Mixed methods evaluation research for a mental health screening and referral clinical pathway

<b>Rationale: b>This study is an exemplar of mixed method evaluation research for development of a clinical pathway.<br /><b><br />Aim:b> To develop and evaluate an evidence-based, feasible mental health screening and referral clinical pathway for Department of Veterans’ Affairs-funded community nursing care of war veterans and war widows in the Australian context.<br /><b><br />Methods:b> Mixed methods were applied to formulate and clinically evaluate an appropriate pathway. The pathway was applied at urban and rural sites for the nursing care of 97 war veteran and war widow clients. Evaluative data were collected from clients, their informal carers, community nurses, and general practitioners. Chart auditing and pre-post measures were undertaken. Collaboration occurred with an interdisciplinary design team.<br /><b><br />Results:b> The final modified six-page pathway includes use of validated screening tools (Kessler Psychological Distress Scale [K10]) and Alcohol Use Disorder Identification Test, appropriate referral information, directions for support and health-promoting education, and evidence-based guidelines. Implications for Practice: The clinical pathway is a useful, tested, evidence-based guide for generalist community nurses to identify and suitably respond to common mental healthcare needs of war veterans and war widows. The pathway provides outcomes acceptable to clients and their carers, nurses and doctors.<br /><b><br />Conclusions:b> This study provides an evaluated clinical pathway for generalist community nurses to screen for mental health difficulties, make appropriate referrals as required and to support war veteran and war widow clients. However, the study also shows how research can be used to develop and evaluate<br />practical, evidence-based clinical pathways.<br />

Undergraduate nursing students' performance in recognising and responding to sudden patient deterioration in high psychological fidelity simulated environments: an Australian multi-centre study

<b>Objectivesb><br />This paper reports the quantitative findings of the first phase of a larger program of ongoing research: Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST2ACTTM). It specifically aims to identify the characteristics that may predict primary outcome measures of clinical performance, teamwork and situation awareness in the management of deteriorating patients.<br /><br /><b>Designb><br />Mixed-method multi-centre study.<br /><br /><b>Settingb><br />High fidelity simulated acute clinical environment in three Australian universities.<br /><br /><b>Participantsb><br />A convenience sample of 97 final year nursing students enrolled in an undergraduate Bachelor of Nursing or combined Bachelor of Nursing degree were included in the study.<br /><br /><b>Methodb><br />In groups of three, participants proceeded through three phases: (i) pre-briefing and completion of a multi-choice question test, (ii) three video-recorded simulated clinical scenarios where actors substituted real patients with deteriorating conditions, and (iii) post-scenario debriefing. Clinical performance, teamwork and situation awareness were evaluated, using a validated standard checklist (OSCE), Team Emergency Assessment Measure (TEAM) score sheet and Situation Awareness Global Assessment Technique (SAGAT). A Modified Angoff technique was used to establish cut points for clinical performance.<br /><br /><b>Resultsb><br />Student teams engaged in 97 simulation experiences across the three scenarios and achieved a level of clinical performance consistent with the experts' identified pass level point in only 9 (1%) of the simulation experiences. Knowledge was significantly associated with overall teamwork (p = .034), overall situation awareness (p = .05) and clinical performance in two of the three scenarios (p = .032 cardiac and p = .006 shock). Situation awareness scores of scenario team leaders were low overall, with an average total score of 41%.<br /><br /><b>Conclusionsb><br />Final year undergraduate nursing students may have difficulty recognising and responding appropriately to patient deterioration. Improving pre-requisite knowledge, rehearsal of first response and team management strategies need to be a key component of undergraduate nursing students' education and ought to specifically address clinical performance, teamwork and situation awareness.

Sensitivity of the final properties of tailored hot stamping components to the process and material parameters

The final mechanical properties of hot stamped components are affected by many process and material parameters due to the multidisciplinary nature of this thermal-mechanical-metallurgical process. The phase transformation, which depends on the temperature field and history, determines the final microstructure and consequently the final mechanical properties. Tailored hot stamping parts - where the cooling rates are locally chosen to achieve structures with graded properties - has been increasingly adopted in the automotive industry. In this case, the robustness of final part properties is more critical than in the conventional hot stamping parts, where the part is fully quenched. In this study, a wide range of input parameters in a generalized hot stamping model have been investigated, examining the effect on the temperature history and resulting final material properties. A generic thermo-mechanical finite element model of hot stamping was created and a modified phase transformation model, based on Scheil's additive principle, has been applied. The comparison between modeling and experiments shows that the modified phase transformation model coupled with the incubation time provides higher accuracy on the simulation of transformation kinetics history. The robustness of four conditions relevant to tailored hot stamping was investigated: heated tooling (with low and high tool conductance), air cooling, and conventional hot stamping. The results show the high robustness of the conventional hot stamping compared to tailored hot stamping, with respect to the stamped component's final material properties (i.e. phase fraction and hardness). Furthermore, tailored hot stamping showed higher robustness when low conductivity tools are used relative to high conductivity tools.

Microstructure and hardness characterisation of laser coatings produced with a mixture of AISI 420 stainless steel and Fe-C-Cr-Nb-B-Mo steel alloy powders

Fe-C-Cr-Nb-B-Mo alloy powder and AISI 420 SS powder are deposited using laser cladding to increase the hardness for wear resistant applications. Mixtures from 0 to 100 wt.% were evaluated to understand the effect on the elemental composition, microstructure, phases, and microhardness. The mixture of carbon, boron and niobium in the Fe-C-Cr-Nb-B-Mo alloy powder introduces complex carbides into a Fe-based matrix of AISI 420 SS which increases its hardness. Hardness increased linearly with increasing Fe-C-Cr-Nb-B-Mo alloy, but substantial micro-cracking was observed in the clad layer at additions of 60 wt.% and above; related to a transition from a hypoeutectic alloy containing α-Fe/α' dendrites with an (Fe,Cr)2B and γ-Fe eutectic to primary and continuous carbo-borides M2B (where M represents Fe and Cr) and M23(B,C)6 carbides (where M represents Fe, Cr, Mo) with MC particles (where M represents Nb and Mo). The highest average hardness, for an alloy without micro-cracking, of 952 HV was observed in a 40 wt.% alloy. High stress abrasive scratch testing was conducted on all alloys at various loads (500, 1500, 2500 N). Alloy content was found to have a strong effect on the wear mode and the abrasive wear rate, and the presence of micro-cracks was detrimental to abrasive wear resistance.

Grain size effect on behaviour and microstructure of a warm deformed Ti-IF steel

The effect of grain size on the deformation behaviour in the fenite region of a Titanium stabilized Interstitial Free steel was investigated by hot torsion. The initial work hardening regime is followed by a softening regime where a broad peak stress develops. The peak stress and the stress at final strain were relatively insensitive to grain size. However, at low values of the Zener-Hollomon parameter, the strain to the peak stress was strongly dependent on the grain size. A series of microstructural parameters were examined to explain these observations.

Effect of deformation schedule on the microstructure and mechanical properties of a thermomechanically processed C-Mn-Si transformation-induced plasticity steel

Thermomechanical processing simulations were performed using a hot-torsion machine, in order to develop a comprehensive understanding of the effect of severe deformation in the recrystallized and nonrecrystallized austenite regions on the microstructural evolution and mechanical properties of the 0.2 wt pct C-1.55 wt pct Mn-1.5 wt pct Si transformation-induced plasticity (TRIP) steel. The deformation schedule affected all constituents (polygonal ferrite, bainite in different morphologies, retained austenite, and martensite) of the multiphased TRIP steel microstructure. The complex relationships between the volume fraction of the retained austenite, the morphology and distribution of all phases present in the microstructure, and the mechanical properties of TRIP steel were revealed. The bainite morphology had a more pronounced effect on the mechanical behavior than the refinement of the microstructure. The improvement of the mechanical properties of TRIP steel was achieved by variation of the volume fraction of the retained austenite rather than the overall refinement of the microstructure. <br />

Effect of thermomechanical parameters on the critical strain for ultrafine ferrite formation through hot torsion testing

A C–Mn–V steel was used to study ultrafine ferrite formation (1–3 μm) through dynamic strain-induced transformation (DSIT) using hot torsion experiments. A systematic study determined the critical strain for the start of DSIT (C,DSIT), although this may not lead to a fully ultrafine microstructure. Therefore, the strain to produce an ultrafine ferrite (UFF) as final microstructure (C,UFF) during deformation was also determined. In addition, the effect of thermomechanical parameters such as deformation temperature, prior austenite grain size, strain rate and cooling rate on C,DSIT and C,UFF has been evaluated. DSIT ferrite nucleated on prior austenite grain boundaries at an early stage of straining followed by intragranular nucleation at higher strains. The prior austenite grain size affected the distribution of DSIT ferrite nucleation sites at an early stage of transformation and the subsequent coarsening behaviour of the grain boundary and intragranular ferrite grains during post-deformation cooling. Also, C,DSIT and C,UFF increased with an increase in the prior austenite grain size and deformation temperature. The post-deformation cooling had a strong effect not only on C,UFF but also the UFF microstructure (i.e. final ferrite grain size and second phase characteristics).<br />

The effect of Nb, Mo, and A1 additions on the transformation behaviour and mechanical properties of thermomechanically processed C-Si-Mn trip steel

The effect of additions of Nb, A1 and Mo to Fe-C-Mn-Si TRIP steels on the final microstructure and mechanical properties after simulated thermomechanical processing (TMP) has been studied. Laboratory simulations of continuous cooling during TMP were performed using a quench deformation dilatometer, while laboratory simulations of discontinuous cooling during TMP were performed using a hot rolling mill. From this a comprehensive understanding of the structural and kinetic aspects of the bainite transformation in these types of TRIP steels has been developed. All samples were characterised using optical microscopy and XRD. The relationships between the morphology of bainitic structure, volume fraction, stability of RA and mechanical properties were investigated.<br />

Effect of the thermomechanical processing parameters on the microstructure-property relationships in C-Mn-Si TRIP steel

In this work a wide range of roughing (deformation in the austenite recrystallised region) and finishing (deformation in the non-recrystallised region) strains and isothermal holding times were used to clarify the effect of processing parameters on the transformation kinetics and mechanical properties of 0.2C-1.55Mn-1.55Si (wt%) TRIP steel. The results have highlighted the complex relationships between multi-phase microstructure and mechanical properties of TRIP steel. The presence of the triclinic carbides, formed during isothermal holding, deteriorated the mechanical properties of steel studied.<br />

Microstructure and mechanical properties of C-Si-Mn(-Nb) TRIP steels after simulated thermomechanical processing

Continuous and discontinuous cooling tests were performed using a quench deformation dilatometer to develop a comprehensive understanding of the structural and kinetic aspects of the bainite transformation in low carbon TRIP (transformation induced plasticity) steels as a function of thermomechanical processing and composition. Deformation in the unrecrystallised austenite region refined the ferrite grain size and increased the ferrite and bainite transformation temperatures for cooling rates from 10 to 90 K s^-1. The influence of niobium on the transformation kinetics was also investigated. Niobium increases the ferrite start transformation temperature, refines the ferrite microstructure, and stimulates the formation of acicular ferrite. The effect of the bainite isothermal transformation temperature on the final microstructure of steels with and without a small addition of niobium was studied. Niobium promotes the formation of stable retained austenite, which influences the mechanical properties of TRIP steels. The optimum mechanical properties were obtained after isothermal holding at 400°C in the niobium steel containing the maximum volume fraction of retained austenite with acicular ferrite as the predominant second phase.<br />

Effect of alloying elements on the microstructure property relationship in thermomechanically processed C-Mn-Si TRIP steels

The effect of additions of Nb, Al and Mo to Fe-C-Mn-Si TRIP steel on the final microstructure and mechanical properties after simulated&nbsp; thermomechanical processing (TMP) has been studied. The laboratory simulations of discontinuous cooling during TMP were performed using a hot rolling mill. All samples were characterised using optical microscopy and image analysis. The volume fraction of retained austenite was ascertained using a heat tinting technique and X-ray diffraction measurements. Room temperature mechanical properties were determined by a tensile test. From this a comprehensive understanding of the structural aspect of the bainite transformation in these types of TRIP steels has been developed. The&nbsp; results have shown that the final microstructures of thermomechanically processed TRIP steels comprise 50 % of polygonal ferrite, 7 - 12 % of retained austenite, non-carbide bainitic structure and martensite. All steels exhibited a good combination of ultimate tensile strength and total elongation. The microstructure-property examination revealed the relationship between the composition of TRIP steels and their mechanical properties. It has been shown that the addition of Mo to the C-Si-Mn-Nb TRIP steel increases the ultimate tensile strength up to 1020 MPa. The stability of the retained austenite of the Nb-Mo steel was degraded, which led to a decrease in the elongation (24 %). The results have demonstrated that the addition of Al to C-Si-Mn-Nb steel leads to a good combination of strength (∼ 940 MPa) and elongation (∼ 30 %) due to the formation of refined acicular ferrite and granular bainite structure with ∼7 - 8 % of stable retained austenite. Furthermore, it has been found that the addition of Al increases the volume fraction of bainitic ferrite laths. The investigations have shown an interesting result that, in the Nb-Mo-Al steel, Al has a more pronounced effect on the microstructure in comparison with Mo. It has been found that the bainitic structure of the Nb-Mo-Al steel appears to be more granular than in the Nb-Mo steel. Moreover, the volume fraction of the retained austenite increased (12 %) with decreasing bainitic ferrite content. The results have demonstrated that this steel has the best mechanical properties (1100 MPa and 28 % elongation). It has been concluded that the combined effect of Nb, Mo, and Al addition on the dispersion of the bainite, martensite and retained austenite in the ferrite matrix and the morphology of these phases is different than effect of Nb, Mo and Al, separately.<br />

Characterization on ferrite microstructure evolution during large strain warm torsion testing of plain low carbon steel

Ferrite grain/subgrain structures evolution during the extended dynamic softening of a plain low carbon steel was investigated throughout the large strain warm deformation by hot torsion. Microstructural analysis with electron back-scattering diffraction (EBSD) scanning electron microscope (FEG/SEM) was carried out on the ferrite microstructural parameters. The results showed that the warm flow stress–strain curves are similar to those affected only by dynamic softening and an extended warm flow softening is seen during large strain deformation up to 30. Furthermore, with an increase in strain up to ~ vert, similar1 the grain size of ferrite, misorientation angle and fraction of high-angle boundaries gradually decrease and fraction of low-angle boundaries increases. With a further increase in the strain beyond ~, vert, similar2, these parameters remain approximately unchanged. No evidence of discontinuous dynamic recrystallisation involving nucleation and growth of new grains was found within ferrite. Therefore, the dynamic softening mechanism observed during large strain ferritic deformation is explained by continuous dynamic recrystallization (CDRX).<br />