University of Groningen
Trauma leadership and ICU shift-handovers
Leenstra, Nico
DOI:
10.33612/diss.145055952
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Publication date: 2020
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Leenstra, N. (2020). Trauma leadership and ICU shift-handovers: Identification, observation and integration of key skills. University of Groningen. https://doi.org/10.33612/diss.145055952
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y an d g en er al d is cu ss io n SUMMARY OF FINDINGS Overall aim
In recognition of the crucial role of teamwork in healthcare, residency training programs are now formally required to include extensive non-technical skills training.1,2 Two skills that have been spearheaded for specific attention are team
leadership and handovers,2,3 but the literature is not entirely clear on what
constitutes ‘good performance’ in the specific contexts of trauma leadership and ICU shift-handovers. In this thesis, we aimed to clarify the skill components and concrete behaviors by which they can be trained and evaluated, and identify facilitators and barriers for evaluating performances and integrating skills into practice. In this chapter, we summarize and reflect on our findings and discuss the practical implications and the directions for future research.
What are the key leadership skills for the trauma leader and the specific behavioral components by which they can be learned?
Prior to this study, it was not clear to what extent leadership skills identified in studies on resuscitation, surgery or hands-on leadership would also apply to the leadership provided by a hands-off, designated trauma leader. Taxonomies that have been specifically developed for trauma care focus on the team rather than on the trauma leader,4,5 and thereby lack the detail needed for deliberate practice and
in-depth feedback. To address the need for a more detailed, updated framework of trauma leadership skills, we conducted critical incident interviews with trauma leaders and other trauma team members focusing on effective leadership performances (chapter 2). We identified the elements of good leadership from the interview transcripts, categorized them, and arranged them into the comprehensive Taxonomy for Trauma Leadership Skills (TTLS). Our findings
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confirm and extend notions of the trauma leader’s role in the following team tasks: action coordination, information coordination, decision making, communication management, and coaching and team development. A comparison of the TTLS elements with those summarized in a review of leadership assessment tools across various health care action teams6 shows that we included almost all
elements identified in the review. This suggests that leadership serves identical functions across contexts, and more importantly, that the TTLS’ skill categories capture those functions really well. Due to the specification of the elements and behavioral examples, and its identification of skills for all phases in trauma care (briefing, handovers, patient handling, and debriefing), the TTLS is an important addition to previously available taxonomies. It provides a necessary additional level of detail regarding the exact use and timing of non-technical skills over the complete course of trauma management.
How can instructors be supported in observing and reflecting on residents’ trauma leadership performances?
During simulation-based scenario training, residents are engaged in the deliberate practice of their trauma leadership skills. It is the instructor’s role to facilitate their learning by guided reflection and valid recommendations. As observing and evaluating leadership performances – while running the simulation – can be complex and cognitively demanding tasks,7 we set out to develop a cognitive aid to
support their targeted evaluations. We alternately wanted to explore how such a tool can be optimized in terms of ease-of-use and usefulness, as previous tools have been found difficult to use.8–11 In chapter 3, we used the comprehensive TTLS
from chapter 2 as a valid starting point for the development of a more lean observation tool. Prototypes of our tool were tested and modified in an iterative and user-centered testing approach with trauma instructors. A central theme in their feedback was striking a balance between specificity and conciseness. A balance was achieved by omitting the ‘example’-level of the original taxonomy (i.e., significantly reducing the amount of text) and by compensating for the lack of examples by making the element labels more self-explanatory. The resultant element labels were more specific than those provided in previous tools, but it made our tool a longer one. From our testing panels’ evaluations it appears that the increase in the number of elements was deemed preferable over a shorter, but less-concrete list. Further, note-taking fields were provided at the category level of
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skills – enabling flexible prioritization of elements based on the performance – which is in contrast to previous assessment tools that encourage each element to be assessed individually (e.g., ANTS12, NOTSS13). The resultant tool, called the
TTLS Shortened for Observation and Reflection in Training (TTLS-SHORT), received positive evaluations regarding its ease-of-use and usefulness in setting performance expectations, quick note-taking and guiding observations and debriefings.
What are residents’ current strategies for structuring handovers, and are specific structure characteristics related to improved information processing?
There is a large variety in the content and structure of published handover schemes and only limited evidence regarding improved information processing to favor any specific structure. 14–16 We therefore videotaped simulated handovers
between residents and analyzed the various ‘move structures’ applied by residents and evaluated how these various strategies affect the reception of handover information (chapter 4). We observed that residents’ handovers were seemingly similar in terms of main moves. Their move structures approximate those specified in known ‘problem-based’ handover schemes such as SBAR and I-PASS.17 Interestingly, all residents also integrated a ‘systems-based’ approach (i.e.,
either ABCDE or tracts) into their problem-based structure, as a means of systematically going down the patient’s (sub-)problems. Such a combined approach resonates with previously presented handover schemes,18 and might be
used as a specific strategy to handle the complexity of ICU patients. Combining the two methods may promote both that the ‘story’ of the patient is told and that no vital information is missed.
Whereas residents applied seemingly similar moves, they used these moves in notably differing ways. We identified three important differences: 1) working diagnoses were provided either more towards the beginning or end of the handover; 2) explanations of the diagnostic assessment were provided in a more narrative or checklist-based structure; and 3) some residents provided instructions once their diagnostic assessment was complete while others mixed instructions and diagnostic assessments. An analysis of the impact of these variations on information processing foremost showed an effect of the placement of the working diagnosis: stating the working diagnosis early in the handover (as
opposed to more towards the end) was associated with more critical reflections and information seeking by the receiver. This seems to suggest that the working diagnosis may have acted as a cognitive frame that helped to see the significance of the information that followed, and consequently better positioned receivers to critically reflect on the case.19 This is an important finding as it suggests that the
ease of information processing can be influenced by the way the handover is structured. Importantly, it also shows that handover structure can be used instrumentally to actively involve the incoming party. We found no significant relationships with the other two variations, but more research is needed to consolidate our findings.
What are intensivists’ and residents’ perceptions regarding the use of handovers as multi-functional collaborative conversations?
In chapter 5, we extended our scope from presentation skills (chapter 4) to teamwork skills in handovers. Despite the growing case for handovers being used for team functions such as joint sense-making and option generation,20–24 reviews
of current practice suggest that it proves challenging.25–29 As little is known of why
this may be, and what this implies to resident training, we aimed to gain a better understanding of the dynamics of using ICU shift-handovers for functions beyond information transfer (chapter 5). From our interviews with intensivists, fellows and residents, we found that they felt that joint reflections and discussions in handovers are an important means to enhance the resilience of patient care, particularly in rare, uncertain or complex cases. Certain situational factors, such as high case complexity, serve as helpful cues for physicians to determine communication needs. However, the simultaneous influence of other factors face physicians with dilemmas with regards to what must and can be achieved in the handover. Most often, dilemmas involved trade-offs between efficiency and thoroughness due to time pressure or a high number of patients to hand over. This trade-off was often reflected in physicians’ tendency to prioritize the function of information transfer over joint reflections or discussions. However, the pressure to be concise and clear-cut may even hamper the goal of allowing all residents to fully achieve understanding of the case. The function of learning was reported to occur only if the number of patients, the available time and the number of attendants for whom the teaching would be relevant allowed it. As a consequence, residents’ learning was mostly described as a by-product of the handover. Our
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findings add to the growing case for handovers in complex settings being educated as more than information transfers, but also revealed dilemmas for the transfer of these skills into practice.
GENERAL DISCUSSION
At the onset of our studies, we set relatively simple aims (‘what makes for an effective trauma leader?’ ‘what is an effective shift-handover?’), hoping for simple answers that could be translated into clear-cut training packages for residents. But as we engaged in the details of trauma leadership and shift-handovers, a more complex picture emerged: situational influences affect what is required of residents’ non-technical performances (i.e., what is appropriate now, may not be in other situations) and, more importantly, conflicting goals may emerge by the simultaneous presence of multiple influences. In the following sections, we will reflect on our findings in terms of these dynamic skill demands and discuss the teaching of adaptability.
Dynamic skill demands and teaching adaptability
Situational influences on skill use
Both our findings on leadership and handovers speak to a need for flexible skill use and adaptability. For instance, we observed in chapter 2 that trauma leaders apply various strategies to support team decision making (i.e., varying in the extent to which they suggest team-involvement and the leader’s explication of reasoning) and to alternate between explicit coordination (e.g., clear instructions, prioritization) and implicit coordination (e.g., giving updates to enhance mutual anticipation). This is in line with notions that decision making in simple and complex situations rely on different cognitive processes30 and that acuity and
team experience affect the role of the leader.31 Regarding ICU shift-handovers, we
found that physicians adapt their shift-handover presentations to receiver experience or the ambiguity of the case by providing more details, explanations and critical reflections (chapter 5). Such adaptations are not only made to better enable receivers to comprehend the case, but also to support other ‘macro-cognitive’ functions of the handover. These findings resonate with the suggestion that handing over patients requires flexible ways of telling the story,10,17–19,32 the
provision of details “on demand”, 25,29 and flexible engagement in two-way
interactions.29
Teaching standardized handover schemes or not?
Our finding that handover presentations are adapted to accommodate situational demands can be seen to raise questions about the current gravitation towards teaching standardized handover schemes. The dialogue in the handover literature reflects a similar dichotomy: whereas some studies have shown the benefit of standardizing handovers,37–39 others warn for potential unintentional, unexpected
side-effects.20,23,24,32 Three main concerns have been raised which we will address
below. We believe our findings shed a nuanced perspective on these concerns and can inform approaches of ‘flexible standardization’.
A first concern with standardized handover schemes is that they may provide a too simplified model of communication that could unintentionally de-emphasize or even disrupt adaptive communication features by which teams usually manage complex work.23,32 In chapter 5, we indeed found that physicians
adapt the amount of detail, reflection and explanation to the receiver or the ambiguity of the case. On the other hand, it may be questioned whether teaching a sophisticated model that is too complex to grasp for novice residents may not be equally counterproductive. For instance, cognitive load theory suggests that if the task demands exceed learners’ working memory capacity, this creates a ‘bottleneck’ to learning.40 Studies on cognitive load suggest that novice residents’
information-processing capacity during complex handovers can easily be exceeded, creating the risk of miscommunication and a wrong situation awareness.41 It is suggested that working memory capacity may be freed up with
the provision of a simplified scheme as fewer resources have to be spent on selecting and ordering information, which alternately can be invested in the clarity and accuracy of the message – or in the actual learning of the handover process.42 Continuing this line of reasoning, we believe that teaching a
standardized structure may be a good starting point and that, as residents’ illness scripts mature with experience and presenting clinical cases becomes easier, handover training can be gradually shifted to more refined, adaptive strategies and to functions beyond information transfer.
A second concern voiced in the literature is that the focus on standardized communication structures may neglect or even de-emphasize the role of the
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receiver in establishing understanding.20,24,43 We found in chapter 4 that stating
the working diagnosis towards the beginning of the handover appears to act as an encouragement for the incoming team to provide critical input. This finding seems to support a more nuanced perspective that there are actually specific ‘structuring principles’ that can be used instrumentally to actively engage the incoming team.
Finally, concerns are that standardized handover schemes may degrade to presentations of ‘categorized units of information’ that promote paradigms of ‘going down the list’ rather than a holistic understanding of the case.19,20,32,36 It has
been suggested that handovers of complex cases would rather benefit from more freely structured, narrative approaches as they may better enable the establishment of causal and temporal relations between information.32 In chapter
4, we observed both strategies – conveying diagnostic assessments through a free narrative or a checklist-based structure – but did not find significant differences in receivers’ comprehension of the information. In other contexts, a narrative structure has been found to be superior to more objective presentations of events, for which the explanation was that narratives would better align with our natural tendency of processing events as linear sequences44 and would depend less
heavily on receivers’ semantic memory.45 That we did not find a similar
superiority for a narrative structure may be due to the fact that most residents who used the checklist-based structure nonetheless put effort in establishing the bigger picture, for instance, by going back and forth between tracts, by highlighting the interactions between problems, by comparing-contrasting hypotheses, or by synthesizing the information into a conclusion. Our findings may indicate that establishing understanding is not so much dependent on a narrative or checklist-based structure, but rather on senders’ efforts of expressing their clinical reasoning.
Dilemmas involved in adaptability
Our findings not only show the need for adaptability but also that adapting the performance to the situation does not necessarily involve linear ‘if-then’ heuristics. Particularly the interviews on the integration of teamwork skills in the handover (chapter 5) show that multiple factors may create dilemmas between conflicting goals. The most notable dilemma in shift-handovers was that extended discussions and reflections take time – resulting in less time for other patients – but on the other hand may benefit the patient through fresh perspectives, error
detection and the calibration of care plans. A similar ‘efficiency-thoroughness’ trade-off can be seen in trauma teams: whereas perceptions of urgency may engender the need to act fast and be decisive, increasing the speed of performance may also increase the risk of deterioration in other areas, such as joint sense-making or the weighing of risks.
When faced with novel, unexpected, complex or ambiguous situations, higher performing teams have been found to engage more in ‘slowing down’ techniques.46–48 ‘Slowing down’ entails the transition from more automatic modes
of thinking to more effortful modes. For instance, when faced with an unexpected crisis, effective anesthesia teams were found to increase their information coordination and assessment of the situation – while briefly decreasing their clinical activities – in order to better re-direct their actions.47 Initially investing
more effort in coordination reduced coordination needs during the remainder of the clinical situation, and importantly yielded higher clinical performance rates. Studies suggest that ‘slowing down’ during shift-handovers can similarly translate into enhanced efficiency and quality in subsequent care. For instance, one study showed that cross-covering ICU fellows were more vigilant and made more decisions when compared with continuity-of-care fellows, and thereby reduced mortality.49 The authors suggest that “the balance between medical errors from
handovers and the benefit of a ‘second look’ seems to favor the latter”.
In teams, striking a balance between efficiency and thoroughness will inherently involve the negotiation and coordination of aims between team members.50,51 Our findings in chapter 5 suggest that – at least in handover
communication – these negotiation processes are currently occurring fairly implicit and may result in feelings of frustration or uncertainty. One way for solving dilemmas may then be to make the negotiation of communication aims more explicit. This implies the need for meta-communication skills. In handovers, this may entail, for instance, that the goals are communicated at the beginning of the presentation (e.g., I have some doubts about Mr. Brink which I would like to discuss with you) or during unfolding discussions (e.g., I do not think we have enough time to decide right now but I do want to collect your perspectives). Such meta-communication skills may be a necessary complementary layer of competence to the skills identified in this thesis.
y an d g en er al d is cu ss io n Training adaptability
An important question that follows from our findings is how training programs can support residents’ establishment of broad skill repertoires and refined frames of when to apply them. Teaching techniques derived from cognitive load theory offer helpful directions.40 The general principle in teaching from the perspective of
cognitive load theory is to manage the demands on working memory so that sufficient working memory capacity is available to spend on learning. This is ideally done by reducing extraneous load (e.g., distractions in the learning environment or instruction method) and to match the intrinsic load of the task (e.g., complexity and/or number of simultaneous tasks) to the level of the learner, gradually increasing the complexity and variety of tasks to finally arrive at whole-task, full-complexity skill proficiency.40,52 When translated to the training of
trauma leaders, for instance, a training program may include the following build-ups in training complexity: smaller-to-larger trauma teams, simple-to-complex patient cases, low-to-high urgency and high-to-low predictability. This enables residents to first practice the fundamental skills and then gradually exposes the resident to a variety of situations in which they can create refined frames of what works best in which situation.
The dynamic demands on trauma leadership and shift-handovers also hold important implications to observation and evaluation. It is important to recognize that multiple factors may simultaneously affect performance demands, resulting in various and sometimes conflicting goals. What is deemed ‘effective’ then depends on which goal is primarily pursued. In other words, there is not necessarily a single, objective ‘gold standard’ to performance. This can be seen to call for flexible evaluation approaches in which both the instructor and the trainee is involved in making sense of the performance and deriving lessons from it.11,53
These conversations then must include not only instructors’ feedback, but also a joint exploration of the mental frames (e.g., perception of the situation, past experiences, assumptions, beliefs) that led to the trainee’s actions and the instructor’s evaluation of those actions. By exchanging perspectives regarding, for instance, the characteristics of the situation and the benefits and drawbacks of certain behaviors, residents might establish new or more refined frames for how behaviors may or may not apply to situations.53
The need for flexible evaluation is being reflected in our decision with the TTLS-SHORT (chapter 3) to focus on the development of a cognitive aid that
supports learning rather than an assessment tool that measures performance. To us, an important distinction is that assessment tools are inherently more concerned with objectivity and standardization of norms, and consequently omit those elements that cannot be defined as such. In contrast, the TTLS-SHORT integrates the reality that some areas do not necessarily involve a clear norm (e.g., “number of instructions”), may be experienced differently by team members (e.g., “balances inclusiveness and directness”) or may be more or less appropriate in certain situations (e.g., the extent of coaching in urgent situations). The inclusion of such elements encourages that critical reflections on these ‘grey zones’ take place.
Future research
This thesis consists of two studies in which we explored the necessary leadership skills to support trauma teams and how they may be recognized and evaluated, and two studies on how ICU shift-handovers may be structured and incorporate teamwork. These studies raised a number of new questions, and while our findings must be viewed in the limitations of the studies, future research is needed.
Leadership
In this thesis, we took on a qualitative approach to identifying the behaviors associated with effective leadership. By using content experts – first in our initial exploration of the leadership constructs and later in the review of our skills taxonomy – we aimed to establish the taxonomy’s content validity. Future studies could further establish its validity by examining the correlations between skill use and measures of team performance. Such examinations would also be particularly helpful to prioritizing training needs.
Future studies must further clarify how leadership might best be adapted to accommodate differing conditions. For instance, our qualitative findings indicate the need for a leader who is clear and assertive in delegating tasks and decision making while, at the same time, enhances individuals’ performance and invites and constructively incorporates team members’ input. Future research should establish a clearer picture of the specific behaviors that are needed in specific situations, and of how team leaders alternate between directive and inclusive strategies. Observations should be complemented by measures of how differing
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styles affect the team’s cognitive functions. Such an understanding can be further strengthened by combining observations with measures of team performance, such as team involvement, diagnostic accuracy, task efficiency and the quality of decisions.
Another area of interest is improving our understanding of the design criteria of observation tools. Previous studies suggest that using observation tools for non-technical skill assessment requires extensive background knowledge and rater training, and thus appear only applicable by expert raters.8–10 With the
development of the TTLS-SHORT, we aimed to optimize its ease-of-use by balancing its conciseness and specificity. Nonetheless, we could not achieve absolute consensus among our testing panels regarding the length of the tool, and suggested that this might reflect differing expectations due to instructor experience and background knowledge. This raises the question of whether observation tools should be adapted to differing levels of experience. Future studies could compare uses by novice and expert instructors, and how fundamentally different tools impact instructors’ cognitive load during observations and their ability to identify trainees’ learning points.
Handovers
How to structure handovers remains an important area for future work. In this thesis, we used simulated handovers and interviews to identify current practices and perceptions of what is needed. Our simulation study importantly enabled us to identify three notably different structure variations and explain them primarily as a function of individuals’ preferences or habits. We therefore think that simulation offers an excellent way to expand investigations into the effects of structure variations. We suggest using two specific, experimental designs. The first is to deliberately manipulate information structure – including the three variations identified in chapter 4 – and compare receivers’ information processing. The second is to manipulate the characteristics of the case (e.g., diagnostic ambiguity) to assess how structures and content may need to be adapted. We further recommend complementing our outcome measures (i.e., questionnaire data on the comprehension of information and observations of question type and duration) with measures that give additional depth to how well understanding is achieved and the mental effort it takes, including cognitive load,54 information recall and concept mapping (i.e., a visual, hierarchical
representation of the problems and their interrelations).55 Finally, experimental
designs should include multiple patients to increase their sensitivity to any ‘cumulative effects’ of information overload or attention loss.
Another area requiring specific attention is that of the interactive nature of the handover. In chapter 4 we looked into how information structure can support the establishment of an accurate and complete picture, and by doing so primarily focused on the role of the ‘sender’. A better understanding is needed of how ‘conversational turn-taking’ takes place during handovers, and how receivers’ questions and remarks can support the clinical reasoning process.15 This might be
achieved by using ‘conversation analysis’, a set of techniques from the study of discourse that has been used successfully in a wide variety of professional domains and ‘high-stakes’ interactions.
By using interviews regarding the use of handovers for purposes beyond information transfer, we were able to identify physicians’ considerations, dilemmas and misaligned perceptions that underlie their collaborative interactions. Such insights would not have emerged if only observations had been used. At the same time, the lack of observations gave us less information on the magnitude of the problem and the exact processes that help physicians ‘negotiate’ their collaborative interactions. We suggest continuing our work by combining observations of actual handovers with interviews, for instance, by using video-assisted recall.
Finally, empirical data is needed that can facilitate physicians’ consensus-finding regarding what can and must be achieved during the handover. Based on our findings in chapter 5, a priority is to refine our understanding of how trade-offs between efficiency (e.g., concise presentations) and thoroughness (e.g., more detailed presentations of diagnostics and considerations) are related to the care processes in subsequent shifts and patient safety. For instance, studies could explore how joint reflections and discussions during shift-handovers may leverage subsequent decision-making during consultations, rounds or night-shifts.
Practical implications
Teaching trauma leadership
With regard to the content of training programs, our findings imply that a diverse skills set should be addressed, ranging from instructive to coaching, empowering and inclusive leadership behaviors. Our findings further highlight the need to also
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address skills that go beyond the ‘action-phase’ of trauma care, and pay specific attention to the conduct of briefings, handovers and debriefings.
The two tools presented in this thesis can leverage the development and conduct of trauma leadership training. The comprehensive TTLS supports the development of objectives for training programs. It specifies the behavioral markers that illustrate the desired performance, and by using such guidelines, residents can identify skill categories or elements in which they are lacking and choose particular behaviors to model. In turn, the TTLS provides educators and trainees with a framework that can be used to focus feedback effectively. Within simulation-based team training, the skill elements and behavioral markers can be used to design triggering events in the scenarios to practice targeted skills.39,40
With the more lean and practical TTLS-SHORT, we laid the foundation for targeted observations and feedback of real-time performances. The tool can be consulted to set performance expectations at the onset of training – preferably together with the trainees. It directs attention, supports note-taking, and it provides a helpful framework to discuss performances during the scenario debriefing. We recommend prioritizing skill categories or elements for evaluation per scenario in order to lower workload and heighten the specificity of feedback. The TTLS-SHORT can help educators form judgments and explain their judgments to trainees using the behavioral markers, but, alternatively, instructors are also recommended to verify their view with trainees and to combine their statements with genuine inquiry into the frames that drove the trainees’ actions.53 We further
advise that educators practice their use of the tool and establish a broader sense of the psychological underpinnings of teamwork and the factors affecting human performance.
Teaching shift-handovers
We think that teaching a basic handover structure can be a helpful way to support novice residents’ communication of complex patients. The commonly used structure as observed in chapter 4, where a checklist-based structure is integrated within a more narrative approach, appears to be a sound method to ensure that both the story of the patient is told and that no vital information is missed. It may prove a helpful system to fall back on if a more holistic understanding of the case is lacking. When teaching a handover structure, our findings suggest that the working diagnosis should be mentioned early – as it serves as a cognitive frame
that helps to frame the significance of the information that followed and promotes critical reflection. Also, specific attention should go out to how clinical reasoning is expressed in order to prevent paradigms of ‘going down the list’ and to enable receivers to reflect critically on the interpretation of the case.
Whereas teaching a basic structure can be a helpful starting point, we believe that supplemental training is needed that addresses more flexible narrative approaches to accommodate receiver experience, case complexity and ambiguity. Importantly, training programs must emphasize the multi-functional nature of the shift-handover and include skills that support joint reflections, establishing shared understanding and decision-making. Feedback on-the-job is vital and could be supplemented with role-playing exercises and simulation training. Residents should be engaged in handovers of varying complexity and diagnostic ambiguity, involving receivers with varying experience, and under different situational conditions, as this would help to establish their refined strategies for varying circumstances.
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