With today’s complex needs of the population and high demands in quality of care, there will be a continuing need for expanding role of nurses to assume more responsibilities in healthcare. Newly graduated nurses, who possess the competence to function as Registered Nurses, will soon recognize that lecture-based, passive delivery of content is not sufficient to deal with the complex healthcare environment.This study aimed to compare the effects of a blended video watching and peer learning program and the usual lecture-based program on the levels of satisfaction and self-confidence in learning, perceptions of peer learning, and academic performance of students enrolled in a master’s nursing program.A quasi-experimental study was conducted. The program was offered to Master of Science in Nursing students during Spring 2021 , while the usual face-to-face lectures and tutorial classes were provided to students enrolled during Fall 2020 .There was a statistically significant increase in satisfaction, self-confidence in learning, and academic performance in the intervention group after learning in a blended video-watching and peer learning mode.This study fills a knowledge gap to meet the learning needs of time-conscious, part-time students working full time in hospitals. This paper equips nurses with advanced knowledge and competence in solving complex clinical situations and eventually prepare them to progress their careers to the advanced practice nurse level.TA blended video watching, and peer learning model will provide evidence support to further develop online learning and peer teaching that suits the learning needs of mature students.Although in recent years online, interactive learning formats are increasingly being adopted, master-level nursing programs have employed face-to-face lectures as their primary channel for delivering knowledge to students . With thVideo watching and peer learning are two educational modalities that promote learning by allowing junior nurses to learn essential knowledge and skills at their own time and pace. Video learning is particularly valuable to master’s nursing students who are working shifts since the videos can be made conveniently available on Internet-based video-sharing sites, thereby eliminating geographic barriers, and providing time and cost savings. Studies have revealed that using a video as a teaching medium can increase the students critical thinking abilities  and helpPeer learning is another teaching pedagogy that is used to motivate students to actively participate in constructing their own concept and understanding based on their previous knowledge. Peer learning refers to the building of new knowledge through active learning support from peers . Peers cBy combining video watching and peer learning activities, nurses have the freedom to prepare learning activities outside the set classroom time, which allows them some flexibility to engage in self-directed learning, reflection, and critical thinking. Instead of emphasizing one-way lecturing and face-to-face contact hours, the focus is on devoting more time to collaborative learning. All students can benefit from learning with and from each other. Incorporating these two concepts may be challenging due to logistic and timetabling issues, yet it is worth making the effort due to the above-mentioned benefits.Considering the individual positive effects of video-based and peer learning, what their combined effect might be for nursing students is a matter of interest. There is a dearth of studies combining both video watching and peer learning as a teaching methodology. One recent study analyzed the use of self- and peer-assessments of a video of a group of physician assistant students practicing their clinical skills. It was found that the students increased their awareness of their own strengths and weaknesses in verbal and nonverbal communication and increased their motivation to practice . SimilarThe present study adopted a quasi-experimental, non-equivalent control group design. It was conducted at a university in Hong Kong. The study has been reported according to the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) checklist .Students enrolled in the subject “Concepts of Advanced Nursing Practice” in a Master of Science in Nursing program at the university during the Fall 2020 or Spring 2021 semester were recruited to participate in the study. Only postgraduate students enrolled in the specified course, working in any healthcare facility in Hong Kong, and willing to participate were considered eligible to participate. Students who were enrolled during the Fall 2020 semester and who agreed to participate were recruited to the control group, while those enrolled during Spring 2021 were recruited to the intervention group with their consent. The priori sample size was calculated by using Raosoft® software. Assume a margin of error of 10% and consider a confidence interval of 95%, the total sample size required was 92 participants. Both groups were taught by the same teaching team, consisting of one Chair Professor, one Assistant Professor, and three Advanced Nurse Practitioners from the Hospital Authority (HA).Conventionally, the learning activities of this subject employed lectures as the primary channel to deliver theoretical knowledge. One Professor and one Assistant Professor provided the theoretical and evidence-based input of the subject titled “Concepts of Advanced Nursing Practice” in five lectures, with three advanced nurse practitioners from the Hospital Authority providing lectures illustrating how advanced nursing practice is realized in their day-to-day work. Apart from the lectures, three face-to-face 3-hour tutorial sessions were held as a platform for stimulating ideas and generating debate on key concepts of advanced practice in nursing, which included the seven domains of the advanced nursing practice competence framework. In these tutorial sessions, students were divided into small groups to engage in discussions with the subject lecturers on the topic of the seven domains of the advanced nursing practice competence framework formulated by the Hong Kong Academy of Nursing . StudentInstead of face-to-face tutoring, the three Advanced Nurse Practitioners (APNs) who worked in the three specialty areas of critical care, wound care, and midwifery, recorded, and uploaded their daily work on an online blackboard platform. The Chair Professor and Assistant Professor in this study provided theoretical input alongside the recorded content by the APNs and moderated the online platform during discussions or question/answer sessions. The contents of the video included comprehensive health assessments, relationship building, physical examinations and history taking, patient education, and advanced nursing management which were released to the blackboard at least a week to the scheduled module date. It is worth mentioning that the content of the videos was congruent with the subject matter of concepts of Advanced Practice Nursing. The videos lasted approximately 10 min with an option to repeat each viewing if required. The purpose of providing videos illustrating the work of Nurse Practitioners in clinical settings was to give the students an idea of advanced nursing practice and facilitate their discussion online. The Advanced Nurse Practitioners were present in the online discussions that followed afterwards to respond to questions and engage in discussions with the students about the advanced nursing practice in their real-life settings. These online discussions were held on the blackboard platform. No time limits were set for these discussions, and they depended on the questions that the students had noted. The lead author of the study served as a moderator for all the sessions.In addition to watching the videos, peer learning activities were provided to students on an online platform. Students were randomly organized in constant groups of 5–6 during all three virtual tutorial sessions. Before the sessions, one or two members of each group were required to use their own time to interview an Advanced Nursing Practitioner in their own working environment to compare the similarities and differences of levels of competencies of the work of advanced nursing practitioners in the video. These tutorial sessions were moderated by the Assistant Professor. This comparison stimulated the students to probe further how advanced nursing practice can happen in reality taking into account of the factors of contextual and professional factors. In the first session, each group had to write a simulation case scenario based on what they had learned in the videos. The content of the simulation case scenario had to include the background, medical history, chief complaint, progress, investigation results, and medical treatments of a simulated patient based on the students’ area of specialty. In addition, they had to think of some nursing measures that could fulfill at least three of the seven competence domains of the advanced nursing practice competence framework. In the second session, they had to pass the simulation case scenario description to another group, and in return receive that group’s simulation case scenario. In this second tutorial session, students had to hold a discussion with their groupmates and use the knowledge gained from the lectures, videos, and formulate a nursing care plan that could suit at least three of the seven advanced nursing practice competence domains and the simulated patient situation. In the third tutorial session, the group that wrote the simulation case scenario would take turns providing guidance and feedback to the group that formulated the nursing care plan in accordance with the scenario description. The aim of this final session was to allow both groups to reflect upon, discuss, and clarify issues relating to the patient clinical presentation and the care of the Advanced Nurse Practitioner, and to communicate and exchange experiences within and across the groups. The virtual discussion platform allowed students to learn from each other by sharing their experiences related to their own work environment without the need to travel to school. This peer learning arrangement augmented group learning effects because each member in the group bring his/her unique learning experiences to share with other group members. The discussion forum provided a new way of gathering the students together and implementing peer support where the students were able to reflect their learning experiences in a safe environment. Compared to the conventional face-to-face discussion that was led by the subject lecturers in tutorial class, this discussion forum among peers could promote critical thinking and reasoning skills, use their own experience to enrich each other’s learning.After the three virtual tutorial sessions, each group was required to create a video that mimic the videos made by the advanced nursing practitioners, using the outcomes of the third tutorial session as a script. In the video, some students acted as patients and one student acted as an advanced nursing practitioner who provided advanced nursing care. The dialogue and interactions between the patients and the advanced nursing practitioner were based on the comments and feedbacks from the peers in virtual tutorials. Student-generated video, used as one of the assignment components of this subject, could reflect whether the students were able to fulfill the learning outcomes such as identifying issues encountered by the advanced practicing nurse in their daily work, understanding the roles and responsibilities of advanced nursing practitioners in clinic, and indicating the differences between a registered nurse and an advanced nursing practitioner.All the students were present for all the peer learning activities with no absentees recorded. As with the control group, students in the intervention group presented their critical analysis of the advanced nursing roles in these competence domains substantiated with literature and the use of a real clinical case in the format of a group presentation after the three tutorial sessions.For each cohort of students, data were collected at two time points, pre- and post-intervention. After the students had been divided into groups in the first lecture, a project assistant who was not involved in teaching and blinded to the student groupings was responsible for providing and collecting the questionnaires. The project assistant was trained and five per cent of the gathered data were randomly selected for an independent review to ensure the quality of the data. Following recruitment, the project assistant contacted the participant to complete a bundle of questionnaire. Following this, the project assistant reviewed it for completeness. Following the completion of the intervention, the same procedure was followed to complete the questionnaires.There were four outcomes evaluated in this study: satisfaction, self-confidence in learning, perceptions of peer learning, and academic performance in the advance nursing practice course. There were five sets of measures, including a background demographic survey, the Student Satisfaction and Self-confidence in Learning scale, the perceptions of peer-assisted learning questionnaire, a rating scale for video content and quality, and an assessment criterion for measuring the performance of students in illustrating their understanding of the seven competence domains of advanced nursing practice.The data collected in the background demographic survey included age, gender, marital status, hospital type, years of working as a registered nurse, and department in which one worked.The Student Satisfaction and Self-confidence in Learning scale has two subscales, satisfaction, and self-confidence, with a total of 12 items . The tooThe perception of peer-assisted learning questionnaire was developed by Sevenhuysen and her colleagues  and AnanThe content and quality of the videos uploaded by the three APNs were evaluated by the students using a 5-item scale. The scale measures the overall quality of the video, its technical quality, fluidity, loading, and the general experience of the students after watching the video. Students rated each item with 1 = very inappropriate to 5 = very appropriate, with higher scores representing the perception that the videos were of better content and quality. The face validity and content validity (CVI = 94%) of the scale were established.For academic performance in relation to the subject, students were required to make a 7-minute video that demonstrated their understanding of the concepts of advanced nursing practice using seven domains of advanced practice nursing competence. The videos were assessed according to a set of criteria that included the students’ ability to collect and process information, identify, and prioritize relevant issues or problems, implement intervention strategies, evaluate outcomes, and make required modifications, as well as the students’ self-reflections. The total score for this assignment was 100. The face validity and content validity (CVI = 91%) confirmed the criteria was validated.IBM SPSS, Version 26.0 software was employed for data analysis in this study. Descriptive analyses were used to describe the data collected at baseline, such as the background demographic data of the students. All the demographic data of the students in the two cohorts were compared to ensure that there were no significant differences between the groups and to determine if there was any need to adjust through a sensitivity analysis.Perceptions of Peer Learning and the rating of the content and quality of the video were presented in mean and standard deviations. An independent sample t-test or a Mann-Whitney U test was used to compare differences in the demographic data, in Student Satisfaction and Self-confidence in Learning, and in the performance of the two cohorts. A Paired t-test or Wilcoxon signed-rank test was adopted to compare pre- and post-intervention differences in Student Satisfaction and Self-confidence in Learning for both cohorts. The Cohen’s d was also calculated from the group means, as well as the pooled standard deviation, to ascertain the effect sizes following the implementation of the teaching pedagogies. Per-protocol was used for missing data.The University’s institutional review board approved the study. Information about and an explanation of the ethical considerations of the study were provided to all the students, and they had to sign a consent form prior to the commencement of the study. They were also reminded that their personal information and responses would be kept confidential.A total of 120 participants were screened for eligibility. Following screening, 92 participants met the criterion for inclusion and agreed to participate. These participants were assigned to the two arms based on the subject enrollment period, with 46 in both the intervention and control groups. The response rates were high for both groups, with 77% (46/60) of students in each semester agreeing to participate. The mean age of the students was 29 years. Most of the participants were single and working in a public hospital. Of the 92 students, more than half had been working as a registered nurse for 1–3 years, a quarter had been working for 4–6 years, and around 15% had been working for more than 7 years (Table p = .048), and in their self-confidence in learning sub-score (p = .049). There was a small effect size for the intervention on improving student satisfaction (0.39) and student self-confidence (0.40). The overall effect size for the entire scale remained small, yet positive (0.42), highlighting the potentially positive effects of video-based and peer learning.The Student Satisfaction and Self-confidence in Learning scores for participants in both the intervention and control group participants are summarized in Table p = .004). The Cohen’s d that was calculated based on the group means and pooled standard deviation showed a positive, medium effect size (0.60).Table Students in the intervention group were required to watch the videos taken by the three advanced nurse practitioners and rate them in seven dimensions: overall quality, technical quality, fluidity, loading, experience, length, and content Table . In summAfter completing the program in the Spring 2021 semester, students in the intervention group expressed their views on peer learning in the Perceptions of peer-assisted learning questionnaire. As seen in Table The current study demonstrated that students in the intervention group experienced a significant increase in their overall satisfaction and self-confidence in learning, and in their academic performance after learning in a blended video-watching and peer learning mode. In addition, when compared to pre-intervention, the post-intervention increases in the sub-scores for student satisfaction and self-confidence in both the control and intervention groups hints at the educational value of both the conventional teaching approach and the blended approach.Past teaching strategies that focused on the lecture-based, one-way passive delivery of content can no longer satisfy the learning requirements of students today . BesidesThe videos used in this study served as a good medium for teaching, as evidenced by the high score ratings from the students. In fact, it is a commonly used method in lecture settings to help nursing students grasp theoretical knowledge on advanced nursing practices . HoweverThe videos, unlike the conventional face-to-face approach offers the unique opportunity of revisiting them and learning as much as one wants to. This approach therefore may have offered some flexibility considering that the participants are practicing nurses faced with varying time pressures. Previous studies have also showed that the pause and rewind function of video-taped contents allowed students to engage in self-paced learning , 35. BloThere are several limitations to this study. First, blinding of the three advanced nurse practitioners was not feasible, which may have led to the differences in academic performance scores between the intervention and control groups. However, the subject has a stringent assessment rubric for Nurse Practitioners to follow to minimize possible biases. Second, the number of students recruited to this study was relatively small, and the study was conducted at one institution. The findings of the study may therefore not be generalizable to nursing students enrolled in master’s programs in other universities. Finally, a qualitative enquiry with both the students and Nurse Practitioners was not performed, leading to difficulty in achieving an in-depth understanding of the results of the current study.This study indicated that the blended video watching, and peer learning program may be an effective pedagogical strategy for increasing the self-confidence and satisfaction in learning, and academic performance of master’s students. Because of the positive perceptions of peer learning, we recommend that active learning approaches, emphasizing self-learning, and co-responsibility in learning, be adopted in master’s programs. Further randomized controlled trials adopting the double-blinded approach would be needed to confirm these results.


Interventional radiological procedures have significantly increased in recent years. Most of them are minimally invasive and require a short hospitalization, mainly done in other non-radiological units nowadays. Limited bed availability and high occupancy rates in these units create longer waiting lists and cancellations. The aim of this retrospective study is to assess the creation and functioning of a Radiology Day Unit (RDU) and evaluating its outcomes. For this purpose, data about interventional procedures and its complications, incidents, patient safety, quality and satisfaction rates were collected from May 2018 to December 2020, and posteriorly analyzed to evaluate its implementation.During the assessed period, 3841 patients were admitted into the RDU, with a net increase of 13% and 26% in the second and third year, respectively. Procedures performed by the Abdominal Radiology section were the most frequent (76–85%) followed by Interventional Vascular Radiology and Thoracic Radiology. Complication rates were low (1.5%) and most of them were self-limited and managed in the own department. Waiting lists were significantly reduced, from 2 months to 1 week in case of procedures performed by the Abdominal Radiology section. Patient satisfaction was higher than 80% in all the items evaluated with a global satisfaction of 93%.The RDU in our hospital has become a vital section for the management and post-procedure caring of patients undergoing interventional procedures in the Radiology Service with low complication rates and overall high levels of quality and patient safety, allowing the reduction of waiting lists and occupancy rates. Radiology Day Unit (RDU) is a specialized unit dedicated to patient pre- and post-procedure caring.Fully organized by the Radiology Service staff.Low rate of post procedure complications and shortening of waiting lists.Global patient satisfaction is high (above 90%).Diagnostic and therapeutic interventional procedures have significantly increased in Radiology Services in recent years. In addition, the need for biopsies is rising due to personalized oncology, especially in hospitals with a strong focus on research. These paired with recent advances in interventional radiology techniques have triggered an evolution of the specialty, from being primarily diagnostic in the past to being considered treatment units nowadays.Most of these procedures are minimally invasive, and patients are only required to rest for a few hours before discharge. Currently, most of these patients occupy beds or spots in Day Hospitals from other medical specialties, even for elective procedures and short hospital admissions of less than 24 h. This results in longer waiting lists because of limited bed availability and high occupancy rates in other services and could also cause cancellation of the elective procedure.An additional problem is the lack of specialized nurses in this kind of post-procedure caring in other non-radiological hospital facilities. Moreover, Radiology Services are usually located far from hospitalization areas, hindering communication between interventional radiologists and the nurses previously mentioned. This highlights the need for staff familiar with these interventional procedures and optimal post-procedure care .Many of these procedures have low complication rates, which would allow for the post-procedure monitoring to be performed within the Radiology Service itself, given an adequate selection of patients, techniques –6 and trDay Hospitals dedicated to selected radiological interventional procedures that require short hospital admissions (< 24 h) are not standard in our country. There have been previous reports in other European countries such as United Kingdom , 9.This study describes the methodology for implementing a Radiology Day Unit (RDU) in a leading university hospital, the advantages such a facility brings for the Radiology Service, and the results obtained in the first two years and eight months after its implementation. The indicators used for evaluating and assessing the functioning of the RDU are focused on overall and specific RDU activity, post-procedure complication rates, quality control (including patient’s satisfaction), and other positive gains such as reduction of waiting lists for specific procedures or net gain of hospital beds.The first step was to elaborate an operational plan to provide personalized and quality care at the Radiology Service for patients undergoing interventional procedures requiring less than 24 h of hospitalization .This plan was reviewed and approved by the Clinical Direction of our hospital and by the clinical services that request interventional procedures. It consists of 11 main points (Table The RDU is located in the same area as the rooms for ultrasound (US) and computed tomography (CT) guided interventionism, as well as vascular interventionism. It consists of a space with seven cubicles communicated with the nursing control area and is fully equipped for patient pre- and post-procedure care. In addition, it is equipped with six beds and a recliner chair, each with an individual light, nurse call button, oxygen outlet, vacuum system, and a chair for the companion. There is also a nurse control zone with a workstation with access to clinical history, office supplies, medications, and dressing material. Other services in the RDU include bathroom, catering service, and cleaning service.It is open from 8 am until 9 pm during working days. There are two nurse shifts, one from 8 am to 3 pm and one from 2 to 9 pm. Moreover, there is a nursing assistant giving support from 9 am to 5 pm.The Abdominal Radiology, Thoracic Radiology, Vascular Interventional Radiology, and Interventional Neuroradiology decided upon the interventional procedures whose subsequent patient care should be performed at the RDU. Procedures that require short recovery time < 24 h) with low complication rates were initially considered, and more procedures were progressively added given the good results of patient care and low complications rates once the study was started (Table 4 h with Patients with classes I and II of the American Society of Anesthesiologists (ASA) Physical Status Classification System  were admIn coordination with clinicians and radiologists, selected staff members are in charge of scheduling interventional-guided procedures  according to requests.Upon arrival the patient is admitted and identified with an Identity Document (ID) wristband. An informative document about the RDU and a copy of the informed consent form is also handed to the patient. The nursing team is in charge of welcoming and accommodating the patient inside the RDU, as well as explaining the procedure and ensure proper preparation. To accelerate this process the nursing team calls the patient 48 h before the scheduled day to corroborate the following items: recommended hours of fasting, pre-procedure personal hygiene, prescribed medication , anticoagulation regimen, allergy history, and appointment verification. It is also recommended to get a companion the day of the procedure.Before the procedure, the interventional radiologist introduces himself/herself and confirms that the patient understands the procedure as well as answering any questions or doubts.Once the intervention is done, the patient is taken back to the RDU, where the nursing team will follow up on the patient and make the appropriate patient care according to the indications of the radiologist, as well as monitoring possible complications. Once discharged, the nursing team hands the patient a document containing specific post-procedure and the opening hours of the RDU, as well as a phone number in case of questions or doubts. The radiologist is the final responsible of the discharge order, as well as the main responsible of the well-being of the patient while in the RDU. If a patient is not fit to discharge it is derived for longer hospitalization in the most suitable service and management of complications.The day after the procedure, the nursing team does a follow-up call to ensure that the patient is recovering, and no complications have appeared.The administrative staff at the Radiology Service keeps a record of all the interventional procedures performed at the RDU. Other things monitored are: validated and pending of review or scheduling requests, requests pending of further tests  and schedule changes and/or cancellations (including the cause).Any event or complication is recorded in a specific Microsoft Excel file meant for internal usage and with limited access to the RDU staff and the members of the Quality Commission of the Radiology Service. Different protocols have been established in the event of post-procedure complications depending on their nature and severity.The responsible interventional radiologist registers the procedure, recommendations, possible complications and subsequent actions to be taken in the radiological report and the medical history of the patient, and finally the discharge order document. RDU nurses also report relevant clinical data during the post-procedure caring in the patient medical history.Overall, recording this information makes it possible to perform a complete quality control from an administrative and assistant perspective.Patients are given a satisfaction survey with ten closed-ended questions with 5-point scale answers about different aspects of the Service. Two open-ended questions about positive and negative aspects and one suggestion box are also provided Table . In almoBetween May 2018 and December 2020, 3841 patients were admitted to our hospital RDU. 752 patients were admitted between May 2018 and December 2018, 1295 in 2019, and 1794 in 2020. Thus, there was an increase of 13% and 26% in the usage of the RDU from 2018 to 2019 and 2019 to 2020, respectively.Most of the procedures are performed by the Abdominal Radiology section, followed by the Vascular Interventionism one. Procedures encased inside the Thoracic Radiology section are sparse. This is partially explained by the reluctance of the clinicians to allow less than 24 h resting after lung biopsies, even though the complication rates for lung punctures and biopsies at our Service are well below the results published in the literature  –15. TherIn 2018, among the 752 patients admitted to the RDU, 642 (85%) underwent procedures performed by the Abdominal Radiology section, and 85 (11%) by the Vascular Interventional Radiology section. In 2019, out of 1295 patients, 1000 (77%) were admitted for procedures performed by the Abdominal Radiology section and 180 (14%) by the Vascular Interventional Radiology section. In 2020, out of 1747 patients, 1328 (76%) were admitted for procedures performed by the Abdominal Radiology section and 298 (17%) by the Vascular Interventional Radiology section. In 2019 and 2020, there were also procedures performed exclusively by the nursing staff such as CT colonography preparation. Moreover, from July 2020 to December 2020, there were some procedures (66 patients) performed by the Hepatology Service clinicians since their Day Unit was under construction. The lowest activity periods corresponded to summer months and intervals with a higher incidence of the COVID-19 pandemic in 2020. All this data is represented in Figs. The net gain of hospital beds in other facilities due to the implementation of the RDU were 752 in 2018, 1295 in 2019 and 1794 in 2020. The waiting list for renal or hepatic biopsies performed by the Abdominal Radiology section went from two months to one week, one year after the RDU was set.The rate of complications reported during these procedures or while the patient was resting at the RDU was 54 out of 3700 procedures performed (1.5%). Bleeding was the most common complication , and it mainly happened in procedures performed by the Abdominal Radiology section, such as hepatic and renal biopsies. It was self-limited in 18 patients, while 12 require embolization by the Vascular Interventional radiologists. The rest of the complications are described in Table The most common incident has been the lack of recent coagulation tests before the procedure. Other incidents include non-discontinuity of anticoagulant or antiplatelet drugs before procedure, lack of radiological images of target lesions in the medical history, patient misinformation and the inability to schedule the procedure in the hospital intranet.In the particular case of the procedures performed by the Abdominal Radiology section, 48% of them reported some incident, which resulted in an overall cancellation rate of 16% in 2018 and 2019. In 2020, however, the incident rate was lowered to 22% and the cancellation rate was much lower, about 4%.Monitoring the RDU events has allowed a constant update and improvement of the different patient-specific documents such as informed consent forms for each procedure, informative documents for patients and caregivers, post-procedure recommendations, and standard operating procedures (administrative and assistance circuits). Moreover, new records were generated as new interventional procedures were added to the RDU.Finally, the results of the survey show a satisfaction level greater than 80% in all questions. It is worth noting that the satisfaction level for the information received about the test was 95%. The satisfaction level for the care received by the healthcare professionals was 99%, and the global satisfaction level was 93%.To the best of our knowledge, there is no precedent of a similar RDU like the one explained in this article in our country, in which the Radiology Service staff is in charge of the patient before, during, and after a radiological interventional procedure. There are, however, reports of similar experiences in other countries , 9.The main concern we had before the creation of this unit was patient safety. However, it is widely accepted that many of the interventional procedures in Radiology Services can be performed on an outpatient basis, given an adequate selection of procedures in low-risk patients. Several reports show that there are no statistically significant differences in the number and severity of complications between inpatient and outpatient settings for the same interventional procedures –20. In oPatients who underwent interventional procedures at our hospital have also traditionally occupied hospital beds or spots at other Day Units. Since the creation of the RDU these procedures can still be performed in an outpatient setting in our service with similar safety levels, allowing a lower bed occupancy rate in other services. The net gaining of beds due to the implementation of RDU was 3842 over the spawn of the evaluating period. This allowed the shortening of waiting lists and reduction of cancellations, as well as avoiding longer hospitalizations in other units that does not have the RDU flexibility. This has also allowed channeling the increasing demand for biopsies of patients who are candidates for clinical trials, especially from the Oncology Service, without increasing the waiting list of biopsies needed for assistance reasons. The multi-person usage of beds during the day, doubling or tripling its use in some cases, has also contributed to the reduction of waiting lists. This is possible thanks to the coordination between the administration team and radiologists in organizing the schedule and alternating procedures that require more or less post-procedure resting time. Moreover, the armchair can be used up to five or six times during the workday because some procedures require between 30 and 60 min of resting, such as Port-a-cath implantation, superficial soft tissue biopsies, and alcoholizations or radiofrequency ablations of thyroid nodules.The constant quality control in which the RDU was submitted also allowed the decrease in the incidence and cancellation rates in the period evaluated. This was possible thanks to the pre-48 h checklist and the constant collaboration and communication with the other clinical services to ensure that patients are fully prepared for the interventional procedure.In the light of the above, there was an increasing usage of the RDU in our hospital during the evaluated period. The addition of tasks not directly related to an interventional procedure and performed by specialized nurses has also contributed to the rising of its usage. Some of these procedures include mild/moderate allergic reactions monitorization, treatment and control of extravasations of iodinated contrast at the CT, information about the preparation for CT colonography, and patient control before and after intratumoral injections of drugs or virus. In the second half of 2020 there was also a slight increase in its usage due to hepatic biopsies performed by the Hepatology Service since its Day Unit was under construction. The vascular interventional section has its own recovery room with 2 beds. Since the inception of the RDU, there has been a net increase in the number of vascular interventional procedures performed at the RDU due to the availability of more beds.The 2020 COVID-19 global pandemic resulted in a decrease in the usage of the RDU, specially from March to May. This was offset in the fourth term of 2020, in which there was a peak usage of the RDU, with numbers similar to the ones that are being recorded nowadays.The fact that the radiologist is in charge of the patient before, during, and after the procedure is a paradigm shift from a professional perspective. This was particularly surprising for radiologists at the Abdominal and Thoracic Radiology sections since they are less used to patient care and management than, for instance, vascular interventional radiologists , 21, 22.Other clinicians have also gained progressive trusting in the RDU. As previously stated, the number of patients that underwent thoracic procedures and rest in the RDU is increasing yearly, halving the previous reluctance of the clinicians to allow less than 24 h resting after lung biopsies. This further enhances the viability and benefits of implementing a unit of such characteristics.The high patient satisfaction levels achieved is also an important indicator of the healthy functioning of the RDU and the benefits its implementation has offered.There is still a long way to go for the fully implementation of these kind of units despite our results and in other countries. RDU brings benefits for patients and the hospital, since it decreases bed occupancy, shortens waiting lists and decreases cancellations, while maintaining low complication rates and high patient satisfaction. An effort shall be done to encourage the creation of this kind of units.The main limitation of our prospective non-comparative study is the absence of data before the instauration of the RDU to make a comparison between both situations. Data before the inception of the unit was scattered and extremely hard to obtain since the patients rested in other services beds after an interventional procedure, making us unable to have control over that data.In conclusion, the opening of the RDU at our Service has enabled the creation of a work unit in which all the professionals have common values and goals, where everybody feels that actions taken are for the patient's best interest, where we encourage sharing information and where everybody, by mutual agreement, carries out his/her work according to his/her skills and competences. This allows us to ensure patient safety with greater efficiency while decreasing bed occupancy rates and waiting lists.


The major impact on healthcare through the ongoing digital transformation and new technologies results in opportunities for improving quality of care. Electronic patient records (EPR) are a substantial part in this transformation, even though their influence on documentation remains often unclear. This review aims to answer the question of which effect the introduction of the EPR has on the documentation proper in hospitals. To do this, studies are reviewed that analyze the documentation itself, rather than merely conducting interviews or surveys about it. Several databases were searched in this systematic review . To be included, studies needed to analyze written documentation and empirical data, be in either German or English language, published between 2010 and 2020, conducted in a hospital setting, focused on transition from paper-based to electronic patient records, and peer reviewed. Quantitative, qualitative and mixed methods studies were included. Studies were independently screened for inclusion by two researchers in three stages  and, in case of disagreement, discussed with a third person from the research team until consensus was reached. The main outcome assessed was whether the studies indicated a negative or positive effect on documentation (e.g. changing the completeness of documentation) by introducing an EPR. Mixed Methods Appraisal Tool was used to assess the individual risk of bias in the included studies. Overall, 264 studies were found. Of these, 17 met the inclusion criteria and were included in this review. Of all included studies, 11 of 17 proved a positive effect of the introduction of the EPR on documentation such as an improved completeness or guideline adherence of the documentation. Six of 17 showed a mixed effect with positive and negative or no changes. No study showed an exclusively negative effect. Most studies found a positive effect of EPR introduction on documentation. However, it is difficult to draw specific conclusions about how the EPR affects or does not affect documentation since the included studies examined a variety of outcomes. As a result, various scenarios are conceivable with higher or reduced burden for practitioners. Additionally, the impact on treatment remains unclear.The online version contains supplementary material available at 10.1007/s10916-022-01840-0. The ongoing digital transformation is having a major impact on healthcare. New technologies offer great opportunities to improve the quality of care. Electronic patient records (EPR) are key components for the digital transformation in hospitals and determine several clinical elements like communication and collaboration, information availability and workflows . There iTo shed light on the research question, a systematic review was conducted and is reported based on the most recent version of the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) guidelines described by Page et al. whenever it is applicable . See OnlFollowing a sensitive search strategy to identify all suitable studies, several electronic bibliographic databases were searched including PubMed , Web of Science Core Collection, CINAHL, and PDQ Evidence. The components for the database search were “implementation”, “electronic patient record”, “paper-based”, “documentation”, and “hospital”. For all databases, filters were used to limit the results to English and German language and the period of publication from 2010–2020. The period of publication was limited as previous, unsystematic research showed that some studies from before 2010 examined technologies that are no longer in use today due to the rapid progress of digital systems. See Online Resource Screening of results was conducted in three steps by three researchers  with inclusion or exclusion of studies following the criteria in Table The extracted data included authors, year, country, setting, study design, number of analyzed records, outcomes, results, and, if applicable, a use case. The outcomes were classified into the framework given by Nonnemacher, Nasseh, and Stausberg regarding their dimension of quality, meaning that e.g. the analysis of the outcome usage of standardized nursing language could be assigned to the dimension of structural quality . For quaThe Mixed Methods Appraisal Tool (MMAT) (Version 2018) proposed by Hong et al. was used to assess the quality of the included studies . MMAT isThe study selection process and the reasons for excluding studies are depicted in Fig. All included studies examine the documentation by performing a document analysis with comparison of the paper-based patient records and EPRs. Due to the hospital setting and the explicit exclusion of the outpatient setting, this concerns only the hospital's internal documentation in the patient records. Although the hospital setting was an inclusion criterion, the hospital setting still varies. There are differences in specialty  , 14, sizThe most commonly analyzed outcomes were completeness , 25, 26,MMAT was used to assess the individual risk of bias in the included studies and to rate their quality based on questions like “Are there complete outcome data?”. The two screening questions whether the study is an empirical one were fulfilled in all cases except one study . That stThe database search identified 264 studies of which 17 met the inclusion criteria. The majority of those showed improved documentation after the introduction of the EPR. Although none of the studies followed a theoretical framework, there are certainly several more general frameworks that might have suited after an adaption to the topic. A framework for data quality in medical research was presented , originaEPRs provide the possibility to automatically fill fields with information that are collected from other digital sources. This was seen in the study by Jang et al. where electronic documentation significantly improved only the automatically documented items but not the manually documented items . EPRs alWhen talking about improved documentation, the interpretation of the presented results and outcomes is often ambiguous. For example, it is not clarified, whether the outcome volume of documentation evaluates length of documentation only or also takes information density into account. Therefore, a lengthening documentation is not necessarily to be evaluated negatively, if at the same time completeness increases and vice versa. Moreover, regarding the frequently analyzed outcome guideline adherence, it remains unclear whether the improvements are due to a mere change in documentation or whether the actual treatment has changed due to the introduction of the EPR and is more guideline-compliant thereafter. This could be the case if the EPR conveys guideline information or offers clinical decision support based on guidelines or care might have delivered but was not documented before the introduction and is now forced to be documented with mandatory fields.A challenge of this review was the heterogeneity of the setting, outcomes, and the lack of the outcome definitions in some studies. However, the differently shaped setting and variety of outcomes gives a wide overview of the different applications of the EPR and how documentation changes in different views. Moreover, except for Zargaran et al. from South Africa , which iThere are some limitations of the present review that must be stated. Although the searched databases were carefully selected based on their topic and range, important results in other databases may still have been missed. Moreover, only studies from the last ten years were included. Nevertheless, some studies might have addressed the topic of this review, which were published before 2010 and could still be valid today. This could be an important aspect, as some healthcare systems are already highly digitized and thereby a lot of research might have been conducted before 2010. On the other hand, the results of this review generate evidence regarding the analyzation of change in documentation through EPRs of the current state of the art.Due to the ongoing digital transformation of the healthcare systems worldwide, it is expected that many hospitals will continue to implement new EPRs or adapt existing EPRs in the future. Each of these episodes of organizational change offers the opportunity to customize the structure of the record in terms of what is documented where and how. This results in the possibility of optimizing documentation regarding treatment quality or billing purposes on the one hand. On the other hand, documenting itself could be made as non-stressful as possible for the healthcare professionals. To make this process efficient, a systematic analysis of the change in documentation is essential. Healthcare professionals should use the existing validated instruments to produce comparable results. Also, future research should aim at developing further, more specific instruments to make it as easy as possible for practitioners to systematically collect data and publish results. This allows growing evidence on how to design documentation in the best way for all parties involved.Supplementary file1 (PDF 361 KB)Below is the link to the electronic supplementary material.


Using data from the Bucharest Stock Exchange, we examine the factors influencing the probability of informed trading (PIN) during February—October 2020, a COVID-19 pandemic period. Based on an unconditional quantile regression approach, we show that PIN exhibit asymmetric dependency with liquidity and trading costs. Furthermore, building a customized database that contains all insider transactions on the Bucharest Stock Exchange, we reveal that these types of orders monotonically increase the information asymmetry from the 50th to the 90th quantile throughout the PIN distribution. Finally, we bring strong empirical evidence associating the level of information asymmetry to the level of fake news related to the COVID-19 pandemic. This novel result suggests that during episodes when the level of PIN is medium to high (between 15 and 50%), any COVID-19 related news classified as misinformation released during the lockdown period, is discouraging informed traders to place buy or sell orders conditioned by their private information. The recent COVID-19 pandemic has led to a quick response of financial markets , a lockdown period (16 March 2020 to 14 May 2020), and a period of revival of the Romanian capital market (15 May to 1 October 2020). Based on an unconditional quantile regression approach, we show that PIN exhibits asymmetric dependency with liquidity and trading costs. Furthermore, by building a customized database that contains all insider transactions on the Bucharest Stock Exchange, we reveal that these types of orders monotonically increase the information asymmetry from the 50th to the 90th quantile throughout the PIN distribution. Finally, we bring forth strong empirical evidence associating the level of information asymmetry with the level of fake news related to the COVID-19 pandemic. This novel result suggests that during episodes when the level of PIN is medium to high (between 15 and 50%), any COVID-19 related news classified as misinformation released during the lockdown period is discouraging informed traders to place buy or sell orders conditioned by their private information.Our paper may be useful to academics, investors, and regulators. A single country analysis can provide a deeper understanding of a financial phenomenon, as long as substantial differences from one market to another, even for apparently similar cases, are noticed in different studies  should try to benefit from the periods of panic manifested on the stock exchanges during crisis times, like the COVID-19 pandemic. They should try to practice active portfolio management and earn systematic abnormal earnings, using different strategies  Thaler ; Lo 2019PIN decreases in the COVID-19 period.Investor behaviour should be influenced by the presence of uncertainty amplified by the number of news related to the COVID-19 pandemic. This uncertainty is determined by epidemiological evolutions, but also by the authorities’ decisions .The relationship between information asymmetry and insider trading has been analyzed by several researchers  for panel data developed by Borgen , which aTo investigate the factors influencing information asymmetry, we rely on 12 companies listed on the Bucharest Stock Exchange (BSE) from February 2020 to October 2020. The selection of shares was constrained by the lack of liquidity in the market. However, this portfolio is representative of the Romanian capital market and is diversified, including companies from key sectors , covering more than 50% of the market capitalization. We extract from Bloomberg 1 min tick data regarding the best ask, the best bid, and the associated volumes. The trade direction was computed using the Lee and Ready  algorithAs we can see in Fig. This implies that the increase in uncertainty due to the pandemic in the Romanian capital market has led to a decrease in information asymmetry during periods of bear market. Moreover, during periods of sustained recovery, the information asymmetry measured by PIN experienced smooth and gradual increases. These empirical facts urge for a more thorough investigation regarding the factors that contributed to this dynamic of PIN. We control for this aspect by considering the interactions between the lockdown period and COVID-19 related variables.The average PIN for all companies included in the study is around 18% according to the Yan and Zhang  estimatiTo have a more comprehensive view of the distribution of PIN, we present the histogram in Fig. To account for the impact induced by the novel pandemic, we include, alongside the control variables, three additional measures related to COVID-19 extracted from the RavenPack analytics tool. This platform provides real-time media analytics and statistics, related to the Coronavirus pandemic and various topics from corporate finance to financial markets. It covers sources such as Dow Jones Newswire, Wallstreet Journal, and StockTwits among others , name, and position within the company, while trade specifics refer to transaction date, type , underlying stock, volume, and price. An insider is defined by the Bucharest Stock Exchange as “any agent that holds a leadership position  within a listed company, as well as those with whom she/he has a close relationship  or with whom she/he acts in concert”.Apart from any corporate insiders’ trades, there are also reported share buyback programs by the issuing companies, which represent approx. 80% of all insider trades reported within the analysed timeframe and accounted for approx. 88% of all trades volume. In general, these operations have a certain period in which they take place, with the issuer being able to repurchase only a maximum of 10% out of the total number of shares. The price in these cases is flexible and allows the company's management to buy the necessary package of shares within the established term.There can be multiple reasons behind these share buybacks. The management of a company considers that the price is undervalued and performs a share buyback program, thus reducing the outstanding number of shares on the market, increasing the percentage of shares owned by the firm's investors   preventing some shareholders from taking a controlling stake in the company  is made up of corporate transactions , the remaining 30 transactions being instructed by individuals, especially current and former managers within the company. This is not surprising. Firstly, in terms of the total number of trades, there are fewer during the analysed period than in previous years, mainly due to pandemics, lockdown, and restrictive measures that followed since the beginning of the spring of 2020, but also due to their effects on businesses and the entire local economy. The activity of companies has been limited and changes were made concerning the handling of their daily activities, initial forecasts have been re-examined, various financing programs were taken into account, etc. Secondly, when looking at the individual transactions being instructed by management, these may be due to their informational advantage over the other insiders/outsiders, having privileged access to confidential or valuable information regarding the current situation of their company, in terms of both financial and operational perspectives, as well as its future prospects Seyhun .A detailed description of the variables and their sources is presented in Table Table We report a negative relationship between PIN and its previous values, which contradicts the findings of Chen et al.  for NYSEFurthermore, the trading volume has a positive and monotonically decreasing impact on PIN from inferior to superior quantiles. This result is in line with Chen and Choi , but conThe inclusion of some spread measures among the major drivers of information asymmetry proxied by PIN is justified since a longer time lag between trades causes spreads to narrow, as market makers update their beliefs. Thus, an informed trader will enter the market when the spread is relatively large, in order to optimally execute its private-information driven orders. In our case, the spread exhibits a positive impact on PIN, similar to Chen and Choi . InteresMoving forward, market capitalization has an interesting impact on PIN. Across the 10th quantile, market capitalization positively impacts PIN, but the rest of the coefficients associated to higher quantiles are not statistically significant. More to the point, during episodes of reduced informed trading, an increase in the size of the company leads to an increase in the PIN. Considering the chosen period, we document that increases in market capitalizations are only determined by increases in prices. Thus, the speed or velocity of price changes, i.e., the momentum is influencing the arrival of informed traders, but only in times when the latter is reduced. This is a normal result that confirms the systematic abnormal earnings based on the informational asymmetry hypothesis mentioned previously.In addition, volatility has a negative impact on information asymmetry (PIN), which is in line with previous studies  or high (75th quantile) information asymmetry, confirming the first hypothesis. The same conclusion can be drawn for both media coverage and Infodemic index which validates the second stated hypothesis.Finally, insider transactions are positively associated with PIN, which confirms the third hypothesis. This result is also valid for the majority of quantiles throughout the PIN distribution, except for the inferior ones. Compared to previous studies, this novel result directly links information asymmetry (PIN) with a measurable indicator that is not publicly available during trading sessions. In this way, we validate PIN as a predictor of the level of information asymmetry.We end this section with some robustness checks. Firstly, we use another measure for PIN, i.e. the one proposed by Gan et al. . SecondlFirstly, the first-order lagged values of PIN are statistically significant only at the 50th quantile compared to the 25th and 50th quantiles in the baseline specification. The GMM estimates confirm this fact.Nevertheless, with some minor exceptions, the trading volume retains its sign and statistical significance throughout the entire distribution of PIN, suggesting that liquidity is the main driver of information asymmetry in an emerging market, especially for medium and high levels of the latter. Moreover, the higher the insider transactions, the higher the information asymmetry, especially when the level of PIN is inflated (middle and upper quantiles).Finally, the coefficients associated with fake news during the lockdown period retain their signs, impact values, and statistical significance. This indicates that informed traders were inclined to withdraw from the market in conditions of medium or high information competition and amid the rise of COVID-19 related fake news during the lockdown period. This novel result suggests that during episodes when the level of information asymmetry proxied by PIN is medium or high (between 15 and 50%), any COVID-19 related news classified as misinformation released during the lockdown period is discouraging informed traders to place buy or sell orders conditioned by their private information. Thus, given the high uncertainty regarding the economic activity in Romania during the lockdown period  the econometric approach and (2) the sample. Regarding unconditional quantile regression, this method offers a broader view, and ultimately new insights, compared to other studies such as Aslan et al. , and SanThese findings, especially the one linking insider trading with information asymmetry, provide a novel perspective for researchers who look for a better understanding of the price-discovery process. A slow price discovery process means that public disclosure of these trades is not sufficient to achieve price efficiency. Lastly, these results are also useful to policy makers in terms of market integrity and fairness in the capital market.All things considered, even though this study is carried out on a single capital market, we have delivered some robust conclusions regarding the evolution of PIN and its driving factors. This approach has certain advantages in getting deeper into its specific behaviour, and might be compared to other emerging markets worldwide. A possible future direction of the study to be taken into account can be to extend the database to a panel of data during a similar uncertainty period.Based on our results, another possible direction for future research is to find suitable strategies in an active portfolio management context, based on the premise that processing value-relevant information can lead to abnormal returns. Lastly, given the evolution of the information asymmetry and the processing needs within a pandemic context, further research can be conducted with a more pronounced focus on behavioural aspects, such as the way that different types of financial agents on the stock market address the information asymmetry throughout the evolution of the pandemic context.


To better comprehend the relationship between the environment and walking, this study developed a conceptual framework that explained the association between the street environment and the route choice behavior of pedestrians. We collected the route choice data of 219 residents of the Chunliu community in Dalian and used a conditional Logit model to analyze the factors influencing route choice behavior to explain how the street environment affected pedestrians' walking habits and induced them to choose longer or more complicated routes for their activities. We found that sidewalk and driveway width, garbage bins, green spaces, the characteristics of street walls, the proportion of facilities could influence pedestrians' walking habits and compel them to choose longer and more complex routes. This study would provide new insights into walking characteristics and offer policy recommendations to the government on improving the street environment. Walking has been widely perceived as a sustainable and effective method of promoting physical health and social interaction. The enhanced ability to walk could potentially reduce the risk of obesity and increase economic employment , 2. ManyMany studies are now examining the correlation between the built environment and walking behavior. Existing studies typically use the social-ecological theory of human behavior, suggesting that environmental factors also impact an individual's behavior . When coRoute choice is a decision-making process that involves pedestrians selecting a route from among all options that link the origin and the destination . ConsequEmpirical research on route choice based on the route choice model obtained route data by directly observing or investigating actual walking routes, and then employing appropriate statistical techniques to infer the implied utility function for the pedestrian, and interpret pedestrian preferences by comparing a chosen route with an alternative one. Specifically, the environmental factors that affect pedestrians' perceptions and preferences can be explained by establishing a route choice model. Research on route choice analysis was mainly comprised of behavioral analysis and model development types . The behThis study focuses on assessing the components of the micro-level environment, which is referred to as the street environment tool, and is built by combining categorical and quantitative measurement methods based on the correlation in literature between the street environment and walking behavior. The purpose of this study is to find out how the street environment affects pedestrians' route choices and walking experience during walks. Hence, we discuss the relationship between the street environment, walking behavior, and route choice behavior, and discover the street environmental factors that influence route choice behavior by means of literature reviews. We then use various forms of the pedestrians' route adjustment process: (1) pedestrians determine the route before departure and do not adjust the route during the trip, indicating long-term habitual behavior (2) pedestrians obtain certain spatial information during walks, and make real-time adjustments of the route at each decision point (intersection), indicating that they were stimulated by the environment, and this affected their walking experience during the trip. Finally, we arrive at the factors that affect route choice behavior using the route choice model.Our study began with the Chunliu community, one of the old communities that was formed in the 1990s in Dalian, but lacked good quality walking conditions, such as pedestrian facilities and infrastructure, as well as policies that considered the needs of pedestrians. Since this study concentrates on the interaction of the street environment with walking behavior, we explore the environmental factors that affect pedestrian perception and preferences from route choice behavior and offer policy suggestions to improve the prevalent street environment.The behavior model for the environment explains that regional features influence actual or potential volumes of pedestrians, route choices, and the availability of alternative transportation modes. Likewise, route characteristics define the quality of a route and primarily influence the safety, comfort, experience, and perceptions of pedestrians . This imMeasurement of the street environment is achieved with a tool that assesses physical environmental situations related to physical activities and which is derived from the quantitative indicators of urban planning, transportation, and public health to promote the quality of physical activity. Many of the tools used to comprehensively and accurately measure the quality of the physical environment have been derived from other fields, including urban design, transportation, and public health –22. HoweMoreover, a few studies have suggested a correlation between positive perceptions about the external environment and increased walking , 24. AltRoute choice behavior refers to the decision taken as a result of the interaction between the street environment and walking behavior. However, research on the impact of the street environment on pedestrian route choice is fairly limited due to the difficulty in obtaining detailed street environmental data. Of these studies, almost all of them indicated that distance was the key determinant of route choice. For example, the shortest route is the most preferred among competing routes, as it was generally perceived that pedestrians frequently minimize distance and walking time when selecting a route , 31 and Another non-built environmental factor that is consistently identified as significantly influencing route choice behavior is habit. This signifies that the chosen route is the one that has always been used. Thus, it could be surmised that the street environment plays a significant role in pedestrian route choice behavior only if a pedestrian's actual travel route deviates from the route with the shortest distance . Based oInterestingly, a few studies observed that other factors such as distance and network and personal and trip characteristics also affect pedestrian route choice . SimilarDespite the wide range of factors, it is possible to classify the process of route choice behavior into two forms of route adjustment. One occurs when pedestrians determine the route before departure and do not adjust the route during the trip. The other takes place when pedestrians obtain certain spatial information when walking and make real-time adjustments to the route at each decision point (intersection).Therefore, we analyzed route choice behavior to find out how the street environment affects pedestrians' route choices and walking experience. We assume the first form of route adjustment, wherein the route they choose is determined by habitual behavior. Moreover, the second form of route adjustment reflected in the walking experience is caused by the appeal of the environment.The influence of the street environment on walking behavior has previously been examined in the public health field to increase trip generation , choice of travel mode , and choice of destinations using the area-based measurement. Then again, a significantly lesser amount of work has been carried out on route choices, even though the determinants of route choice could reveal important information about the role of the environment in influencing active travel behavior. When route choice behavior is the end result of the interaction between pedestrians and the street environment, it reflects pedestrians' preference for a particular street environment. This preference is engendered by pedestrians' walking habits after a long-term interaction with the street environment or as a result of being attracted by the street environment of a certain road segment during the walking process.This study has been developed on a micro-level street environment to explain the association between the street environment and walking behavior . We beliRoute choice behavior explains the consequences of the interaction of the environment with behavior. Thus, from the literature review on route choice behavior, we can conclude that although there are certain rules to such behavior, such as minimizing distance or direction, the street environment affects route choice behavior only when a pedestrian's actual travel route deviates from specific routes. Hence, we compared chosen routes to alternative routes  to find the environmental factors influencing walking habits and experience.Moreover, the impact of the street environment on route choice behavior is reflected in two forms of route adjustment: (1) pedestrians determine the route before departure and do not adjust the route during the trip, which is indicative of long-term habitual behavior and affects the overall perception of the street environment. (2) pedestrians can obtain certain spatial information during a trip and make real-time adjustments to the route at each decision point (intersection), which suggests behavior that has been stimulated by the environment and affects the walking experience during the trip.All of these factors—street environment and individual reactions—can influence how individuals feel about the environment. By generating a route choice model, scholars can better correlate street environment-related physical factors with walking behavior.The focus on route choice behavior is affected by data feasibility because of the limitations of the data collection methods . MoreoveAs discussed above, our study site was located in the Chunliu community in Dalian, China . The ChuTo record pedestrian route behavior in Chunliu, we conducted an unobtrusive tracking method that did not rely on the subject's memories and could record reliable routes. In particular, we invited participants to install the “2bulu” App, which is software that records behavioral trajectories. We then encouraged participants to send us the routes that took them to their first destination from their residence after having completed their trips. We have excluded routes from residents who are dog walkers since they have the same origin and destination points. The experiment was conducted from 3:00 to 5:00 p.m. every Sunday of October 2020. Sunday afternoon was selected for this study because it was easier to collect data on active travel for utilitarian walks, including grocery shopping, walking to the park, and walking to access public transportation to visit other locations. Ultimately, we collected the route data of 219 residents.For environmental measurements, we reorganized the street environment factors collected from studies on the relationship between the street environment and walking behavior and summarized the street environment and route choice behavior. Based on the functional characteristics of the physical aspects of roads, we classified environmental features as roadway features, streetscape, pedestrian infrastructure, and facilities .We gathered street environments from multiple sources, including the road network data provided by the OSM map and the Points of Interest data collected by the Baidu Map to discover facilities such as retail establishments, catering, public services, parking lots, and medical facilities, bus stations, and so on. To measure the quality and extent of street environment features such as width and walkability of sidewalks and driveways and building heights, we recruited a well-trained auditor to perform a survey and gather data for each road segment along the route. For variables that were related to the functional condition of pedestrian infrastructure  and specific values , we created a length-weighted average.According to the utility theory, people tend to make reasonable decisions to maximize personal interests , 47. RouHowever, the study of route choice behavior needs to transcend two technical barriers. The first involves identifying feasible but unchosen routes. This was apparently more complicated than the study of other travel mode options. For instance, a few travel options were not that difficult to be defined and visualized, such as travel by car, bus, and train. However, for route choice, numerous alternative routes become almost impossible to cite or visualize. Moreover, available routes for traveling remain uncertain and covered by street networks that are almost unidentifiable . ConsequSince the route data we collected from the residential area to the first destination point indicated that most of the routes explored involved short walking trips, we employed the labeling method and generated two alternative routes  to replace the complex alternative route generation techniques.The route with the shortest distance between the residential location as the origin and the first destination, as generated by the road network dataset in ArcGIS, uses distance as an impedance to form the route. Generating a route with the least directional change is more complex. We used the Depthmap software to convert the road network to a segment map, which was adopted for calculating angular step depth from each origin, with a total of 219 angular step depth maps being formed. Lastly, we generated the route with the least directional change by converting the 219 angular step depth maps into a shapefile using ArcGIS.The second barrier to be overcome is route correlation due to the overlap among various alternative routes. From a traditional perspective, route choice models are based on the assumption of maximum utility, which can be classified under the discrete choice mathematical models. Nevertheless, there exists route correlation and overlapping among various alternative routes, which violates the assumption of the random utility theory. The model method solves the correlation problem between alternatives, thus altering choice probabilities for overlapping routes . The rouFor this study, we chose the CL model, which is suitable to examine the difference between the environmental factors of the chosen route and the alternative route  . Unlike We analyzed the characteristics of route choice to understand the relationship between the alternative route  and the chosen route. Firstly, we statistically analyzed the rate at which chosen routes overlapped with the alternative route. For example, a 100% overlapping route between the chosen and the shortest distance routes implies pedestrians' preference for the route with the shortest distance.Subsequently, we excluded samples that overlapped 100% on alternative routes as the determinants for choosing these routes probably depended on distance or direction, or both. We hypothesized that when the street environments influenced pedestrians to deviate from the alternative routes, it caused <100% of overlapped routes, which was also the case in prior studies , 34, 56.Lastly, we defined the two forms of the route adjustment process to account for how the street environment factors influenced walking habits and compelled pedestrians to alter their behavior. For this, we assessed the street environment of the entire route between the origin and the destination (OD pairs) as being the environmental factors that affect the walking habit. We also assessed the part-route which deviated from the alternative route as an attractive segment that affected a change in behavior . All anaN = 145) of chosen routes completely overlap the shortest distance routes, and 71% (N = 156) of pedestrians choose the route with the least directional change. Also, 56% (N = 122) of the chosen routes completely overlap the routes with the shortest distances and the least directional changes. This is attributable to fewer alternative routes or the choice of only a single route for short walking trips. When compared to the route with the shortest distance, pedestrians appear more inclined to opt for the route with the least directional change, which was similar to the findings of previous studies in Queensland  adjust their routes from alternative routes during the trip, which displays a high value of effectiveness that matches the actual routes . As a coWe found no regularity in the relationship between distance and the proportion of change in the overlap. However, the distance factor becomes significantly shorter in the 100% overlap route than in the <100% overlap one. This indicates that walking distance exhibits discrepancies, with pedestrians choosing between alternative routes and then deviating from them, which could be attributed to the fact that long-distance walks offered more alternative routes. Thus, pedestrians with longer routes could potentially be affected by more favorable street environments and deviate from the alternative routes .After excluding samples where the chosen route completely overlapped the alternative route, we compare the chosen route, which measures the street environment of the entire route between the OD pairs, with that of the shortest distance route as the long-term interaction between a pedestrian and the street environment . We use a CL model for this purpose, and the different route attributes that were statistically significant and associated with route choice behavior are presented in In our model that adopts the shortest distance route as the alternative route, driveway width, garbage bins, characteristics of street walls, green spaces, and the proportion of shopping facilities have significant positive effects. Our findings on driveway width and garbage bins are contrary to our expectations. Driveway width implied high traffic volumes that could possibly provide more street views, which was similar to the observations by Guo and Loo  in the HWe compare the chosen route, which measures the street environment of the entire route between the OD pairs with that of the route with the least directional changes, and the different route attributes that are statistically significant and associated with route choice behavior have been laid out in Findings for the model that adopts the route with the least directional change as the alternative route prove that other than the number of benches having a positive effect, the sidewalk width, the proportion of leisure facilities, and bus stops all negatively impact any deviation from the route with the least directional changes. Although sidewalk width, leisure facilities, and bus stops reflect a perception of additional comfort and convenience when walking, in this model, pedestrians were more willing to pick an alley rather than the route with the least directional changes. This could be due to the mode they adopt for determining the route with the least directional changes that were based on the geometric form and topology of the road network. Thus, the generation mode is established according to the accessibility degree of each road segment. Therefore, the route with the least directional changes is likely to be a set of routes with high accessibility, which is generally the case with a relatively well-appointed route in terms of sidewalk width and facilities.We consider the chosen route and route with the shortest distance, as well as the chosen route and the route with the least directional changes, as the street environment motivates pedestrians to change their behavior during a walk. The different route attributes, along with their statistical significance associated with route choice behavior, have been presented in The findings for the model  that conThis work studies the impact exerted by the street environment on a pedestrian's walking behavior within a conceptual framework defined by the street environment, walking behavior, and route choice behavior. We used unobtrusive tracking methods to observe route choice characteristics and correlated the street environment with walking behavior using the route choice model. Our findings indicate that certain factors of street environments can influence walking behavior, and as such, route choice behavior can change a pedestrians' walking habits and induce pedestrians to deviate from the route with the shortest distance and the least directional changes to take longer or more complicated routes for their trips.Pertaining to pedestrian route choice behavior characteristics, we agree with previous research work, which suggests that distance and direction cannot be used as alternative routes at the same time. Specifically, distance and direction can explain 66 and 71% of route choice behavior which is higher than that reported by the other study . The finThe environmental features influencing route choice behavior vary with the different forms of the route adjustment process. Our findings empirically reaffirm that walking habits among pedestrians can affect the generation of alternative routes, and as such, route choice patterns can be influenced by the street environment. When pedestrians determine the route before departure and do not adjust the route during the trip, it signifies habitual behavior brought on by a long-term interaction between the environment and walking behavior. The results of our models prove that driveway width, garbage bins, green spaces, and the proportion of shopping facilities can affect pedestrians' willingness to foster a longer-distance walking habit. Also, sidewalk width, green spaces, characteristics of street walls, the proportion of shopping facilities, and bus stops can influence pedestrians' walking habits and prompt them to choose more complex routes. On the other hand, when pedestrians obtain certain spatial information during a walk and make real-time adjustments to the route at each decision point (intersection), it reflects environmental appeal affecting the walking experience. Again, the results obtained from our models demonstrate that sidewalk width, characteristics of street walls, and green spaces can prompt pedestrians to choose routes with longer distances. Besides, driveway width and on-street parking can also compel a pedestrian to walk a complicated route.However, some of the results were contrary to our expectations. For example, the sidewalk width had a negative influence, with pedestrians choosing more complicated routes. This could be attributable to the mode of generating the route with the least directional change, which is likely to be a set of routes with high accessibility. Also, the model results for the roadway width appeared ambiguous. For instance, for the street environment of the entire route between the OD pairs, the driveway width had a positive effect on pedestrians altering their walking habits by deviating from the route with the shortest distance. On the contrary, for the street environment of a part-route that deviated from the alternative route, the model threw up the opposite results, with narrower driveways motivating pedestrians to deviate from the route with the shortest distance. These contradictory results exemplify the difficulty in collecting and interpreting street environment data at the micro-scale, where the number of potential variables to be considered is high, and the number of potential correlations among these variables could also be high . AnotherBased on the above findings, we recommend the following for the street environment of the Chunliu Community. For the macro-level built-up environment, it is necessary to improve the road environment. Specifically, this includes solving the parking problem on the sidewalk by constructing isolation facilities between the sidewalk and driveways to alter pedestrians' walking habits so that they take longer walks or choose more complicated routes. At the micro-level of street environment aspects, some of the pedestrian infrastructures such as benches and shopping facilities increase the perception of comfort and pleasure, motivating pedestrians to increase their walking activity and improve their physical health.This research is limited in the sense that, firstly, other factors such as individual variables are not considered, and therefore, other underlying effects may perhaps not be precisely recognized. Secondly, the micro-scale environment tool we used cannot measure comprehensively. Though numerous and varied environmental factors have been measured in our model, other physical factors, such as the traffic environment (pedestrian and vehicular volume), aesthetics , etc., have not been included. Finally, pedestrians are unable to describe and explain the feasible but unchosen routes, making it hard to analyze the causal relationship between the walking environment and behavior.In addition, our relatively small sample size only allows us to evaluate and examine the existing street environment, contrasting and complementing the typical results of correlation studies at a micro-scale. Even so, pedestrian route choice behavior can allow researchers to understand how the street environment affects pedestrians' route choices and walking experience. Finally, as technology enables the monitoring of pedestrian route choice and makes it more accurate, cost-effective, and less intrusive, the number of studies on how pedestrians choose and experience routes and to what extent quality route environments impact pedestrian walking will increase, which will provide a more reliable research basis on the street environment and walking behavior.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.LJ contributed to the conceptualization, methodology, investigation, writing—original draft and visualization of the study. WL performed the supervision and project administration. PS performed the writing—review and editing. All authors contributed to manuscript revision, read, and approved the submitted version.This study was supported by the Fundamental Research Funds for the Central Universities with funding number: DUT20RC (3) 051.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.