBM minimized false positives, indicating higher specificity but lower sensitivity. Feature-importance analysis identified cultural facilities, residential affordability, activities and events, parks, structural safety, and cleanliness as key contributors to predictions. Overall, the findings emphasize the value of machine learning in uncovering non-linear patterns in livability data and demonstrate the potential of algorithmic diversity to guide evidence-based residential interventions for older adults.
The Multidimensional Psychological Flexibility Inventory (MPFI) is a complex self-report measurement tool designed to assess Acceptance and Commitment Therapy's (ACT) Hexaflex model components of psychological flexibility and inflexibility. There is a lack of literature on the invariance of the MPFI and its discriminant validity in relationship to second-wave therapy concepts such negative automatic thoughts. In this study, we present a Romanian adaptation and validation of the MPFI performed on a sample of 1109 participants from the general population. The results indicated an adequate fit to the data of the original MPFI factor model, high internal consistency levels, the ability to be invariant across levels of gender and age, and supported the MPFI's convergent, and discriminant. Some theory incongruent correlations emerged between MPFI dimensions and acceptance and experiential avoidance that suggest the need for further refinement of the MPFI. We discuss this unexpected correlation in relationship to explanatory factors such as the COVID lockdown context, personality, and age. Altogether, our results indicate that the Romanian version of the MPFI is a psychometrically sound instrument that can be used to study the Hexaflex ACT model and to evaluate psychological flexibility and inflexibility and their sub-processes in practice.
This study aimed to adapt the Social Participation Restrictions Questionnaire (SPaRQ) into Turkish (SPaRQ-T) and assess its validity and reliability for evaluating participation restrictions in adults with hearing loss. A cross-sectional, multicenter study was conducted with 278 individuals with hearing loss who had used hearing aids for at least one year. The adaptation process followed international guidelines, including back-translation and expert evaluation. Rasch analysis, test-retest reliability, and concurrent validity assessments were performed.The SPaRQ-T demonstrated strong internal consistency (Cronbach's α = 0.926 for Social Behaviors and 0.871 for Social Perceptions) and test-retest reliability (ICC = 0.928 and 0.773, respectively). Rasch analysis confirmed the unidimensionality of both subscales and supported good model fit. The SPaRQ-T is a reliable and valid instrument for assessing social participation restrictions in Turkish-speaking adults with hearing loss. It provides a comprehensive evaluation of the social and emotional dimensions of participation and can be used in clinical and research settings.
Clinical empathy is central to the physician-patient relationship, and there is an increasing need for valid and reliable instruments to assess self-reported clinical empathy. Although the Consultation and Relational Empathy (CARE) Measure is widely used in its patient-reported form, it has not been validated for physician self-assessment. This study examined the construct validity and internal consistency of the Portuguese self-report version of the CARE Measure in 221 physicians who completed an online survey. The sample was randomly divided into two subsamples for exploratory and confirmatory factor analyses (EFA and CFA). Measurement invariance was tested across gender, age, and professional status. Internal consistency, convergent validity, and known-groups validity were also evaluated. EFA revealed a two-factor structure - Cognitive and Affective Empathy - supported by CFA. Measurement invariance was confirmed across gender, age, and professional status. The scale showed good internal consistency for both factors. Convergent validity was indicated by correlations with communication competence and therapeutic relationship quality. Known-groups validity was demonstrated by higher cognitive empathy scores among physicians aged 41 and older and among men. These findings provide robust evidence for the validity and reliability of the Portuguese self-report CARE Measure, supporting its use in clinical training, self-assessment, and empathy research.
The primary objectives of the present cross-sectional study were to translate and culturally adapt the YouTube Addiction Scale (YAS) into Malay and to evaluate its reliability, factorial validity, concurrent validity, and measurement invariance across gender and ethnicity among Malaysian university students. A total of 690 students participated (mean age = 21.29 years [SD ± 2.42]; 74% female). Confirmatory factor analysis supported a unidimensional YAS structure with good fit (CFI = 0.98, TLI = 0.97, SRMR = 0.06, RMSEA = 0.07). The scale exhibited strong reliability (α = 0.83, ω = 0.84) and measurement invariance across gender and ethnicity. YAS scores showed correlation with Smartphone Application-Based Addiction Scale score (r = 0.17, p < 0.001) and Bergen Social Media Addiction Scale score (r = 0.23, p < 0.001), a weak correlation with time spent on social media (r = 0.09, p = 0.02), and no significant relationship with time spent on online gaming (r = 0.03, p = 0.47). The Malay YAS is a reliable and valid instrument for assessing YouTube addiction among Malaysian university students. Its unidimensional structure, strong reliability, robust measurement invariance across gender and ethnicity, and satisfactory concurrent validity support its application in research, screening, and intervention programs.
Active, student-centred teaching strategies are increasingly being adopted to bridge the gap between biomedical knowledge and clinical performance in health-profession education. This systematic review and meta-analysis aims to evaluate the comparative effectiveness of five student-centred educational approaches in medical students' knowledge acquisition and clinical skills performance. We conducted a systematic review with random-effects meta-analysis of 21 controlled trials enrolling 1,028 intervention and 961 control participants. Outcomes were classified as knowledge based (MCQ or written exams; n = 11) or skills based (Objective Structured Clinical Examination, Objective Structured Assessment of Technical Skills, Script Concordance Test; n = 10). Interventions were grouped into five categories: case-based methods, conventional simulation, virtual reality (VR)/video simulation, artificial intelligence-guided tutoring and flipped/outcome-based formats. Heterogeneity was assessed using I2 and τ2, with leave-one-out and trim-and-fill sensitivity analyses, and subgroup differences were tested by χ2. Knowledge-based outcomes showed a pooled Hedges' g of 1.40 (95% confidence interval [CI] 0.78-2.01; I2 = 95.0%), whereas skills-based outcomes yielded 3.11 (95% CI 1.83-4.39; I2 = 97.7%), with a significant domain difference (χ2 = 5.60, p = 0.018). Subgroup analysis by pedagogical mechanism demonstrated significant effect variation (χ2 = 15.03, df = 4, p = 0.018), with conventional simulation and VR/video simulation producing the largest gains. It should be noted that some categories, such as AI-guided tutoring, were represented by only a single study. Despite extreme heterogeneity, sensitivity analyses confirmed robustness, and publication bias minimally attenuated skills-based estimates. Student-centred approaches markedly outperform lectures for both knowledge acquisition and clinical skills, notably with simulation-based methods. Educators should integrate these strategies according to learning objectives and context. This study provides novel comparative evidence that the magnitude of benefit varies substantially across pedagogical approaches, with conventional simulation showing the greatest impact on skill acquisition, a distinction crucial for strategic curriculum design. Future research should explore long-term outcomes, cost-effectiveness and patient-care impact.
The objective was to analyze the factorial structure, reliability, and cross-national measurement invariance of the 8-item Short Form Health Survey (SF-8) in 1,940 individuals from five Latin American countries (El Salvador, Honduras, Guatemala, Colombia, and Venezuela). Five CFA models were estimated based on previous findings and considerations of the content validity. The results indicated that the two-factor model (physical and mental health) without items 1 and 5 provided the best fit across all countries. Item 5 was removed due to low factor loadings in all estimated models and across all countries, while item 1 was removed because it was too general, making it difficult to determine whether it measured physical or mental health. The six-item version (SF-6) demonstrated adequate reliability and strict invariance across all countries in the invariance sequence models. The reported differences in physical and mental health dimensions were negligible and minor among all countries. In conclusion, a 6-item version of the Short Form Health Survey (SF-6) was proposed, which is better represented by two dimensions (physical and mental health) and is invariant across Latin American countries.
Psychosocial factors such as organizational cynicism and work motivation are associated with clinical outcomes, along with the knowledge and skills of medical professionals. Oncology surgeons, in particular, represent a critical group in terms of patient safety and mortality due to the high-risk surgical environment. The study aims to examine the association of organizational cynicism, work motivation, and professional and demographic characteristics of oncology surgeons with patient mortality. Face-to-face interviews were conducted with 107 surgeons practicing in Türkiye to collect data. A cross-sectional, descriptive approach was selected as the research design. The study followed the STROBE checklist for observational research. The Multidimensional Work Motivation Scale (MWMS) and the Organizational Cynicism Scale (OCS) were used as measurement tools. To predict patient mortality rate, negative binomial regression analysis was used. Increased cognitive cynicism (IRR = 1.033, p < .001) and identified regulation (IRR = 1.188, p < .001) were associated with higher patient mortality rate. Contrastingly, increased intrinsic motivation (IRR = 0.944, p < .001) was associated with decreased mortality rate. Furthermore, gender and managerial position were associated with clinical outcomes as control variables. Reducing organizational cynicism and supporting autonomous motivation may inform strategic approaches to strengthening patient safety.
