To i) identify and map the available evidence regarding effectiveness and harms of spinal manipulation and mobilisation for infants, children and adolescents with a broad range of conditions; ii) identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use.th February 2021.Systematic scoping review, utilising four electronic databases  and grey literature from root to 4Infants, children and adolescents (birth to < 18 years) with any childhood disorder/condition.Spinal manipulation and mobilisationOutcomes relating to common childhood conditions were explored.Two reviewers  independently screened and selected studies, extracted key findings and assessed methodological quality of included papers using Joanna Briggs Institute Checklist for Systematic Reviews and Research Synthesis, Joanna Briggs Institute Critical Appraisal Checklist for Text and Opinion Papers, Mixed Methods Appraisal Tool and International Centre for Allied Health Evidence Guideline Quality Checklist. A descriptive synthesis of reported findings was undertaken using a levels of evidence approach.manipulation and mobilisation are being utilised clinically by a variety of health professionals to manage paediatric populations with adolescent idiopathic scoliosis (AIS), asthma, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, excessive crying, headaches, infantile colic, kinetic imbalances due to suboccipital strain (KISS), nocturnal enuresis, otitis media, torticollis and plagiocephaly. The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipulation or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic reviews of randomised controlled trials and other lower quality studies. There was strong to very strong evidence for ‘no significant effect’ of spinal manipulation for managing asthma (pulmonary function), headache and nocturnal enuresis, and inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw conclusions regarding spinal mobilisation to treat paediatric populations with any condition.Eighty-seven articles were included. Methodological quality of articles varied. Spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks. Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric populations are warranted.Whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal The online version contains supplementary material available at 10.1186/s12887-022-03781-6. In this systematic scoping review, we identified and mapped the results of empirical research, reviews of empirical research, published guidelines for practice, policies and position statements. In relation to infants, children and adolescents, we addressed the following questions:https://osf.io/zm8e6) prior to conducting the search.The PRISMA statement extension for scoping reviews (PRISMA-ScR) was used to guide the reporting of this systematic scoping review . The revAfter consulting with the Health Sciences and Medicine Faculty librarian at the host university, the appropriate Medical Subject Headings (MeSH terms) and Boolean operations were incorporated before the empirical literature was systematically searched, combining synonyms for “infant”, “child” and “adolescent”, and key words related to “spinal manipulation” and “spinal mobilisation”, followed by outcomes associated with common childhood conditions. The following databases were searched: PubMed, Embase, CINAHL and Cochrane. Grey literature was searched using Google utilising key terms including “paediatric” (and associated synonyms) AND “spinal manipulation” OR “spinal mobilisation” (and associated synonyms) AND “policies” OR “guidelines” OR “statements”, hand-searching reference lists from all included research articles and reviewing articles via expert referral of relevant literature. The search strategy was wide in scope to support the nature of the review and details on the search strategy are presented in Supplementary File th February 2021. To identify relevant grey literature, a google search for files ending with [file: PDF] and [file: doc] was conducted. The initial and follow-up search was performed independently by two authors (A.P. and L.L.). Studies were gathered, and duplicates were removed using EndNote . Once duplicate articles were removed, two authors (A.P. and L.L.) independently conducted title and abstract screening to identify potentially relevant articles for full-text review. After undertaking an initial process of consensus, outstanding disagreements between two authors (A.P. and L.L.) were resolved by a third author (N.M.). Studies that appeared to meet the inclusion criteria at title and abstract screening stage were retrieved in full text. Eligibility criteria were applied. Table The four databases were searched from root up to 18 June 2020 with an updated search up to 4The Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Synthesis was used to assess quality of included Systematic Reviews  Supplem. This toThe Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the quantitative and qualitative studies  Supplem. MMAT apThe International Centre for Allied Health Evidence Guideline Quality Checklist (ICAHE) was used to assess the quality of guidelines included in grey literature  Supplem. This toThe Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Text and Opinion Papers was used to assess quality of the text and opinion papers  Supplem. This toThe quality assessment process was independently conducted by two authors (A.P. and L.L.) (see Supplementary File Data was extracted independently by two authors (A.P. and L.L.) using a standardised pre-piloted data extraction form . For transparency of overlap between studies and reviews, a matrix (Supplementary File p < 0.05) favouring the intervention group or control group was coded (+ or -) respectively [After data extraction, a descriptive synthesis was completed to explore the effectiveness of spinal manipulation and mobilisation with paediatric populations. The descriptive synthesis involved two stages. Initially, the results from investigations (reviews and studies) were coded based on whether the effect was significantly positive  ( +), negative  ( −), had no significant effect (0) or was inconclusive (Inc – for reviews only). For individual studies with control groups when there was no difference in effect between control (standard care) and intervention groups , a code of zero (0) was applied, or a statistically significant difference , two guidelines, 14 text and opinion papers and nine policy and policy developments . After a process of consensus, 100% agreement was achieved for all papers during the consensus process. Critical appraisal revealed that review articles generally scored poorly in questions regarding methods to minimise errors in data extraction, and in their assessment of the likelihood of publication bias. Regarding grey literature  of psychometric properties for the outcome measures being utilised in the research evaluations and none of the articles provided actual psychometric values for reliability, validity and responsiveness, to suggest the selected outcome measure was a suitable tool to measure effectiveness of treatment. The findings from the descriptive synthesis using the levels of evidence approach are provided below for each condition which met our methodological thresholds for undertaking a descriptive synthesis.descriptive synthesis revealed ‘inconclusive’ results for using spinal manipulation to manage impairments and symptoms of AIS  concluding favourable outcomes for reducing a mixture of acute and chronic back pain severity in children and adolescents, with the second review [ur descriptive synthesis of the collective evidence suggests the effectiveness of spinal manipulation for managing spinal (back and neck) pain in paediatric populations remains ‘inconclusive’.Two reviews , 109 expd review , 67, 89 d review  showed sd review , 89 and d review  providedd review , 67. TheOur descriptive synthesis suggests that the evidence for using spinal manipulation in infants to improve breastfeeding outcomes is ‘inconclusive’  RCT [descriptive synthesis of the collective research revealed there is strong evidence that spinal manipulation has ‘no significant effective’ on headache  RCT  found sphe Table .descriptive synthesis revealed ‘inconclusive’ findings for the effectiveness of spinal manipulation to manage infantile colic for both crying time and sleep disturbances  or upper cervical dysfunction.  or headache. The evidence was inconclusive regarding the effectiveness of spinal manipulation for managing impairments related to AIS, ASD, back/neck pain (acute and chronic) and CP in children and adolescents. Additionally, the evidence was inconclusive regarding the effectiveness of spinal manipulation for managing impairments and symptoms related to breastfeeding difficulties, infantile colic (excessive crying and sleep disturbances), and otitis media in infants and children. There was insufficient evidence to report on the effectiveness of spinal manipulation for infants and children with torticollis and ADHD. Further, there is insufficient evidence to determine the effectiveness of spinal mobilisation on paediatric populations for managing any condition.The primary aim of this systematic scoping review was to identify and map the available evidence regarding the effectiveness and harms of spinal manipulation and mobilisation of infants, children, and adolescents. Additionally, we aimed to identify and synthesise policies, regulations, position statements and practice guidelines informing the clinical application of spinal manipulation and mobilisation in paediatric populations. In relation to our first aim, this systematic scoping review revealed that spinal within its anatomical limit [mobilisation in paediatric populations, with one review article [To further address our first aim, we explored the adverse events/harms associated with spinal manipulation and/or mobilisation in paediatric populations. The findings in the present systematic scoping review revealed that there is limited reporting of adverse events in the included systematic reviews and studies, with six reviews, eight RCTs and five other studies making no mention of adverse events or harms associated with their spinal manipulation intervention of focus Table . Althougal limit . Whilst al limit  infantilal limit ). Notabl article  identifyMost studies within the included reviews came from low levels of evidence such as case studies or case series, which were not included as individual studies for our current systematic scoping review as we felt they were too low in the levels of evidence hierarchy to provide additional meaningful results regarding effectiveness. The inclusion of adverse events extracted from lower levels of research published in the included systematic reviews, has provided important safety related information for readers to consider. However, since most of the literature is based on low-level studies such as case reports, it is not safe to assume that their conclusions can be generalised to larger or alternate populations. Health professionals would benefit from further training, either as graduates or in entry-level programs, to better understand levels of evidence to assist with interpretation of research, to inform their choice of treatment techniques and to guide design of future research, should they choose to do it. Consistent with the lower levels of evidence and methodological quality of studies, it was noted that very few studies reported on the clinometric properties of the outcome measures utilised, and we recommend future research on this topic to include references regarding the reliability, validity, utility, and efficacy of outcome measures used to explore effectiveness and to improve credibility of study findings. Healthcare professionals and researchers should be aware of the reliability, validity, and responsiveness of assessment tools and outcome measures to assist in their clinical reasoning, instrument selection and interpretation of clinical or research results. Further evaluation of these factors must be completed in future research to assist with interpretation of the collective findings on this important topic.Regarding our final aim, we have identified that most policy and policy development statements included in this systematic scoping review were developed in the United States of America, many by third party payers, and only three published in Australia. This highlights the need for more policies globally across all professions who are performing spinal manipulation and mobilisation with paediatric populations. Evidence-based guidelines and policy or position statements are needed to guide health professionals on the appropriateness of spinal manipulation and mobilisation to manage a variety of conditions for which paediatric clients commonly present for care. This is particularly important considering our comprehensive review and descriptive synthesis did not determine spinal manipulation or mobilisation to be effective for treating any condition examined Tables  and 6, aThe findings from the present systematic scoping review align with the findings from the previous work by Green  for the A challenge that we faced in screening, appraising, data extracting and synthesising the included articles, was the lack of detailed descriptions of therapeutic techniques being applied  on infants, children and adolescents; a concern raised in a previous review on the topic . RelevanA strength of this systematic scoping review includes the wide breadth of searches undertaken. Several major databases were searched with a detailed search strategy and with a broad, yet specific inclusion criteria to ensure the scope of existing literature was included. Hand searching of reference lists for all included studies and reviews was undertaken to ensure all relevant literature was captured for this systematic scoping review. The study selection, data extraction process and critical appraisal was completed independently by two reviewers to reduce the risk of reviewer error or bias and a third reviewer was utilised to validate data extraction and provide consensus for critical appraisal. Our review sets itself apart from previous research by focusing on both spinal manipulation and mobilisation, as well as including participants from birth to 18 years of age. Exclusion of individual case studies and case reports allowed for conclusions to be based on higher levels of evidence and this was particularly important when the collective evidence from systematic reviews were inconclusive.n = 2 conditions), we have highlighted this to the reader ; the synthesis findings may have been influenced by one study population or methods if they had completed multiple investigations, and therefore, one population sample may have biased our analysis. On the occasion that this was likely  and these findings can be used to guide more impairment focused quantitative analysis in future meta-analyses. The results of this systematic scoping review will also help to inform the future development of a shared position statement between the IFOMPT and IOPTP to guide clinical practice.manipulation or mobilisation as an effective intervention for any condition in paediatric populations with mild to severe adverse events reported. Strong to very strong evidence exists to suggest that spinal manipulation is not effective for managing asthma, headache or nocturnal enuresis whereas, there was inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to determine the effectiveness of spinal mobilisation for treating paediatric populations with any condition, with some mild adverse responses reported. Despite spinal manipulation and mobilisation being used to treat infants, children, and adolescents internationally, there is a lack of conclusive high-level evidence providing positive  results with paediatric populations. More high-level clinically reasoned RCT’s, expressing the magnitude of effect from spinal manipulation and mobilisation are needed, to further allow exploration of the safety and effectiveness of these interventions with infants, children and adolescents, for further conclusions to be drawn. Future research should include strict monitoring and recording of adverse events to determine true risks and could start with small long term RCTs. If evidence was accumulating for a given condition, a large multicentre RCT would be beneficial. In addition, future research in this field, should provide detailed information about the therapeutic technique, the clinical reasoning, and theoretical underpinnings for its use, particularly in non-musculoskeletal conditions. Currently most research informing the results of this systematic scoping review are based on chiropractic interventions. Research regarding physiotherapy methods for mobilisation and manipulation for some conditions  in older children and adolescents is warranted as it remains a gap in the literature.The present systematic scoping review revealed spinal manipulation and mobilisation are utilised clinically by a variety of health professionals to manage many different musculoskeletal and non-musculoskeletal impairments for paediatric populations. A broad descriptive synthesis of the collective evidence (using a levels-of-evidence approach) did not demonstrate evidence to explicitly support spinal Additional file 1: Supplementary File 1. Search Strategy Additional file 2: Supplementary File 2. Critical Appraisal Consensus ScoresAdditional file 3: Supplementary File 3. Data Extraction Additional file 4: Supplementary File 4. Matrix with RCT's and other studies included across all systematicreviews Additional file 5: Supplementary File 5. Descriptive Synthesis


The involvement of the subtalar joint is uncommon in the early stages of rheumatoid arthritis (RA). We report a case of a 47-year-old female who had RA with isolated subtalar joint arthritis. The clinical history, magnetic resonance imaging, and pathological findings of the patient are presented. A careful evaluation of the patients for chronic ankle-to-heel pain should be conducted, and concomitant evaluation for inflammatory arthritis, including RA, should be considered. Foot involvement is not uncommon in rheumatoid arthritis (RA). The frequency of foot deformities in RA patients is reportedly 78%, and metatarsus primus varus account for 62% and the splaying of the forefoot for 41% of these types of deformities [A 47-year-old female presented to her orthopedist with a 2-year history of ankle-to-heel pain. She did not have a history of trauma and smoking or a family history of rheumatic diseases. Examination demonstrated tenderness only over the right subtalar joint. Although her plain radiographs were normal a,b, in nMoreover, MRI showed an effusion of the tibiotalar joint, the posterior tibial tendon, and the flexor hallucis longus tendon, suggesting tendonitis. The patient refused a biopsy because treatment with non-steroidal anti-inflammatory drugs improved her ankle-to-heel pain. Therefore, the patient was examined at an outpatient clinic with orthopedic tests, including plain radiography and MRI.One year later, a follow-up MRI showed a remarkable change in synovial enhancement surrounding the subtalar joint. The bone destruction of the subtalar joint had progressed, and inflammatory arthritis had spread to the tibiotalar joint a–d. ThusArthroscopic biopsy and synovectomy were performed. As the bone destruction of the subtalar joint had already progressed, subtalar joint fusion was performed with synovectomy. Intra-operatively, the subtalar joint was found to be stable; however, the cartilage had degenerated, and the synovium was severely inflamed. The histological analysis of the biopsy specimen showed synovial proliferation and lymphocytes. In the synovium, the synovial lining cell and vascular proliferation and lymphocyte infiltration were observed a,b. SubtThe plain radiographs of her hands and left foot were normal; significant atrophy was seen in the right foot compared with the left foot . After sOngoing joint inflammation with synovitis leads to joint destruction and deformation, as well as chronic pain and disability. In the early stage of the disease, the most commonly affected areas are small joints such as the wrists, metacarpophalangeal joints, proximal interphalangeal joints of fingers, and metatarsophalangeal joints. However, with disease progression, large joints such as shoulders, elbows, knees, feet, and ankles may also become involved if the diagnosis is delayed, and early treatment is not provided ,4. The sȘerban et al. found that the quality of life (QoL) of patients with RA is significantly affected due to ankle and hindfoot pathology, including tibiotalar synovitis, subtalar synovitis, tibialis posterior tenosynovitis/tendinosis, and peroneal tendinosis. Inflammation, as well as degeneration and deformities, were diagnosed . TibialiFoot pain is common in RA, from the forefoot involvement in early RA to the later involvement of the hindfoot . Spiegel et al. observed that only 8% of patients with rheumatoid disease for less than 5 years demonstrated hindfoot changes, whereas these changes were present in 25% of patients with the disease for over 5 years.Foot and ankle involvement can lead to reduced walking distance and affect QoL . In addiPreceding subtalar destruction and alignment should be carefully monitored and treated to avoid excessive stress on the ankle joint in patients with RA. Subtalar joint pain is mainly expressed in the lateral hindfoot during activity due to chronic inflammation and destruction. If untreated, progressive eversion at the subtalar joint, together with the dysfunction of peritalar ligaments and the tibialis posterior tendon, subsequently leads to the instability of the subtalar and midtarsal joints ,14. HoweMonoarticular RA is rare, and reaching a diagnosis can be challenging. However, a case series involved four patients diagnosed with chronic monoarthritis . Further workup such as histopathological and radiological analyses (MRI and ultrasound) revealed a diagnosis of seropositive RA .RA treatment usually starts with methotrexate. In this case, the bone destruction of the subtalar joint had already progressed; therefore, histological workup, followed by synovectomy and joint fusion surgery, was performed first. To minimize surgical invasion and reduce the risk of complications for subtalar arthrodesis, we proposed an arthroscopic posterior approach to implant an osseous allograft into the joint space. As its advantages include the minimal invasion of the soft tissue around the hindfoot and the preservation of the blood supply to the talus, arthroscopic subtalar arthrodesis has been reported as an alternative to traditional open methods for intractable hindfoot disorders such as subtalar arthritis after fracture and inflammatory arthritis . In the We reported a case of subtalar joint monoarthritis in a patient with RA. Inflammatory arthritis of the subtalar joint is uncommon and underdiagnosed because of ankle-to-heel pain. RA, in this case, progressed due to delayed diagnosis, and arthroscopic subtalar arthrodesis was performed. After surgery for monoarthritis of the subtalar joint, RA was diagnosed based on radiological findings, the synovial histological analysis, the results of serological tests, and the occasional complaint of small joint pain. This novel case highlights the need for careful evaluation of inflammatory arthritis, including RA, in patients with chronic ankle-to-heel pain.


Decision-making in clinical assessment, such as exit-level medical school Objective Structured Clinical Examinations (OSCEs), is complex. This study utilized an empirical phenomenological qualitative approach with thematic analysis to explore OSCE assessors' perceptions of the concept of a “prototypical intern” expressed during focus group discussions. Topics discussed included the concept of a prototypical intern, qualities to be assessed, and approaches to clinical assessment decision-making. The thematic analysis was then applied to a theoretical framework  that explored the complexity of making assessment decisions amidst potentially contradicting pressures from academic and clinical perspectives. Ten Australasian medical schools were involved with 15 experienced and five less experienced assessors participating. Thematic analysis of the data revealed four major themes in relation to how the prototypical intern concept influences clinical assessors' judgements: (a) Suitability of marking rubric based on assessor characteristics and expectations; (b) Competence as final year student vs. performance as a prototypical intern; (c) Safety, trustworthiness and reliability as constructs requiring assessment and (d) Contradictions in decision making process due to assessor differences. These themes mapped well within the interaction between two proposed activity systems in the CHAT model: academic and clinical. More clinically engaged and more experienced assessors tend to fall back on a heuristic, mental construct of a “prototypical intern,” to calibrate judgements, particularly, in difficult situations. Further research is needed to explore whether consensus on desirable intern qualities and their inclusion into OSCE marksheets decreases the cognitive load and increases the validity of assessor decision making. The assessment of clinical, communication, and practical skills is an important component of health professions education for both feedback provision and informing progress decisions. Learners are placed and observed in a variety of settings—teaching facilities, simulation centers, and “real world” practice—to ensure that learning outcomes are achieved. Expectations of learners evolve through programs, with the focus changing from individual components  to more integrated comprehensive tasks that require focus on presentations, diagnostic reasoning, and management plans. Marking sheets may include checklists, rating scales for individual items or competencies, global scores and free-text comments. Assessors are a diverse group, including people in various combinations of academic and clinical roles, in different clinical specialties, and with different levels of experience as clinicians and assessors. Their assessments often rely on relatively brief observations of performance to inform judgements, drawing on both stated learning outcomes and their own experiences and expectations of good clinical performance .Significant variability in clinical assessor judgements has been reported –5. HowevIn educational psychology this construct is known as a heuristic cognitive process, conscious or unconscious, whereby “rule of thumb” judgement decisions are made, possibly neglecting some presented information –15. ThisSo far, exploratory studies on assessor cognition have focused mainly on workplace-based assessments (WBAs), usually involving learners performing authentic tasks in clinical settings , 22–25. This research was informed by the interpretivist paradigm, which is a relativist ontology with a subjectivist epistemology . InterprWe focused on exit-level OSCEs in Australian and New Zealand medical schools within the Australasian Collaboration for Clinical Assessment in Medicine (ACCLAiM) network. Their medical programs are mapped to a national medical graduate competencies framework and have similar integrated, outcomes-based curricula and OSCE processes, including some shared stations –35. ThisAll thirteen ACCLAiM member schools were invited by email in November 2020 to purposefully recruit both experienced and less experienced assessors from their OSCE examiner pools. For consistency, an experienced assessor was defined as having five or more years of post-specialty training clinical practice, experience in assessing senior medical students and/or junior doctors, and a record of consistent and reliable scoring. Ten schools agreed to participate, providing a list of 39 assessors  who were invited by email to participate, supplied with an information sheet and provided written consent.Focus group discussions (FGDs) were conducted to enhance exchange and clarification of participants' viewpoints by exploring how and why they think in a particular way . Semi-stThere were two stages of analysis. The first involved the use of inductive thematic analysis with emerging themes identified, based on the tenets of Braun and Clarke . This waWe chose the third-generation cultural historical activity theory (CHAT) developed by Engeström , 40 becaThe value of CHAT is that it develops “conceptual tools for understanding dialogue, multiple perspectives and voices, and networks of interacting activity systems” , centereTranscribed data were analyzed according to framework elements using NVivo version 12 software . This approach utilizes both inductive and deductive analytical techniques and entails six stages: (1) Reading and re-reading the textual data to familiarize oneself with the content, (2) Identifying, devising, or refining a thematic framework to facilitate data analysis, (3) Indexing the data to corresponding themes, (4) Charting the identified themes (5) Mapping, and (6) Interpreting the themes generated . The codA total of 20 assessors participated in the five FGDs, each with between 3 and 6 participants. The number of participants per group was kept low to foster rich FG discussions. There were 7 females and 13 males with, respectively, 8.4 and 14.8 mean years of clinical experience (range 1–45 years). Fifteen were experienced assessors  and 5 less experienced , almost all in dual roles as academics engaged in medical education as well as clinical practice. Less experienced assessors were all clinicians, although one also held an associate lecturer role. All participants were coded by their level of experience , sex  and an individual participant number. Details of the participants' characteristics are shown in Thematic analysis of the FGD transcripts revealed four major themes in relation to how the prototypical intern concept influences clinical assessors' judgements in senior medical student OSCEs. These themes are (a) Suitability of marking rubric based on assessor characteristics and expectations; (b) Competence as final year student versus performance as a prototypical intern; (c) Safety, trustworthiness and reliability as constructs that require assessment; and (d) Contradictions in decision making process due to assessor differences.Participants demonstrated a good understanding of their roles as OSCE assessors within AS1 and the requirement of compliant use of the marking criteria proforma to assess students' clinical performance.“For the OSCE, from my experience, there's a proforma, there's specific questions and there's marking attached to it, and then there's always a clear description. So essentially, when I'm assessing a student using that proforma, I will follow what's written” Exp-F-P09Participants reported knowing that they had to complete both the checklist and global rating scales of the marking rubric and claimed to understand the rationale for adhering to the criteria, despite sometimes experiencing a personal cognitive dissonance with the rubric.“I feel like my job as an assessor in OSCEs is to follow the assessment sheet and follow the criteria fairly closely. And I have been in situations when I've felt that the assessment criteria didn't necessarily reflect what I would expect an intern to be capable of. And so, have provided feedback after the assessment that I felt that, you know, perhaps the assessment criteria, were more pitched at a fourth-year level rather than a fifth-year level or something like that. But I felt that because their criteria for consistency across examiners that it's really important to stick to them.” Exp-F-P07However, when engaging with the marking criteria to assess the students, participants also believed that the listed criteria did not necessarily reflect all aspects of the expected performance. At this point, they felt that there were relevant elements of subjectivity from their clinical experience, and they had their own personal views about expected standards that related to their clinical work environment.“But even just reflecting on our OSCE about a month ago, yeah, examiners still have different views, personal views about what they think the minimum standards should be, despite how the committees…adjudicate as to what is the minimum standard. So, there's always going to be some difference there.” Exp-M-P05The concept of the “prototypical intern” was applied as the assessors began to critically appraise and compare the final-year medical students' performance to that of their junior doctors/interns in the clinical work environment. For most assessors, the comparison between the final year medical student and the prototypical intern happened intuitively, where the student was mentally placed into the AS2 environment for evaluation.“When we're assessing in that final year in the clinical assessments, to my mind, we are explicitly telling students and other examiners, that the level we are setting the assessment at is: will you in the next few months be able to work as a PGY1 doctor, and be able to give me a reasonable differential diagnosis and some initial management steps?” Exp-M-P13“When I think of how to examine these students, I do also think as to what I expect…a standard intern to be. It's a bit easier because I was an intern two years ago. So, it's quite fresh in my mind as to the standard that I was at, and what my peers were at. And then last year, for six months, I was a tutor for sixth year medical students. So, I had a good grasp as to what level they were at, as they were just reaching the end of their internships. And so, looking at that cohort, and teaching them each week, I was able to know what I thought the average graduate should be at.” Less-F-P15The concept of the prototypical intern was used to make judgements at all levels of performance—excellent, borderline or failing student. Interestingly, the ideal of a prototypical intern has been around for a long time.“My views are pretty similar to Exp-M-P14. And they probably began about 30 years ago, when I was an undergraduate at XXX university. And we were told…as we neared the final examinations, the way we would be assessed is as an intern, and we would not pass if we harmed or killed the patient. Otherwise, we're pretty well, right. And that's something that has probably stuck with me all the way along. I tend to use it, if I'm assessing someone, really for a fail. And I say, “Okay, have they caused harm to that patient, as an intern, or has it been worse?”. And if that is the case, which is rare, but if it is, then I'll give a clear fail. If I think it's something that, you know, can be addressed, and requires some, you know, remedial education or something, then I know that a borderline is going to get them a supplementary exam and they can study harder. So, for me, it's similar. But it's the distinction between a clear failure as regards to pass/fail” Exp-M-P16“So when I mark the student, I would think of an intern that is safe, and minimally competent, at the level, and above expectation, is obviously above the level of intern, a minimally competent intern.” Exp-M-P06However, one assessor did not support the idea of using the prototypical intern as the yardstick, finding it unfair for final year students who had yet to experience the intern year.“The only fair way we can assess them is where they are in the course. I don't think there's any way we can be building into our system, some second guessing about…what they're going to be like in a year's time. That's just not fair. I think the only way it's fair to do that is to say, this is a fifth-year medical student, and you judge them at the level of your expectations of a fifth-year medical student. All sorts of things could happen in the next year.” Exp-M-P2Other assessors agreed that it was unfair to judge final year medical students at the level of an intern but attempted to provide a rationale for doing the comparison and described seeking evidence of foundational learning on which internship performance could be constructed.“And so I think when it comes specifically to final year fifth year XXX University OSCEs, I do have that picture of when they're that first day intern, how will …this intern do? When it comes to final year OSCEs, I feel like I interact with a fair number of interns in ED, and I kind of have this idea of what an intern should know when they first come onto the floor.” Less-F-P18“Yeah. But if you're looking at things that would concern you about a student progressing, okay, I agree with the notion that we're not looking for perfection, but we're looking for evidence, if you like, of something that's already there, rather than something that might need to be added on in turn, and I'm thinking more of a skill rather than content” Exp-M-P01Assessors often looked for the professional behavior characteristics of a good intern in candidates' performances. While most of these qualities are not readily assessable in an OSCE, and thus tend not to feature in marking rubric, they still influenced examiner judgements. The criteria that assessors considered during their judgements included important professional behaviors such as good communication, safe practice, trustworthiness, reliability, and insight into one's own limitations and scope of practice.“We're all wanting that registrar, or that student, or an intern whose knowledge isn't as good. But we'll trust them, we'll be more confident with them. If the knowledge isn't good, then that's easily fixed. If they're not trustworthy…then that's really an issue. But how do you test that in an OSCE?” Exp-F-P03“I tend to be looking at qualities in a student and that hypothetical intern that I have in mind is the one that I would trust, to work for me. And I'd be able to trust the information they were giving me; I'd be able to trust that they got the information that they should have got. And I would be sort of, I'd be able to rely on that. And I'd expect to then go and see the patient with them or separately, and to be able to see something that was consistent with that.” Exp-M-P01It was recognized that unconscious positive bias toward candidates of perceived similarity to self may also influence assessor judgements, as a cognitive overlay to the prototypical intern construct.“I imagine we, even if it's just subconsciously, make judgements on how they dress, how they walk, how they talk, how much they're like us because we will probably favor them positively if we think they're like us. How well they interact with the patients, how polite we feel they are, what it is that makes them safe or what makes them unsafe, how prepared we feel they are all probably goes into whether or not we think that they're a responsible and trustworthy candidate.” Less-F-P18Assessors also acknowledged the role of other health professionals and health service consumers in the AS2 system and integrated these perspectives into their judgements of candidate performances. The assessors expected students to demonstrate an understanding of the professional and interprofessional relationships that exist within the clinical environment. Less experienced assessors, in particular, valued the input of the simulated patients (SP) in making judgement about students' performance.“I always also try to get a gauge of what the SP or the patient felt overall as well to see their thoughts because you know they've been doing this for years and they've seen many different students compared to us, that's also a good gauge I think.” Less-M-P19“Where a lot of their problems come from is, as Less-M-P17 alluded to, [when they think]“Well, I'm the doctor.” They won't listen to the nurse; they won't escalate things.” Exp-M-P16Assessors identified some areas of conflicting views. This mainly related to the conflicting expectations between activity systems. The assessors felt that faculty is focused on performance on the day, while assessors are more concerned with the general character of the final year medical students and their suitability to fit into the medical team in the clinical environment.“One of the things that our [postgraduate specialty] college exam stressed was to avoid the term borderline, because it allowed the examiner to sit on the fence. And so, we tried to make the examiner be a little bit more specific, just below or just above, but don't use the term borderline. And that's something that I've held, personally, in assessing a student's overall competency. Try and work out what it is that makes them safe or what makes them unsafe but avoid borderline.” Exp-M-P05“We use below expectation [and] at expectation. And that's really interesting. I hadn't reflected on this before. But I think that does bring in what's the expectation? So, if you're using that sort of language, it probably does encourage [if] the expectation is intern level or…graduate, ready to graduate into final year. So, I hadn't thought about that before. But now I think about it when I see those words in a marking rubric for the global score, it does point my attention to what's my expectation? So, it probably does encourage the use of the prototypical intern.” Exp-F-P07Participants also flagged possible differences between male and female assessors as well as junior and experienced assessors; assessors marking stations inside or outside of their particular discipline and among postgraduate specialty college assessors.“And one of the things that I've had to do in my [postgraduate specialty] College job, as chair of examiners, is to actually sit with the cohort of examiners as a co-examiner to see what the discrepancy is. And you are absolutely right that the younger examiners, and often the women, the younger women examiners are tougher than the old men. And it really is something I think examinations have to take into account that the old retirees often [have] soft touches. And they will, because of their experience of having seen mistakes made and rectified, they will be a bit more lenient. So, I think we do have to be careful about examiner variability.” Exp-M-P05“But one of the interesting things we're finding is that it's more junior examiners, who might only be three or four years out themselves that seem to have much higher standards of the students. And those of us who've been around for a bit longer seem to be a little bit more willing to tolerate maybe poor performances.” Exp-F-P04“We've got all sorts of examiners and obviously some [postgraduate specialty] colleges and disciplines rely more on OSCE than others. And I do notice that the colleges who do use OSCEs if we have some of their examiners who are familiar with the college exams come to examine, they tend to be a bit more hawkish. So, they do, I think, bring their expectations over. I think it's almost unavoidable.” Exp-M-P10“At medical school level, it's sometimes difficult to get examiners who have enough knowledge of the subject to do a comfortable OSCE. I'm comfortable with general medicine, I'm comfortable with pain medicine. I am a neurologist. And I've noticed that my co-examiners who are not neurologists let some things through that I would object to.” Exp-M-P05“It's difficult to get the examiner line-up the level that we are expecting. So obviously, we have the specialists in that particular discipline doing the examination in that OSCE station, they will expect more as Exp-M-P05 mentioned… because they are the specialists in that discipline. And they will always argue saying, but the student won't be exposed to the same scenario in year four, so, we need to set the bar high enough to be an exit-level." We will then remind them, the student will still improve their communication skills, their history taking skills, examination skills.” Exp-M-P06To improve the examiner decision making process, the participants suggested the use of calibration sessions and well-defined performance descriptors.“Great descriptors are really important. For example, I'm working in intensive care [and] don't have interns. They have to be PGY [postgraduate year] two, three, and have to be good to get to ICU. So, without good descriptors, I probably wouldn't know what the expected level is going to be.” Exp-F-P09“We have a breakout for each station and all the examiners on one station have anywhere from 30 to 40 minutes to discuss that station to go through it in detail. And usually, we have the person leading that as one of the academics who has helped at least quality assure, if not write, the OSCE so that it can be standardized, and you can thrash out some of those questions about what we're actually looking for. And I think that's a useful approach.” Exp-F-P04“Perhaps having kind of explanatory dot points as to what an excellent candidate would be. And then you know what [a] very poor or definite fail is…Then the examiner can …they had a few excellent qualities, but they did miss some, and therefore I'll put them…not quite there. Rather than explaining each individual one, just giving them a bit of a sense as to… what they could do to move them further in one direction than the other.” Less-F-P15The identified themes mapped well within the interaction between two proposed activity systems in the CHAT model: academic and clinical. In relation to how the CHAT can further explain and structure these perceptions, we present OSCE assessor judgements as an interaction within and between two activity systems (AS)—AS1 “academic” and AS2 “clinical,” which function independently but collaborate to produce an outcome. The interactions commenced in AS1 with the Subject (assessor) engaging with the marking rubric (Mediation Tool 1), provided by the academic faculty (Community 1), based on internal interactions with faculty requirements (Rules 1) and the organization of the community (Division of Labor 1), with the aim of facilitating judgement on demonstration of competence (Object 1) by final year medical students. At this point, should the assessor feel there is a misalignment of the marking criteria (Instrument 1) with their expected performance standards from AS2 elements , the subject (assessor) proceeds to mentally adjust Instrument 1 (OSCE marking criteria) to create a shared object—capability of the medical student to transition as a safe, reliable and trustworthy junior member of the clinical team, based on the concept of the “Prototypical Intern” that is better aligned with their expectations. The academic AS1—the medical program—focuses on curriculum development and delivery, specific learning outcomes, assessment tasks, mark sheets and progress decisions, whereas the clinical AS2 focuses on global application of knowledge and skills in authentic clinical practice. The activity system of authentic clinical practice is different in almost every respect to the academic system, but assessor decision-making requires an interaction between two AS because learners are transitioning from one to the other and the assessors work in both systems. The subject in the clinical practice AS is a practitioner whose object is to care for patients. However, when this practitioner is called into the academic AS to serve as an assessor, the object in this AS is to observe and make progression judgement on the level of competence demonstrated by learners. These manifestly divergent goals/ objects in the two activity systems create tensions and contradictions for the subject. While the OSCE is focused on written rules of standardization as indicated in the marking rubric, the assessors prefer to focus on unwritten but fundamental rules and values that are core to authentic, safe and trustworthy clinical patient care.This study uses the CHAT as the theoretical framework to contribute new knowledge to understanding the decision-making processes of assessors during clinical assessment of candidates at a major professional transition point—graduating from a primary medical degree course to entering the workforce. Clinical assessors make judgements that combine, to a varying extent, two interacting sets of roles and experiences that have different origins. The academic construct is the achievement of agreed, expected, graduate learning outcomes; in contrast, the clinical workplace construct is the ability to successfully work within professional settings. The former is reliant on knowledge, skills and behaviors represented in marking sheets in several scheduled, controlled assessment events, one of which is the OSCE. Academic progress decisions are informed by combining assessment data from many assessment events, converting a series of “snapshots” to a “low frame-rate” moving image. The clinical workplace construct is reliant on respect, organization, reliability, teamwork, and trustworthiness exhibited over time. Clinical assessors form impressions of what constitutes a “safe” junior doctor, a “prototypical intern,” through personal clinical experience of working with graduates. These impressions may be shared by close colleagues but different to those in other fields of health care, producing a form of cognitive bias that is likely based on a combination of “signal” and “noise.” This may provide an implicit set of “rules” that reflects “noise” and necessitates adaptation of the academic marksheet. When candidate performance is “borderline,” time is pressured or the assessor is more experienced, this characteristic heuristic, “how would this person fit into my clinical team?” is likely to be relied upon as a benchmark, either consciously or unconsciously, merging rules and influencing resulting judgements. The application of CHAT explained the intricacies and contradictions that may occur within OSCE assessor decision-making.This study explains how assessors in certain circumstances fall back on the clinical workplace experience to influence judgements about candidates. The extent of the influence may depend on the balance of academic and clinical experiences of individual assessors. Predominantly, clinical assessors may respect the academic rules, but over-ride them or merge them with clinically informed rules. This may explain why some assessors add components to checklists, add data points to rating scales and provide negative feedback to faculty on marksheets content. Another position may be that the more academic and less clinically relevant the marksheet, the more assessors may follow clinical logic in making decisions on clinical performance—overriding the marksheet criteria. The dominance of one or other activity system may also explain why examiner training appears not to be effective and why “doves” and “hawks” are difficult to change. “Debiasing” training is becoming popular to improve clinical reasoning, but success may be elusive . It may The relevance of this theory to other forms of clinical assessment, or clinical assessment at course levels other than the graduating cohort, cannot be determined from this study. The analogy may be stronger for exit assessments for other health professionals, where clinicians are assessors in an OSCE-like event. The model may be less relevant to WBA, where the clinical workplace activity system is likely to dominate, even though relatively low failure rates and the “failure to fail” phenomenon have been reported . AlthougThere are implications for both marksheet design and assessor training. Marking rubrics may reflect what learners are “taught” but not necessarily the expectations of their imminent clinical service roles, suggesting a potential disconnect between achieving program learning outcomes and working in the clinical environment. The OSCE may currently present patient care as a set of individual tasks, whereas healthcare is being conceptualized increasingly as a team activity . Would mLess experienced assessors were less represented because they were more difficult to recruit to interview sessions due to less flexible workload in their clinical service and specialty training requirements and a preference by medical schools for utilizing experienced assessors where available. Therefore, the perspectives of less experienced assessors may be under-represented. “Volunteer bias” is also possible, where assessors who follow medical school examiner training guidelines volunteered to be a part of this study—and “rogue examiners” did not volunteer. Hence, the statement that assessors usually followed institutional rules and guidelines for the OSCE may be overrepresented in this work. Additionally, the authors are insider researchers, and this could serve as potential bias, however, trustworthiness and credibility of the findings were enhanced through member checking and analytical group confirmations.Clinical assessment judgements in exit-level medical school OSCEs are complex, with individual assessors balancing perspectives from two different but interacting constructs that overlap and compete. The first is that of the academic system which is more task-oriented, emphasizing knowledge, skills and behaviors, based on achieving agreed graduate outcomes. The second is that of the clinical workplace, where graduates will soon have defined roles and responsibilities within a clinical team. The balance of the influence of these activity systems on judgements varies for individual assessors. Less experienced assessors tend to follow the academic rules listed in marksheets. More clinically engaged and more experienced assessors tend to fall back on a heuristic, mental construct of a “prototypical intern,” to calibrate judgements, particularly, in difficult situations. This heuristic is based on personal clinical experience and discussions with workplace peers, emphasizing professional attributes and trust, and may lead to a form of confirmation bias, that dominates thinking when candidates are “borderline;” time is pressured; or assessors are more experienced. Further research is needed to explore whether designing assessment marksheets and assessor training to more closely align the two systems decreases the cognitive load and increases the validity of assessor decision making. Designing marking frameworks should consider the possible introduction or amplification of unconscious biases. Further, assessor training may benefit from explicit “de-biasing” by aiming to increase awareness of a heuristic that is shared by assessors and caution against over-reliance on this strategy, thereby reducing unconscious bias.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the James Cook University Human Research Ethics Committee under Permit H6833. In addition, all participating schools obtained ethics approval from their local Ethics Committee. The participants provided their written informed consent to participate in this study.BM-A, RH, and KD'S conceived the study and conducted the focus groups. BM-A, KJ, RH, KD'S, and SS advised on data analysis and interpretation. BM-A, RH, KD'S, SS, AC, and RT contributed to writing the original draft of the manuscript. All authors facilitated collection of data, reviewed, edited, and accepted the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


With the improvement of the higher nursing education system, the overall quality and work ability of clinical nurses have also been significantly improved. Most nursing staff have a positive attitude towards evidence-based nursing medicine but lacking of the knowledge and skills about evidence-based nursing. Clinical nurses are still short of the ability to evaluate relevant research data, which is one of the cause of interference for the clinical nurses to use the latest research results reasonably and effectively at present. The purpose of this paper is to explore the application effect of evidence-based nursing in gastrointestinal surgical pipeline nursing and to clarify the impact of evaluation ability on nurses in clinical practice, investigate, and discuss the application effect of evidence-based nursing in gastrointestinal surgical pipeline nursing. This paper selects the clinical nurses of the three top three hospitals in a province as the research object, using the ways of general data questionnaire, the general individual performance sensitivity scale, the evidence-based nursing application behavior questionnaire, the evidence-based nursing application behavior willingness questionnaire, and the evaluation ability training needs questionnaire to collect data for 100 cases of gastrointestinal surgery clinical nurses. Analyze nurses' awareness level of evidence-based nursing, the willingness of evidence-based nursing behavior, and the relevance of evidence-based nursing behaviors. Use multiple regression analysis methods to explore its influencing factors, and use data statistics to analyze the role and effect of evidence-based nursing in the gastrointestinal surgery pipeline. The research results show that the evaluation ability has a significant promotion effect on clinical nursing application, and it is one of the important factors for clinical nurses to use evidence-based nursing. Clinical nurses have a higher demand for evaluation ability training, and basically here, the application effect of evidence-based nursing in the gastrointestinal surgical pipeline nursing is relatively good. Personal expression is the confidence of a person's ability to achieve a given ultimate goal. Personal performance perception can be divided into general individual performance perception and special performance perception, and its goal is specific and final . In geneIn addition to laparoscopic surgery, there are some minimally invasive surgical techniques for specific surgical procedures and standardized surgical techniques for mild tissue. A person's temperature below 36 degrees Celsius is too low. During operation, the operating room temperature is too low, the veins manage a large amount of cryogenic fluid, anesthesia caused by vasodilation, organ contact, or wounds, and other causes always cause the patient's hypothermia to be too low. Intraoperative hypothermia will increase the patient's stress response, allowing patients to recover quickly after surgery . Lower bScholars such as Tsang found that clinical practical problems have improved the scientific nature of clinical decision-making and improved the overall quality of clinical care services. At present, the ability of clinical nurses to evaluate evidence-based nursing medicine and its application in evidence-based nursing medicine is not very satisfactory. Clinical nutritional support is complex and has many symptoms. In the course of pharmacy care, nutrition evaluation should be carried out according to the specific conditions of patients. This requires clinical pharmacists to use their expertise and appropriate nutrition screening tools to determine the patient's nutritional status and whether nutritional support and nutritional screening tools are needed. Choose the appropriate nutritional prescription . Tahan aThis paper selects the clinical nurses of the three top three hospitals in a province as the research object, using the general data questionnaire, the general individual performance sensitivity scale, the evidence-based nursing application behavior questionnaire, and the evidence-based nursing application behavior willingness questionnaire, and the evaluation ability training needs questionnaire. Data collection was performed on 100 cases of gastrointestinal surgery clinical nurses. Analyze nurses' understanding of evidence-based nursing, the willingness of evidence-based nursing behavior, and the relevance of evidence-based nursing behaviors. Use multiple regression analysis methods to explore the influencing factors, and use statistical analysis of evidence-based nursing in the gastrointestinal surgery pipeline.Evidence-based nursing medicine is a relatively new concept of care with the development of evidence-based medicine. Its core idea is to apply the best contemporary evidence judiciously and unambiguously. It is not only an important part of evidence-based medicine but also a relatively new field of research. Based on the clinical experience of nursing, it is proposed that “evidence-based nursing medicine” is the most appropriate and has skilled clinical knowledge and experience and provide appropriate care according to the patient's wishes. The rules of clinical evidence-based care methods should include knowledge and skills based on clinical experience, patient needs, the most appropriate research basics, and available resources. It includes the following complete process: evidence-based difficulties, support, observe, understand, and apply. Identify suspected clinical experience and theory in the process of nursing clinical experience, discover evidence-based care laws to collect practical application data based on relatively reliable data sources, find the most appropriate care method, and then use a key from the perspective of whether it can achieve the most appropriate effect or whether it is needed. Evidence-based nursing contains three elements, these three elements must be organically combined to establish a correct concept, and nursing discipline can progress further research on its development and gradually cycle, continuous improvement, to achieve continuous improvement of the quality of effective care. Evidence-based nursing medical clinical experience brings nursing science into a new era. Combine nursing research with clinical care experience to make mathematical medicine truly entered the era of research disciplines.The application of evidence-based nursing medicine to nursing staff should follow the following five specific steps: The first step is to clarify the problems in clinical experience, that is, to ask questions and to find out the problems that patients need to solve by evaluating the application of thinking methods; the second step is to find relevant care information, that is, collect relevant information. In the third step, according to the epidemiological discipline and the evidence-based medical evaluation rules, the basic research is strictly evaluated, and the authenticity and reliability of the relevant data are found. The fourth step is to apply the most suitable basic examples. Guide the clinical method, that is, develop the nursing method according to the clinical relevant professional knowledge and the actual situation of the patient; the fifth step: evaluate the nursing effect and efficiency according to the clinical experience and closely observe and scientifically evaluate the basic effect in the application process. Therefore, we continue to summarize each experience and ultimately improve the academic level and quality of care of clinical nurses based on evidence-based clinical experience. Education must not only impart knowledge but also provide opportunities for students to innovate and learn independently. The environment should develop students' ability to acquire, apply, and innovate knowledge. In the teaching environment, students should change their learning concepts, use questionable thinking methods, seek practical application of existing clinical experience rules, and continuously improve the quality of care in future clinical nursing experience. In order to cultivate students' clinical thinking ability and medical ethics in medical teaching, students should pay attention to practical operation and ensure the accuracy and standardization of operation. With the emergence and development of society, the lack of medical and health resources, the rising cost of medical and health services, and the increase in demand have become global issues. This is due to the continuous expansion of the population base. Therefore, the most important thing is to promote the scientific and appropriate clinical methods of medical staff to promote a better clinical experience. The results of foreign medical education research show that the clinical experience and behavior of clinicians are affected by many factors. Therefore, it is necessary to introduce the concepts and methods of evidence-based nursing medicine into education to adapt to future clinical experience. Evidence-based nursing education can reduce the feeling and distance between students and practice and can more effectively promote students to understand and use knowledge.Evidence-based nursing is a scientific research that is based on the problem . Through the essence of evidence-based nursing knowledge, nurses are required to use epidemiological statistical knowledge as a link to evaluate, select evidence, and acquire knowledge in English to obtain the latest information. Evidence-based nursing knowledge emphasizes clinical practice as the starting point, combining scientific research theory with clinical expertise and experience and patient needs. With new and best “bases”, use supplemental information, “specific clinical issues,” to sample some of the data and validate and enrich the best empirical evidence for clinical problem resolution. Through this way of thinking, it is possible to present the specific steps and processes of evidence-based nursing medical knowledge, evidence-based methods, or evidence-based nursing medicine, as well as the knowledge content and ways of thinking involved in the main steps, including nurses' evidence-based nursing medical basic knowledge, scientific research knowledge, epidemiological statistical knowledge, and English knowledge, reflecting nurses' evidence-based nursing medical knowledge ability from different aspects. Nursing majors cultivate basic knowledge of humanities and social sciences, medicine, preventive health care, and basic theoretical knowledge and skills of nursing. Evidence-based nursing medical skills were as follows: nurses must have relevant evidence-based skills to identify problems, find empirical evidence, and then use the best way to solve problems under the guidance of the correct way of thinking. Therefore, nurses are required to have the ability to select information sources, to assess the ability to discover information, to effectively use information to solve problems, to be proficient in identifying problems and clinical solutions, and to make decisions. The nurse's evidence-based nursing medical skills are reflected in different aspects. Evidence-based nursing attitude was as follows: it refers to the research and discussion of nursing staff on nursing theory knowledge, reflecting the attitude ability of nursing staff in evidence-based nursing medicine from different angles.Evidence-based nursing medical behavior was as follows: Nursing staff should often develop positive habits, find relevant information and their professional knowledge, and better integrate the useful research results of the application to solve clinical application problems, mainly reflected in how to obtain evidence-based applications. Basic or guidelines related to the program and solve application problems were as follows. Evidence-based nursing medicine requires modern nurses to have a knowledge structure systematically and modernize knowledge with the depth of professional basic theory and the breadth of relevant disciplines. Only by getting into the understanding of its connotation and basic steps, as well as its meaning and meaning, we combine the theory and knowledge with our common knowledge and effective methods and apply one theory to the specific clinical work. Clinical nurses have basic knowledge and relevant knowledge of evidence-based nursing medicine. Evidence-based nursing medicine focuses on utilizing the best basics available. The best research is basically obtained through scientific clinical research results and verified in clinical applications. Nurses are required to have strong scientific research knowledge and ability to continuously produce new research results. At the same time, when applying evidence-based medicine, nurses must not only use evidence but also learn to study and evaluate it, evaluate whether it is really suitable for the corresponding patients, and use it flexibly. This requires nurses to have clinical knowledge of epidemics and face bedside epidemics. Disease research methods can provide an effective external basis for evidence-based nursing medicine; on the other hand, in the face of bed-related epidemiological critical judgment methods, clinical nurses can more effectively select science from a large number of relevant data. Effective external evidence is based on clinical decision-making. Syndicated nursing medicine is basic. On the other hand, mastering statistical knowledge can help clinical nurses to basically identify the abuse of statistical processing and improve the reliability of systematic evaluation in evidence-based applications. In addition, ANOVA and regression analysis in mathematics are also beneficial for analyzing medical data and making inferences.As the link between medical technology and information dissemination, medical English plays an important role in the introduction of evidence-based nursing medicine. It has a direct impact on learning the advanced experience of international evidence-based nursing medicine. An important reason for medical nursing technology methodology is that nurses are required to have a strong ability to read English in order to achieve the “latest and best evidence” required for the application of evidence-based nursing medicine. Good evidence-based nursing medical skills are key to improving the ability of evidence-based nursing medicine. Nurses must have relevant evidence-based skills in order to identify problems, find empirical evidence, and then use the best methods to solve problems under the guidance of the correct way of thinking. Information ability refers to the ability to select information sources, evaluate and discover information, and effectively use information to solve problems when determining information needs. Information ability is the foundation of development and creation, it is helpful to people's success, and it is the key to distinguish modern talents from traditional talents, mainly in the use of relevant data and search tools, the use of nursing database and Internet query nursing research results, the correct evaluation of nursing professional data, and the ability to find relevant research to solve problems encountered in clinical applications. Critical thinking ability refers to more appropriate questions, good at finding problems, and scientifically solving nursing problems. It can help nurses develop skills and apply the skills necessary for evidence-based nursing medicine, mainly reflected in the ability to find problems, solve clinical problems, and make decisions. Evidence-based attitude refers to the cognition of evidence-based nursing medicine and the behavioral tendency of evidence-based nursing medicine. A correct understanding and positive attitude towards evidence-based nursing medicine is the initiator of evidence-based care applications.It includes the value orientation and acceptance of evidence-based applications. An excellent nursing worker not only needs solid evidence-based nursing knowledge and active evidence-based nursing attitude but also needs solid evidence-based nursing application behavior. Behavior is fundamental to the effectiveness of all good applications, because with the reform of the medical system, research is very important for nurses. Nursing staff should develop the habit of actively and regularly searching for relevant information, better integrate professional knowledge, and use the useful information obtained to ensure certainty.Evidence-based nursing medical behavior is mainly how to actively obtain relevant evidence-based application and solve problems in application. The nurse did not understand the results of the study; the nurse did not believe the results; the nurse did not know how to use the findings. At the same time, the results of nurses' applied research are related to their ability to receive education. The higher the level of nurse education, the better the effect of applied research. Therefore, if these constraints can significantly affect the basic ability of nursing staff to apply evidence-based nursing medicine, the goal of transforming research results into economic benefits and social benefits can be achieved, thereby improving the quality of care. This may be related to the training objectives of nursing education at different levels of education. Undergraduate nursing students have more opportunities to acquire new knowledge and concepts, such as evidence-based nursing medicine, and to obtain broader and in-depth information. Education is also one of the reasons for evidence-based cognition of clinical nurses. The level of evidence-based nursing medical knowledge of general undergraduate nursing staff is higher than that of self-study undergraduate or network undergraduate nursing staff. There was no statistical difference in the level of evidence-based knowledge between general undergraduate nursing students and middle nursing students. The general undergraduate nursing program is more comprehensive and has a wider range of knowledge. This may be due to the fact that the current secondary vocational education is positioned as a skill-based and service-oriented talent. Even if they obtained a bachelor's degree in the later period, they have more theoretical knowledge, but they are subject to past educational experience. Therefore, they cannot be covered and imprisoned by past experiences, and they should strive to pursue new life experiences and do not let past experiences limit future possibilities. The goal of the work is to directly carry out specific steps in the application of care, and there is a lack of questionable thinking in research. At the same time, this difference in attitudes and beliefs may further influence their enthusiasm and enthusiasm for evidence-based nursing medicine in clinical work. The evidence-based cognitive level of general undergraduate nursing staff is higher than that of self-study undergraduate nursing staff. From the influence of learning forms on evidence-based knowledge and attitudes, it can be seen that ordinary undergraduate nursing students have certain advantages in evidence-based knowledge and skills, evidence-based attitudes, and belief levels: the higher the level of evidence-based knowledge of nursing students participating in evidence-based applications. It can be seen that evidence-based knowledge learning promotes the development of evidence-based applications, and evidence-based application behavior further promotes the ownership of evidence-based knowledge, which is interrelated, mutually reinforcing, and jointly improved. Learning evidence-based nursing medicine in clinical applications is also an evidence-based learning method that college students expect. In the future, the evidence-based concepts and skills of clinical nurses should be strengthened. Through oral and individual teaching, nursing students should gradually learn and master evidence-based knowledge and skills and form behaviors that actively use evidence-based concepts and skills in practical work.One of the core elements of evidence-based care medicine is to consider the patient's subjective will. It also includes the most appropriate nursing research evidence available and the nursing staff's personal skills and clinical experience. For example, if care can play an “empathy” role, starting from the patient's actual preferences and trying to meet the patient's needs, the patient will eventually be satisfied, thereby improving the nurse-patient relationship. Evidence-based nursing physicians based on scientific rigorous research will improve the relationship between nurses and patients. Research and application work itself is more conducive to the health of patients. Some people may not have an in-depth understanding of the content of evidence-based nursing medicine. Especially when considering the subjective will of the patient, it is often easy to ignore the content when applying evidence-based applications. Part of the motivation for learning is mainly to complete the learning task and lack of active exploration and experiment in the learning process, which may be limited by the fixed thinking mode in school education. This will cause students to become less and less interested in learning and even have a mentality of learning weariness. In addition, because the nursing nurse works under the guidance of the teacher, the nursing behavior is mainly based on the teacher's behavior, and there is no clinical decision-making power. Clinical decision-making is not just a unilateral event of physicians and must be fully coordinated with patients and families to truly make medical decisions. At this stage, the cognitive rate of evidence-based nursing staff is low, and the application model of evidence-based nursing also hinders the development of evidence-based application behavior of nursing students. Evidence-based nursing medicine requires existing nursing knowledge to keep pace with the times. This requires the idea of lifelong learning. After graduating, they can insist on in-depth exploration of their professional knowledge when they are engaged in practical work. At this time, the autonomous learning method characterized by self-diagnosis, self-planning, and self-learning is more satisfactory, which meets their learning needs. The characteristics of the nursing discipline determine the value of qualitative research. Especially in the field related to human response and consciousness, qualitative research is more meaningful than quantitative research, which can further strengthen the evidence-based ability and ability training of clinical nursing teachers, and help students gradually learn and master evidence-based knowledge and skills through vocabulary and examples. At the same time, teachers and students can work together to find the best query basis, and in combination with the actual working environment and patient needs, and carefully and clearly applied to clinical work to improve the quality of care services.In order to ensure the fairness and justice of the experiment and the reliability of the data, the subjects selected 100 patients and nurses who met the inclusion criteria and underwent surgery in the gastrointestinal surgery wards of three tertiary hospitals in a provinceThe standard patients are older than or equal to 18 years old, less than or equal to 70 years old, hospitalized for surgery, need pipeline care, have smart phones, and will use WeChat function, voluntarily participate, and sign informed consent and patient supervisionPresurvey: according to relevant data, the presurvey sample size is more than 50 cases. In this study, 80 nurses were selected from different levels of nurses. Considering the questionnaire's response rate and other issues, the sample size was appropriately expanded. Preinvestigation can include controversial issues in the plan, in order to demonstrate the design from a clinical perspective, eliminate doubts, and further formulate a reasonable and feasible clinical investigation planCross-sectional survey (the descriptive data obtained were collected at a certain point in time or within a short period of time): more than 90 nurses were randomly selected from the ward. Considering the problems such as the recovery rate of the questionnaire, the sample size is appropriately expanded; so, the sample size of this study is set to 100. The single analysis was as follows: the variance analysis method was used to compare the basic ability of evidence-based nursing and the total score of knowledge dimension; the rank sum test method was used to compare the total scores of empirical skills, attitudes, and behavioral dimensions (deviated distribution measurement data). Multivariate analysis method was as follows: the multiple regression analysis method was used to screen the causes of the impact of evidence-based nursing medical ability on nurses from the four dimensions of evidence-based nursing medical ability and evidence-based nursing medical ability. Canonical correlation was as follows: a typical correlation analysis method was used to analyze the correlation between the two groups of variables and the nurses' evidence-based nursing medical ability. Questionnaire reliability and validity analysis method were as follows: according to the degree of relevance of the questionnaire components and expert description content, the surface validity of the questionnaire was evaluated, and the structural validity of the questionnaire was evaluated by the factor analysis method. The analysis of variance was used to analyze the validity of the questionnaire. Evidence-based ability and its validity were analyzed for differential validity, and questionnaires were conducted. The internal reliability of the volume was as follows: on-site investigation, organization, interpretation, guidance, and recycling inspection. Filter out the abandoned questionnaires, determine the criteria for the valid questionnaire, check the validity of the questionnaire one by one before entering, and record the number of the invalid questionnaireAccording to the statistical data analysis as shown in According to the data analysis, as shown in According to the data analysis, according to the data analysis, as shown in According to the data analysis, as shown in The interaction between individual performance, evidence-based nursing medical application experience and training experience is an important reason for clinical nurses' evaluation ability. The clinical nurses in the top three hospitals have higher requirements for training based on assessment ability, which is why the clinical nurses in the top three hospitals have higher requirements for training based on assessment ability. Under this circumstance, the nurses with higher training requirements are basically more in the early stage, that is, nurses who have basically high evaluation ability can be trained in advance. The nurses are all trained. Managers generally have a positive attitude towards evidence-based nursing medicine. The younger the working life, the more positive the attitude of nurses to evidence-based nursing; the evidence-based skills and behavioral level are good; evidence-based nursing medicine breaks the traditional way of thinking and working mode. This is the basicity of compliance, requiring clinical care to be basically demonstrated in strict scientific factsWays to acquire professional knowledge, solve clinical practical problems, and develop nursing methods. Nursing students mainly rely on professional books and senior nurses, and the opportunity to apply evidence-based nursing medicine is almost zero, which indicates that clinical knowledge is mainly from personal clinical experience. Teaching nursing students or senior nurses. Clinical teachers do not have the ability to actively improve new knowledge to understand the frontiers of nursing development and update existing knowledge. Some inefficient specific steps can also be replaced by specific steps that are proven to be more effective to improve the ability of nursing research staff and care applicants in evidence-based care medicine. Evidence-based nursing medicine capabilities mainly include knowledge integration ability and knowledge application ability. Strengthen the awareness of evidence-based application of nursing staff, and promote the positive, active and full use of basic resources by clinical front-line staff to improve the knowledge application ability of clinical employees. For the systematic education and training of evidence-based application in the later stage, it lays a foundation for cultivating clinical nursing talents with evidence-based nursing medicine ability. Promote the development of evidence-based nursing medicine applications. The application of evidence-based nursing medicine can effectively promote the transformation of nursing knowledge and research results into clinical applications. However, the application of evidence-based nursing medicine is a systematic and complex project involving a wide range of fields that requires a unified understanding and collaboration between decision makers, managers and applicantsThe ideological center of evidence-based nursing medicine is to provide services to customers by using the latest and best scientific evidence. This affects experiential and intuitive care that has long been embedded in nurses and used by nurses. This has made evidence-based nursing medicine a far-reaching impact on nursing disciplines, patients, health care and society. Evidence-based nursing medicine organically combines nursing research and nursing applications, making nursing truly a research-oriented profession, supporting nurses to further seek professional autonomy and autonomy. The concept of evidence-based nursing medicine is a combination of science and technology. It requires medical staff to consider medical costs when developing and implementing a medical plan, and to control the rapid growth of medical expenses


The spleen is supplied by blood flow through the splenic artery and vein. The purpose of this communication is to report an ectopic spleen supplied only by reverse flow through the left gastro-omental vessels. A 14-year-old boy presented with pelvic splenomegaly supplied only by the left gastro-omental artery and veins connected to the inferior polar vessels, which were the only vessels communicating with the spleen. After detorsion of the spleen and splenopexy, the spleen returned to normal dimensions. The patient had uneventful follow-up. In conclusion, the left gastroepiploic vessels are able to maintain the entire spleen blood supply. The splenic artery usually arises from the celiac trunk and divides into two or three branches before entering the hilum of the spleen. The superior and inferior branches of this artery are known as superior and inferior polar arteries. The superior pole of the spleen has an additional arterial supply, separate from the splenic hilar vessels, by mean of the splenogastric arteries, which connect the superior pole of the spleen to the gastric fundus.1,1,2Blood from the parenchyma of the spleen flows through the superior and inferior polar veins, which join together to form the main splenic vein. Along its course, the inferior polar vein receives the left gastro-omental veins as tributaries, which drain blood from the greater omentum and the body of the stomach. The left gastro-omental veins run in the greater omentum as an arch and connect with the right gastro-omental veins, then continue as tributaries of the portal vein.1-8Splenoptosis  is a rare congenital condition defined as an ectopic spleen displaced from its normal anatomical position in the left hypochondrium due to absence of the perisplenic ligaments. This mobile spleen is supplied by a long vascular pedicle and may be associated with other congenital disorders.5The purpose of this communication is to report the case of a spleen supplied only by reverse blood flow through the gastro-omental vessels.The patient provided the authors with a signed written informed consent form for publication of this case report, including images. Ethical approval was not required; this paper reports treatment performed in a patient with no research intention.A 14-year-old boy presented with a pelvic mass associated with abdominal discomfort, dysuria, tenesmus, and constipation. A physical examination of the abdomen revealed a visible tender pelvic mass, changing position with variation of the patient’s decubitus. Axial computed tomography (CT) showed absence of the spleen in the left subphrenic space and a spleen-like mass in the pelvis, suggestive of a wandering spleen, compressing the bladder. Due to the abdominal discomfort and gradual increase in urinary and digestive symptoms, surgical treatment was recommended.After opening the abdomen, an enlarged spleen measuring 22 × 16 × 13 cm with a long epiploic vascular pedicle and absence of perisplenic ligaments was found in the pelvis. The splenic pedicle comprised the greater omentum with the left gastro-omental artery and veins, starting at the tail of the pancreas. These vessels were partially twisted and connected to the inferior splenic polar artery and veins. Due to the splenic torsion, the organ was congested and both the gastro-omental and the inferior polar veins were extremely dilated. No other vessels were found in the splenic hilum .The detectable arterial pulse was from the left gastro-omental artery to the splenic polar artery, characterizing reversed blood flow. The venous blood flow was also reversed from the inferior splenic polar vein to the left gastro-omental veins. The portal vein was formed by the superior and inferior mesenteric veins, associated with the left gastric vein, without the splenic vein. The body and tail of the pancreas were vascularized by vessels connected to the superior mesenteric artery and vein.After detorsion of the spleen, the venous calibers reduced to normal, the dimensions of the spleen reduced, and the signs of congestion disappeared . The spl,5-7,An ectopic spleen is a rare condition, but more than 1000 papers have been published describing this disorder, which is most commonly found in women of reproductive age.1,9-1,10-Splenogastric vessels are able to preserve the viability of the upper splenic pole if the splenic pedicle is damaged or must be ligated.1-18-Warshaw16Previously, we confirmed in a patient with Hodgkin’s lymphoma of the splenic superior margin that reverse blood flow of the gastro-omental vessels through the inferior splenic polar vessels is efficacious for preserving the inferior splenic pole after superior splenectomy.Therefore, this is the first report that demonstrate the entire splenic blood supply by the left gastro-omental vessels only, through the inferior splenic pole artery and veins. These vessels were able to maintain the viability of an enlarged and congestive spleen even when partially twisted. No apparent infarction or other splenic vascular disorder was verified after detorsion of the spleen.In the presence of a congenital disorder, other organic abnormalities must be investigated. In this case, the absence of the perisplenic ligaments was combined with absence of the splenic artery and vein, including the superior polar and splenogastric vessels.The left gastro-omental vessels are able to maintain the entire spleen blood supply.