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Aims and Objectives: Studies have shown that the COVID-19 pandemic has taken a toll on individuals who interact with patients with SARS-CoV-2 but focused largely on clinicians in acute care settings. This qualitative descriptive study aimed to understand the experiences and well-being of essential workers across settings during the pandemic., Background: Multiple studies of the well-being of individuals who have cared for patients during the pandemic have included interviews of clinicians from acute care settings and revealed high levels of stress. However, other essential workers have not been included in most of those studies, yet they may also experience stress., Methods: Individuals who participated in an online study of anxiety, depression, traumatic distress, and insomnia, were invited to provide a free-text comment if they had anything to add. A total of 2,762 essential workers (e.g., nurses, physicians, chaplains, respiratory therapists, emergency medical technicians, housekeeping, and food service staff, etc.) participated in the study with 1,079 (39%) providing text responses. Thematic analysis was used to analyze those responses., Results: Four themes with eight sub-themes were: Facing hopelessness, yet looking for hope; Witnessing frequent death; Experiencing disillusionment and disruption within the healthcare system, and Escalating emotional and physical health problems., Conclusions: The study revealed major psychological and physical stress among essential workers. Understanding highly stressful experiences during the pandemic is essential to identify strategies that ameliorate stress and prevent its negative consequences. This study adds to the research on the psychological and physical impact of the pandemic on workers, including non-clinical support personnel often overlooked as experiencing major negative effects., Relevance to Clinical Practice: The magnitude of stress among all levels of essential workers suggests the need to develop strategies to prevent or alleviate stress across disciplines and all categories of workers., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Copel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Redundancy is an unethical, unscientific, and costly challenge in clinical health research. There is a high risk of redundancy when existing evidence is not used to justify the research question when a new study is initiated. Therefore, the aim of this study was to synthesize meta-research studies evaluating if and how authors of clinical health research studies use systematic reviews when initiating a new study., Methods: Seven electronic bibliographic databases were searched (final search June 2021). Meta-research studies assessing the use of systematic reviews when justifying new clinical health studies were included. Screening and data extraction were performed by two reviewers independently. The primary outcome was defined as the percentage of original studies within the included meta-research studies using systematic reviews of previous studies to justify a new study. Results were synthesized narratively and quantitatively using a random-effects meta-analysis. The protocol has been registered in Open Science Framework (https://osf.io/nw7ch/)., Results: Twenty-one meta-research studies were included, representing 3,621 original studies or protocols. Nineteen of the 21 studies were included in the meta-analysis. The included studies represented different disciplines and exhibited wide variability both in how the use of previous systematic reviews was assessed, and in how this was reported. The use of systematic reviews to justify new studies varied from 16% to 87%. The mean percentage of original studies using systematic reviews to justify their study was 42% (95% CI: 36% to 48%)., Conclusion: Justification of new studies in clinical health research using systematic reviews is highly variable, and fewer than half of new clinical studies in health science were justified using a systematic review. Research redundancy is a challenge for clinical health researchers, as well as for funders, ethics committees, and journals., Competing Interests: The authors have declared that no competing interests exist.

Valid, reliable, and acceptable tools for assessing self-reported competence in evidence-informed decision-making (EIDM) are required to provide insight into the current status of EIDM knowledge, skills, attitudes/beliefs, and behaviours for registered nurses working in public health. The purpose of this study was to assess the validity, reliability, and acceptability of the EIDM Competence Measure. A psychometric study design was employed guided by the Standards for Educational and Psychological Testing and general measurement development principles. All registered nurses working across 16 public health units in Ontario, Canada were invited to complete the newly developed EIDM Competence Measure via an online survey. The EIDM Competence Measure is a self-reported tool consisting of four EIDM subscales: 1) knowledge; 2) skills; 3) attitudes/beliefs; and 4) behaviours. Acceptability was measured by completion time and percentage of missing data of the original 40-item tool. The internal structure of the tool was first assessed through item-subscale total and item-item correlations within subscales for potential item reduction of the original 40-item tool. Following item reduction which resulted in a revised 27-item EIDM Competence Measure, a principal component analysis using an oblique rotation was performed to confirm the four subscale structure. Validity based on relationships to other variables was assessed by exploring associations between EIDM competence attributes and individual factors (e.g., years of nursing experience, education) and organizational factors (e.g., resource allocation). Internal reliability within each subscale was analyzed using Cronbach's alphas. Across 16 participating public health units, 201 nurses (mean years as a registered nurse = 18.1, predominantly female n = 197; 98%) completed the EIDM Competence Measure. Overall missing data were minimal as 93% of participants completed the entire original 40-item tool (i.e., no missing data), with 7% of participants having one or more items with missing data. Only one participant (0.5%) had >10% of missing data (i.e., more than 4 out of 40 items with data missing). Mean completion time was 7 minutes and 20 seconds for the 40-item tool. Extraction of a four-factor model based on the 27-item version of the scale showed substantial factor loadings (>0.4) that aligned with the four EIDM subscales of knowledge, skills, attitudes/beliefs, and behaviours. Significant relationships between EIDM competence subscale scores and education, EIDM training, EIDM project involvement, and supportive organizational culture were observed. Cronbach's alphas exceeded minimum standards for all subscales: knowledge (α = 0.96); skills (α = 0.93); attitudes/beliefs (α = 0.80); and behaviours (α = 0.94)., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Dr. Jennifer Yost is an independent contractor with the American College of Physicians. The other authors confirm they have no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Enhanced immune functioning in response to biodiversity may explain potential health benefits from exposure to green space. Using unique data on urban forest biodiversity at the zip code level for California measured from 2014 to 2019 we test whether greater diversity of street trees is associated with reduced death from cardiovascular disease. We find that urban forests with greater biodiversity measured via the Shannon Index at the genus level are associated with a lower mortality rate for heart disease and stroke. Our estimates imply that increasing the Shannon Index by one standard deviation (0.64) is associated with a decrease in the mortality rate of 21.4 per 100,000 individuals for heart disease or 13% and 7.7 per 100,000 individuals for stroke or 16%. Our estimates remain robust across several sensitivity checks. A policy simulation for tree planting in Los Angeles based on our estimates suggests that if these relationships were causal, investment in planting for a more biodiverse set of street trees would be a cost-effective way to reduce mortality related to cardiovascular disease in urban areas., Competing Interests: No authors have competing interests.

There are professional expectations for public health nurses to develop competencies in evidence-informed decision-making (EIDM) due to its potential for improved client outcomes. Robust tools to assess EIDM competence can encourage increased EIDM engagement and uptake. This study aimed to develop and validate the content of a measure to assess EIDM competence among public health nurses. A four-stage process, based on measure development principles and the Standards for Educational and Psychological Testing, was used to develop and refine items for a new EIDM competence measure: a) content coverage assessment of existing measures; b) identification of existing measures for use and development of items; c) validity assessment based on content; d) validity assessment based on response process. An EIDM competence measurement tool consisting of EIDM knowledge, skills, attitudes/beliefs, and behaviour items was developed using conceptual literature and existing measures (Evidence-Based Practice Competency Tool and Evidence-Based Practice Beliefs Scale) to address limitations of existing EIDM tools identified from the content coverage assessment. Item content validity index ratings ranged from 0.64-1.00. Qualitative themes from validity assessment based on content and response process included word changes to improve clarity, reducing item redundancy, separating multi-component items, and ensuring items reflect nursing role expectations. Upon determining its reliability and validity, there is potential for the EIDM competence measure to be used in: public health nursing practice to identify competence gaps and strengths to facilitate professional development activities; in research to support development of strategies to build EIDM capacity; and for curriculum planning and development across nursing education programs., Competing Interests: Dr. Jennifer Yost is an independent contractor with the American College of Physicians. The other authors confirm they have no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: In Ontario, Canada, healthcare for transgender individuals is accessed through primary care; however, there are a limited number of practitioners providing transgender care, and patients are often on waiting lists and/or traveling great distances to receive care. Understanding how primary care is implemented and delivered to transgender individuals is key to improving access and eliminating healthcare barriers. The purpose of this study is to understand how the implementation of primary care services for transgender individuals compares across various models of primary care delivery in Ontario., Methods: A qualitative, exploratory, multiple-case study guided by Normalization Process Theory (NPT) was used to compare transgender care delivery and implementation across three primary care models. Three cases known to provide transgender primary care and represent different primary care models in Ontario, Canada (i.e., family health team, community health centre, fee-for service physician) were explored. The NoMAD survey, a tool to measure implementation processes, and qualitative interviews with primary care practitioners and allied healthcare staff were administered., Results: Using the NPT framework to guide analysis, key themes emerged about successful implementation of primary care services for transgender individuals. These themes include creating a safe space for patients, identifying gaps in services, understanding practitioners' roles, and the need for more training and education in transgender care for practitioners., Conclusions: Primary care services for transgender individuals can and should be delivered in all models of primary care. Training and awareness for healthcare practitioners are needed to develop capacity in providing primary care to transgender individuals. A greater number of practitioners and organizations are needed to take on this work, embedding and normalizing transgender care into routine practice to address barriers to access and improve quality of care for transgender individuals., Competing Interests: The authors have declared that no competing interests exist.

Background: Self-reported scales and objective measurement tools are used to evaluate self-perceived and objective knowledge of evidence-based practice (EBP). Agreement between self-perceived and objective knowledge of EBP terminology has not been widely investigated among healthcare students., Aim: The aim of this study was to examine agreement between self-reported and objectively assessed knowledge of EBP terminology among healthcare students. A secondary objective was to explore this agreement between students with different levels of EBP exposure., Methods: Students in various healthcare disciplines and at different academic levels from Norway (n = 336) and Canada (n = 154) were invited to answer the Terminology domain items of the Evidence-Based Practice Profile (EBP2) questionnaire (self-reported), an additional item of 'evidence based practice' and six random open-ended questions (objective). The open-ended questions were scored on a five-level scoring rubric. Interrater agreement between self-reported and objective items was investigated with weighted kappa (Kw). Intraclass correlation coefficient (ICC) was used to estimate overall agreement., Results: Mean self-reported scores varied across items from 1.99 ('forest plot') to 4.33 ('evidence-based practice'). Mean assessed open-ended answers varied from 1.23 ('publication bias') to 2.74 ('evidence-based practice'). For all items, mean self-reported knowledge was higher than that assessed from open-ended answers (p<0.001). Interrater agreement between self-reported and assessed open-ended items varied (Kw = 0.04-0.69). The overall agreement for the EBP2 Terminology domain was poor (ICC = 0.29). The self-reported EBP2 Terminology domain discriminated between levels of EBP exposure., Conclusion: An overall low agreement was found between healthcare students' self-reported and objectively assessed knowledge of EBP terminology. As a measurement tool, the EBP2 Terminology scale may be useful to differentiate between levels of EBP exposure. When using the scale as a discriminatory tool, for the purpose of academic promotion or clinical certification, users should be aware that self-ratings would be higher than objectively assessed knowledge., Competing Interests: The authors have declared that no competing interests exist.