Identifying Features of a System of Practice to Inform a Contemporary Competency Framework for Paramedics in Canada.

INTRODUCTION: Paramedic practice is highly variable, occurs in diverse contexts, and involves the assessment and management of a range of presentations of varying acuity across the lifespan. As a result, attempts to define paramedic practice have been challenging and incomplete. This has led to inaccurate or under-representations of practice that can ultimately affect education, assessment, and the delivery of care. In this study, we outline our efforts to better identify, explore, and represent professional practice when developing a national competency framework for paramedics in Canada. METHODS: We used a systems-thinking approach to identify the settings, contexts, features, and influences on paramedic practice in Canada. This approach makes use of the role and influence of system features at the microsystem, mesosystem, exosystem, macrosystem, supra-macrosystem, and chronosystem levels in ways that can provide new insights. We used methods such as rich pictures, diagramming, and systems mapping to explore relationships between these contexts and features. FINDINGS: When we examine the system of practice in paramedicine, multiple layers become evident and within them we start to see details of features that ought to be considered in any future competency development work. Our exploration of the system highlights that paramedic practice considers the person receiving care, caregivers, and paramedics. It involves collaboration within co-located and dispersed teams that are composed of other health and social care professionals, public safety personnel, and others. Practice is enacted across varying geographical, cultural, social, and technical contexts and is subject to multiple levels of policy, regulatory, and legislative influence. CONCLUSION: Using a systems-thinking approach, we developed a detailed systems map of paramedic practice in Canada. This map can be used to inform the initial stages of a more representative, comprehensive, and contemporary national competency framework for paramedics in Canada.

Perspectivism and Health Professions Assessment.

ABSTRACT: This article aims to outline perspectivism and perspectival thinking by drawing on established scholarship from the philosophy of science and to demonstrate its relevance to health professions education. Perspectivism embraces the notion that knowledge always inherently arises from particular perspectives. "Truth" always depends on an evaluative background. Perspectivism is a form of epistemic humility that sees epistemic claims (relating to knowledge) as fundamentally historically and contextually situated. This article contends that perspectivism is a fruitful and relevant lens to apply to health professions assessment. It is a way of thinking that is all around us, even if we do not realize it. It extends discourse around the value of subjectivity in assessment and may cut through many prevailing debates on assessment practice. Perspectivism is a sort of middle-ground that is not meant to be another idea or "-ism" to add to a list of ideas, but constitutes a shift in how philosophy can be applied by adopting a broader, more holistic perspective. Applying a perspectival lens to health professions education embraces the imperative to make interpretive processes in assessment philosophically explicit. This opens the possibility of adopting multiple philosophical stances concurrently and allows actors to appreciate different methodological viewpoints with more charity. This scholarly perspective encourages the assessment community to continue to innovate through an appreciation of the importance of a wide range of assessment perspectives by uncovering the drivers of specific commitments to philosophical positions. Although the focus is on assessment in the health professions, perspectival thinking has the potential to advance medical education discourse and practice more generally beyond assessment. The hope with this essay is that by encouraging more critical reflection, this description of perspectival thinking will further aid researchers and practitioners in health professions education to better understand what is happening philosophically with more frequency.

Validating the Emergency Department Avoidability Classification (EDAC): A cluster randomized single-blinded agreement study.

INTRODUCTION: The Emergency Department Avoidability Classification (EDAC) retrospectively classifies emergency department (ED) visits that could have been safely managed in subacute primary care settings, but has not been validated against a criterion standard. A validated EDAC could enable accurate and reliable quantification of avoidable ED visits. We compared agreement between the EDAC and ED physician judgements to specify avoidable ED visits. MATERIALS AND METHODS: We conducted a cluster randomized, single-blinded agreement study in an academic hospital in Hamilton, Canada. ED visits between January 1, 2019, and December 31, 2019 were clustered based on EDAC classes and randomly sampled evenly. A total of 160 ED visit charts were randomly assigned to ten participating ED physicians at the academic hospital for evaluation. Physicians judged if the ED visit could have been managed appropriately in subacute primary care (an avoidable visit); each ED visit was evaluated by two physicians independently. We measured interrater agreement between physicians with a Cohen's kappa and 95% confidence intervals (CI). We evaluated the correlation between the EDAC and physician judgements using a Spearman rank correlation and ordinal logistic regression with odds ratios (ORs) and 95% CIs. We examined the EDAC's precision to identify avoidable ED visits using accuracy, sensitivity and specificity. RESULTS: ED physicians agreed on 139 visits (86.9%) with a kappa of 0.69 (95% CI 0.59-0.79), indicating substantial agreement. Physicians judged 96.2% of ED visits classified as avoidable by the EDAC as suitable for management in subacute primary care. We found a high correlation between the EDAC and physician judgements (0.64), as well as a very strong association to classify avoidable ED visits (OR 80.0, 95% CI 17.1-374.9). The EDACs avoidable and potentially avoidable classes demonstrated strong accuracy to identify ED visits suitable for management in subacute care (82.8%, 95% CI 78.2-86.8). DISCUSSION: The EDAC demonstrated strong evidence of criterion validity to classify avoidable ED visits. This classification has important potential for accurately monitoring trends in avoidable ED utilization, measuring proportions of ED volume attributed to avoidable visits and informing interventions intended at reducing ED use by patients who do not require emergency or life-saving healthcare.

Attending to Variable Interpretations of Assessment Science and Practice.

Issue: The way educators think about the nature of competence, the approaches one selects for the assessment of competence, what generated data implies, and what counts as good assessment now involve broader and more diverse interpretive processes. Broadening philosophical positions in assessment has educators applying different interpretations to similar assessment concepts. As a result, what is claimed through assessment, including what counts as quality, can be different for each of us despite using similar activities and language. This is leading to some uncertainty on how to proceed or worse, provides opportunities for questioning the legitimacy of any assessment activity or outcome. While some debate in assessment is inevitable, most have been within philosophical positions (e.g., how best to minimize error), whereas newer debates are happening across philosophical positions (e.g., whether error is a useful concept). As new ways of approaching assessment have emerged, the interpretive nature of underlying philosophical positions has not been sufficiently attended to. Evidence: We illustrate interpretive processes of assessment in action by: (a) summarizing the current health professions assessment context from a philosophical perspective as a way of describing its evolution; (b) demonstrating implications in practice using two examples (i.e., analysis of assessment work and validity claims); and (c) examining pragmatism to demonstrate how even within specific philosophical positions opportunities for variable interpretations still exist. Implications: Our concern is not that assessment designers and users have different assumptions, but that practically, educators may unknowingly (or insidiously) apply different assumptions, and methodological and interpretive norms, and subsequently settle on different views on what serves as quality assessment even for the same assessment program or event. With the state of assessment in health professions in flux, we conclude by calling for a philosophically explicit approach to assessment, and underscore assessment as, fundamentally, an interpretive process - one which demands the careful elucidation of philosophical assumptions to promote understanding and ultimately defensibility of assessment processes and outcomes.

Performance Data Advocacy for Continuing Professional Development in Health Professions.

ABSTRACT: Efforts to optimize continuing professional development (CPD) are ongoing and include advocacy for the use of clinician performance data. Several educational and quality-based frameworks support the use of performance data to achieve intended improvement outcomes. Although intuitively appealing, the role of performance data for CPD has been uncertain and its utility mainly assumed. In this Scholarly Perspective, the authors briefly review and trace arguments that have led to the conclusion that performance data are essential for CPD. In addition, they summarize and synthesize a recent and ongoing research program exploring the relationship physicians have with performance data. They draw on Collins, Onwuegbuzie, and Johnson's legitimacy model and Dixon-Woods' integrative approach to generate inferences and ways of moving forward. This interpretive approach encourages questioning or raising of assumptions about related concepts and draws on the perspectives (i.e., interpretive work) of the research team to identify the most salient points to guide future work. The authors identify 6 stimuli for future programs of research intended to support broader and better integration of performance data for CPD. Their aims are to contribute to the discourse on data advocacy for CPD by linking conceptual, methodologic, and analytic processes and to stimulate discussion on how to proceed on the issue of performance data for CPD purposes. They hope to move the field from a discussion on the utility of data for CPD to deeper integration of relevant conceptual frameworks.

Decision making in continuing professional development organisations during a crisis.

INTRODUCTION: Early in COVID-19, continuing professional development (CPD) providers quickly made decisions about program content, design, funding and technology. Although experiences during an earlier pandemic cautioned providers to make disaster plans, CPD was not entirely prepared for this event. We sought to better understand how CPD organisations make decisions about CPD strategy and operations during a crisis. METHODS: This is a descriptive qualitative research study of decision making in two organisations: CPD at the University of Toronto (UofT) and the US-based Society for Academic Continuing Medical Education (SACME). In March 2021, using purposive and snowball sampling, we invited faculty and staff who held leadership positions to participate in semi-structured interviews. The interview focused on the individual's role and organisation, their decision-making process and reflections on how their units had changed because of COVID-19. Transcripts were reviewed, coded and analysed using thematic analysis. We used Mazmanian et al.'s Ecological Framework as a further conceptual tool. RESULTS: We conducted eight interviews from UofT and five from SACME. We identified that decision making during the pandemic occurred over four phases of reactions and impact from COVID-19, including shutdown, pivot, transition and the 'new reality'. The decision-making ability of CPD organisations changed throughout the pandemic, ranging from having little or no independent decision-making ability early on to having considerable control over choosing appropriate pathways forward. Decision making was strongly influenced by the creativity, adaptability and flexibility of the CPD community and the need for social connection. CONCLUSIONS: This adds to literature on the changes CPD organisations faced due to COVID-19, emphasising CPD organisations' adaptability in making decisions. Applying the Ecological Framework further demonstrates the importance of time to decision-making processes and the relational aspect of CPD. To face future crises, CPD will need to embrace creative, flexible and socially connected solutions. Future scholarship could explore an organisation's ability to rapidly adapt to better prepare for future crises.

Recasting Assessment in Continuing Professional Development as a Person-Focused Activity.

ABSTRACT: In this article, we examine assessment as conceptualized and enacted in continuing professional development (CPD). Assessment is pervasive throughout the life of an individual health professional, serving many different purposes compounded by varied and unique contexts, each with their own drivers and consequences, usually casting the person as the object of assessment. Assessment is often assumed as an included part in CPD development conceptualization. Research on assessment in CPD is often focused on systems, utility, and quality instead of intentionally examining the link between assessment and the person. We present an alternative view of assessment in CPD as person-centered, practice-informed, situated and bound by capability, and enacted in social and material contexts. With this lens of assessment as an inherently personal experience, we introduce the concept of subjectification, as described by educationalist Gert Biesta. We propose that subjectification may be a fruitful way of examining assessment in a CPD context. Although the CPD community, researchers, and educators consider this further, we offer some early implications of adopting a subjectification lens on the design and enactment of assessment in CPD.

Elements and Definitions of Continuing Professional Development Leadership: A Scoping Review.

INTRODUCTION: Leaders are being asked to transform the way that continuing professional development (CPD) is delivered to focus on better, safer, and higher quality care. However, there is scarce literature on CPD leadership. We set out to study what CPD leadership means and describe the competencies required for CPD leadership. METHODS: A scoping review following Preferred Reporting Items for Systematic Reviews and Meta-analyses extension guidelines for scoping reviews guidelines was conducted. With librarian support, four databases were searched for publications related to leadership, medical education, and CPD. Publications were screened by two reviewers and three reviewers extracted data. RESULTS: Among 3886 publications, 46 were eligible for a full-text review and 13 met the final inclusion criteria. There was no agreed upon definition of CPD leadership and variable models and approaches to leadership in the literature. Contextual issues shaping CPD (eg, funding, training, and information technology) are evolving. We identified several attitudes and behaviors (eg, strategic thinking), skills (eg, collaboration), and knowledge (eg, organizational awareness) important to CPD leadership, but no established set of unique competencies. DISCUSSION: These results offer the CPD community a foundation on which competencies, models, and training programs can build. This work suggests the need to build consensus on what CPD leadership means, what CPD leaders do, and what they will need to create and sustain change. We suggest the adaptation of existing leadership frameworks to a CPD context to better guide leadership and leadership development programs.

"Rater training" re-imagined for work-based assessment in medical education.

In this perspective, the authors critically examine "rater training" as it has been conceptualized and used in medical education. By "rater training," they mean the educational events intended to improve rater performance and contributions during assessment events. Historically, rater training programs have focused on modifying faculty behaviours to achieve psychometric ideals (e.g., reliability, inter-rater reliability, accuracy). The authors argue these ideals may now be poorly aligned with contemporary research informing work-based assessment, introducing a compatibility threat, with no clear direction on how to proceed. To address this issue, the authors provide a brief historical review of "rater training" and provide an analysis of the literature examining the effectiveness of rater training programs. They focus mainly on what has served to define effectiveness or improvements. They then draw on philosophical and conceptual shifts in assessment to demonstrate why the function, effectiveness aims, and structure of rater training requires reimagining. These include shifting competencies for assessors, viewing assessment as a complex cognitive task enacted in a social context, evolving views on biases, and reprioritizing which validity evidence should be most sought in medical education. The authors aim to advance the discussion on rater training by challenging implicit incompatibility issues and stimulating ways to overcome them. They propose that "rater training" (a moniker they suggest be reserved for strong psychometric aims) be augmented with "assessor readiness" programs that link to contemporary assessment science and enact the principle of compatibility between that science and ways of engaging with advances in real-world faculty-learner contexts.

Exploring the Study of Simulation as a Continuing Professional Development Strategy for Physicians.

INTRODUCTION: Practicing physicians have the responsibility to engage in lifelong learning. Although simulation is an effective experiential educational strategy, physicians seldom select it for continuing professional development (CPD) for reasons that are poorly understood. The objective of this study was to explore existing evidence on simulation-based CPD and the factors influencing physicians' engagement in simulation-based CPD. METHODS: A scoping review of the literature on simulation-based CPD included MEDLINE, Embase, and CINAHL databases. Studies involving the use of simulation for practicing physicians' CPD were included. Information related to motivations for participating in simulation-based CPD, study objectives, research question(s), rationale(s), reasons for using simulation, and simulation features was abstracted. RESULTS: The search yielded 8609 articles, with 6906 articles undergoing title and abstract screening after duplicate removal. Six hundred sixty-one articles underwent full-text screening. Two hundred twenty-five studies (1993-2021) were reviewed for data abstraction. Only four studies explored physicians' motivations directly, while 31 studies described incentives or strategies used to enroll physicians in studies on simulation-based CPD. Most studies focused on leveraging or demonstrating the utility of simulation for CPD. Limited evidence suggests that psychological safety, direct relevance to clinical practice, and familiarity with simulation may promote future engagement. DISCUSSION: Although simulation is an effective experiential educational method, factors explaining its uptake by physicians as a CPD strategy are unclear. Additional evidence of simulation effectiveness may fail to convince physicians to participate in simulation-based CPD unless personal, social, educational, or contextual factors that shape physicians' motivations and choices to engage in simulation-based CPD are explored.

On the use and abuse of metaphors in assessment.

This paper is motivated by a desire to advance assessment in the health professions through encouraging the judicious and productive use of metaphors. Through five specific examples (pixels, driving lesson/test, jury deliberations, signal processing, and assessment as a toolbox), we interrogate how metaphors are being used in assessment to consider what value they add to understanding and implementation of assessment practices. By unpacking these metaphors in action, we probe each metaphor's rationale and function, the gains each metaphor makes, and explore the unintended meanings they may carry. In summarizing common uses of metaphors, we elucidate how there may be both advantages and/or disadvantages. Metaphors can play important roles in simplifying, complexifying, communicating, translating, encouraging reflection, and convincing. They may be powerfully rhetorical, leading to intended consequences, actions, and other pragmatic outcomes. Although metaphors can be extremely helpful, they do not constitute thorough critique, justified evidence or argumentation. We argue that although metaphors have utility, they must be carefully considered if they are to serve assessment needs in intended ways. We should pay attention to how metaphors may be misinterpreted, what they ignore or unintentionally signal, and perhaps mitigate against this with anticipated corrections or nuanced qualifications. Failure to do so may lead to implementing practices that miss underlying and relevant complexities for assessment science and practice. Using metaphors requires careful attention with respect to their role, contributions, benefits and limitations. We highlight the value that comes from critiquing metaphors, and demonstrate the care required to ensure their continued utility.

Copaiba essential oil loaded-nanocapsules film as a potential candidate for treating skin disorders: preparation, characterization, and antibacterial properties.

Infections have emerged as a novel target in managing skin and mucosa diseases. Bacterial resistance to antimicrobials and biofilm elimination from surfaces remains a challenge. Because polymeric nanocapsules (NC) can increase antimicrobial activity, this study aimed to produce and characterize NC into chitosan films (CSF). Copaiba essential oil (CO) presents antimicrobial activity and was chosen to load NC. In addition, the antibacterial activity was evaluated to obtain a new biodegradable polymeric platform system with the potential to treat topical diseases associated with bacterial infections. The CO-NC produced by nanoprecipitation presented particle size lower than 250 nm, negative charge, and encapsulation efficiency higher than 70 %. Direct incorporation of CO into CSF (CO-CSF) by casting method worsened the film's characteristics. However, incorporating CO-NC into CSF (CO-NC-CSF) avoided these drawbacks demonstrating improved physical, mechanical, morphological, and topographical properties. FTIR results demonstrated possible intermolecular interactions among the polymers and CO. The CO-NC-CSF and CO-CSF presented antibacterial properties against Staphylococcus aureus, and Pseudomonas aeruginosa, especially the formulation containing 1 % of CO. These results indicated that CO-NC-CSF is a promising candidate for treating skin disorders.

Inclusion of patient-level emergency department characteristics to classify potentially redirectable visits to subacute care: a modified Delphi consensus study.

BACKGROUND: Most patients transported by Ontario paramedics to the emergency department have non-emergent conditions and may be more appropriately served by subacute community-based care centres. We sought to determine consensus on a set of patient characteristics that could be useful to classify retrospective emergency department visits that had a high probability of being primary care-like and potentially redirectable to a subacute care centre by paramedics. METHODS: We conducted a modified Delphi study to assess expert consensus on characteristics of patients transported by paramedics to the emergency department from August to October 2021. An expert Delphi committee was constructed of emergency and family physicians in Ontario using purposive sampling. Experts rated whether each characteristic was useful to be included in a classification to identify potentially redirectable visits retrospectively, as well as characteristic details (e.g., upper and lower bounds). Consensus was considered 75% agreement. RESULTS: Sixteen experts participated in the study; the experts were mostly male (75%) and evenly divided between emergency and family medicine. After 2 rounds, consensus was achieved on 8 of 9 characteristics (89%). Four characteristics were determined as useful to classify potentially redirectable emergency department visits: age (81%), triage acuity (100%), specialist consult in the emergency department (94%) and emergency department visit outcome (81%). Specifications of each characteristic were refined as follows: young and middle-aged adults with a non-emergent triage acuity, did not receive a specialist physician consult in the emergency department and discharged from the emergency department. INTERPRETATION: Strong consensus was achieved to specify a classification system for potentially redirectable emergency department visits. These results will be combined with knowledge of which subacute care centres could conduct the main physician interventions to retrospectively identify emergency department visits that could have been suitable for paramedic redirection for further research. STUDY REGISTRATION: ID ISRCTN22901977.

CONFERD-HP: recommendations for reporting COmpeteNcy FramEwoRk Development in health professions.

BACKGROUND: Competency frameworks outline the perceived knowledge, skills, attitudes, and other attributes required for professional practice. These frameworks have gained in popularity, in part for their ability to inform health professions education, assessment, professional mobility, and other activities. Previous research has highlighted inadequate reporting related to their development which may then jeopardize their defensibility and utility. METHODS: This study aimed to develop a set of minimum reporting criteria for developers and authors of competency frameworks in an effort to improve transparency, clarity, interpretability and appraisal of the developmental process, and its outputs. Following guidance from the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network, an expert panel was assembled, and a knowledge synthesis, a Delphi study, and workshops were conducted using individuals with experience developing competency frameworks, to identify and achieve consensus on the essential items for a competency framework development reporting guideline. RESULTS: An initial checklist was developed by the 35-member expert panel and the research team. Following the steps listed above, a final reporting guideline including 20 essential items across five sections (title and abstract; framework development; development process; testing; and funding/conflicts of interest) was developed. CONCLUSION: The COmpeteNcy FramEwoRk Development in Health Professions (CONFERD-HP) reporting guideline permits a greater understanding of relevant terminology, core concepts, and key items to report for competency framework development in the health professions.

A Qualitative Study to Understand the Cultural Factors That Influence Clinical Data Use for Continuing Professional Development.

INTRODUCTION: The use of data to inform lifelong learning has become increasingly important in continuing professional development (CPD) practice. Despite the potential benefits of data-driven learning, our understanding of how physicians engage in data-informed learning activities, particularly for CPD, remains unclear and warrants further study. The purpose of this study was to explore how physicians perceive cultural factors (individual, organizational, and systemic) that influence the use of clinical data to inform lifelong learning and self-initiated CPD activities. METHODS: This qualitative study is part of an explanatory sequential mixed-methods study examining data-informed learning. Participants were psychiatrists and general surgeons from Canada and the United States. Recruitment occurred between April 2019 and November 2019, and the authors conducted semistructured telephone interviews between May 2019 and November 2019. The authors performed thematic analysis using an iterative, inductive method of constant comparative analysis. RESULTS: The authors interviewed 28 physicians: 17 psychiatrists (61%) and 11 general surgeons (39%). Three major themes emerged from the continuous, iterative analysis of interview transcripts: (1) a strong relationship between data and trust, (2) a team-based approach to data-informed learning for practice improvement, and (3) a need for organizational support and advocacy to put data into practice. CONCLUSION: Building trust, taking a team-based approach, and engaging multiple stakeholders, such as data specialists and organizational leadership, may significantly improve the use of data-informed learning. The results are situated in the existing literature, and opportunities for future research are summarized.

Validation of a classification to identify emergency department visits suitable for subacute and virtual care models: a randomised single-blinded agreement study protocol.

INTRODUCTION: Redirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed to retrospectively classify ED visits that may have been suitable for safe management in a subacute or virtual clinical setting. The EDAC has established face and content validity but has not been tested against a reference standard as a criterion. OBJECTIVES: Our primary objective is to examine the agreement between the EDAC and ED physician judgements in retrospectively identifying ED visits suitable for subacute care management. Our secondary objective is to assess the validity of ED physicians' judgement as a criterion standard. Our tertiary objective is to examine how the ED physician's perception of a virtual ED care alternative correlates with the EDAC. METHODS AND ANALYSIS: A randomised single-centre, single-blinded agreement study. We will randomly select ED charts between 1 January and 31 December 2019 from an academic hospital in Hamilton, Canada. ED charts will be randomly assigned to participating ED physicians who will evaluate if this ED visit could have been managed appropriately and safely in a subacute and/or virtual model of care. Each chart will be reviewed by two physicians independently. We compute our needed sample size to be 79 charts. We will use kappa statistics to measure inter-rater agreement. A repeated measures regression model of physician ratings will provide variance estimates that we will use to assess the intraclass correlation of ED physician ratings and the EDAC. ETHICS AND DISSEMINATION: This study has been approved by the Hamilton Integrated Research Ethics Board (2022-14625). If validated, the EDAC may provide an ED-based classification to identify potentially avoidable ED visits, monitor ED visit trends, and proactively delineate those best suited for subacute or virtual care models.

Effect of station format on the psychometric properties of Multiple Mini Interviews.

BACKGROUND: Given the widespread use of Multiple Mini Interviews (MMIs), their impact on the selection of candidates and the considerable resources invested in preparing and administering them, it is essential to ensure their quality. Given the variety of station formats used and the degree to which that factor resides in the control of training programmes that we know so little about, format's effect on MMI quality is a considerable oversight. This study assessed the effect of two popular station formats (interview vs. role-play) on the psychometric properties of MMIs. METHODS: We analysed candidate data from the first 8 years of the Integrated French MMIs (IF-MMI) (2010-2017, n = 11 761 applicants), an MMI organised yearly by three francophone universities and administered at four testing sites located in two Canadian provinces. There were 84 role-play and 96 interview stations administered, totalling 180 stations. Mixed design analyses of variance (ANOVAs) were used to test the effect of station format on candidates' scores and stations' discrimination. Cronbach's alpha coefficients for interview and role-play stations were also compared. Predictive validity of both station formats was estimated with a mixed multiple linear regression model testing the relation between interview and role-play scores with average clerkship performance for those who gained entry to medical school (n = 462). RESULTS: Role-play stations (M = 20.67, standard deviation [SD] = 3.38) had a slightly lower mean score than interview stations (M = 21.36, SD = 3.08), p < 0.01, Cohen's d = 0.2. The correlation between role-play and interview stations scores was r = 0.5 (p < 0.01). Discrimination coefficients, Cronbach's alpha and predictive validity statistics did not vary by station format. CONCLUSION: Interview and role-play stations have comparable psychometric properties, suggesting format to be interchangeable. Programmes should select station format based on match to the personal qualities for which they are trying to select.

Designing and Governing Responsive Local Care Systems - Insights from a Scoping Review of Paramedics in Integrated Models of Care.

Introduction: Programs that fill gaps in fractured health and social services in response to local needs can provide insight on enacting integrated care. Grassroots programs and the changing roles of paramedics within them were analyzed to explore how the health workforce, organizations and governance could support integrated care. Methods: A study was conducted following Arksey and O'Malley's method for scoping reviews, using Valentijn's Rainbow Model of Integrated Care as an organizing framework. Qualitative content analysis was done on clinical, professional, organizational, system, functional and normative aspects of integration. Common patterns, challenges and gaps were documented. Results: After literature search and screening, 137 documents with 108 unique programs were analysed. Paramedics bridge reactive and preventative care for a spectrum of population needs through partnerships with hospitals, social services, primary care and public health. Programs encountered challenges with role delineation, segregated organizations, regulation and tensions in professional norms. Discussion: Five concepts were identified for fostering integrated care in local systems: single point-of-entry care pathways; flexible and mobile workforce; geographically-based cross-cutting organizations; permissive regulation; and assessing system-level value. Conclusion: Integrated care may be supported by a generalist health workforce, through cross-cutting organizations that work across silos, and legislation that balances standardization with flexibility.