Medical students' perceptions of prosocial behaviors: a grounded theory study in China.

INTRODUCTION: Prosocial behavior has been shown to be protective against burnout. Yet, we know little about prosocial behavior in medical students. We wanted to know what are chinese medical students' understanding of prosocial behavior and which factors influence their participation in it? METHODS: We undertook a grounded theory study, following Corbin & Strauss. We used convenience sampling and conducted semi-structured individual interviews. We analyzed data using open, axial, and selective coding techniques. Next, we grouped data into concepts. We noticed these concepts aligned with three existing social theories, so we developed our theory in concert with these: the Theory of Planned Behavior, Self-Determination Theory, and Social Support Theory. RESULTS: Twenty-eight medical students participated in this study. Medical students hold especial views on the roles of medical physicians, and most of these views align with students' core values, including the value of prosocial behavior. Students are intrinsically motivated to engage in prosocial behaviors that align with their core values. Personal values, personality traits, perceived self-competence, career motivation, environmental factors, and family influences are the core factors influencing medically positive prosocial behavior. CONCLUSIONS: This study supports a focus on prosocial behavior instead of altruistic behavior in medical education. We anticipate that promoting prosocial behavior through medical curricula will reduce moral distress and burnout among medical students.

Interprofessional identity: an ethnography of clinical simulation learning in New Zealand.

BACKGROUND: This article explores the experiences of clinical healthcare students on an interprofessional simulation course in Auckland, New Zealand. The four-day course aims to provide a formative learning experience for final year medical, pharmacy, nursing, and paramedicine students. It focuses on building skills in professionalism, communication, leadership and interprofessional safe teamwork through structured learning activities and clinical simulation scenarios. METHODS: In 2018, we commenced focused ethnographic research involving participant observation, field notes, interviews, photography and ethnographic film. RESULTS: A total of 112 students participated in this research from the disciplines of medicine (n = 53), nursing (n = 27), pharmacy (n = 17), and paramedicine (n = 15). In a revisit to Van Gennep's (1972) seminal work on liminality, we suggest that the course represents a liminal space where students' ideas about what it means to be a healthcare 'professional' are challenged, disrupted and reconstructed. We observed students emerging from the course with transformed professional and interprofessional identities. CONCLUSIONS: We posit that the ritualised and liminal nature of the course plays a role in the development of interprofessional identities by interrupting the reproduction of siloed biomedical culture. Students are challenged to become effective team members alongside other students and experts from other professions. We discuss these findings as they relate to medical and health sciences education.

The flip side of speaking up: a new model to facilitate positive responses to speaking up in the operating theatre.

BACKGROUND: Speaking up is important for patient safety, but only if the concern raised is acknowledged and responded to appropriately. While the power to change the course of events rests with those in charge, research has focussed on supporting those in subordinate positions to speak up. We propose responsibility also rests with senior clinical staff to respond appropriately. We explored the perceptions of senior staff on being spoken up to in the operating theatre (OT), and factors moderating their response. METHODS: We undertook interviews and focus groups of fully qualified surgeons, anaesthetists, nurses, and anaesthetic technicians working in OTs across New Zealand. We used grounded theory to analyse and interpret the data. RESULTS: With data from 79 participants, we conceptualise three phases in the speaking up interaction: 1) the content of the speaker's message and the tone of delivery; 2) the message interpreted through the receiver's filters, including beliefs on personal fallibility and leadership, respect for the speaker, understanding the challenges of speaking up, and personal cultural and professional norms around communication; and 3) the receiver's subsequent response and its effects on the speaker, the observing OT staff, and patient care. CONCLUSIONS: The speaking up interaction can be high stakes for the whole OT team. The receiver response can strengthen team cohesion and function, or cause distress and tension. Our grounded theory uncovers multiple influences on this interaction, with potential for re-framing and optimising the speaker/receiver interaction to improve team function and patient safety.

Effective virtual patient simulators for medical communication training: A systematic review.

CONTEXT: Despite the growing use of virtual patients (VPs) in medical education, few studies have explored the features and effectiveness of VP-based medical communication skills training. We undertook a systematic review to summarise the design and evaluation of VP-based medical communication skills training systems in order to identify features of successful cases. METHODS: Following PRISMA guidelines, we searched four databases for studies published between 2006 and 2018. Using a refined classification scheme, we extracted data on instructional design (scenario and instructional intervention), technological design (modality and interaction), and evaluation (user experience, learning effectiveness and evaluator). We assessed the quality of studies using the Medical Education Research Study Quality Instrument (MERSQI) and the QualSyst standard assessment criteria. RESULTS: A total of 14 studies were included for review. Of these, 85.7% (n = 12) were quantitative and 71.4% (n = 10) involved undergraduate students. The most common VP training scenario was history taking followed by the delivery of bad news. Diverse instructional interventions, including tutorials, learning activities, and feedback, were embedded in the VPs. The first-person perspective animated within-screen size VP was a popular technological feature. Most evaluations concerned the reality of simulation (for user experience) and skill in expressing empathy (as a learning outcome). Of the eight comparative studies, half reported significant attitude or skill improvements in the VP group. The distinct features of VPs shown to be effective were well-designed instructional interventions (eg, a pre-activity with a protocol-informed tutorial), and post-activity (eg, debrief or reflection), scaffolding and human feedback, but not system feedback. CONCLUSIONS: Evidence-based VP training can enable students to gain communication skills in a safe and affordable learning environment. Elaborate technology alone cannot guarantee effective learning, but evidence-based instructional interventions can facilitate its optimal use and bring about better learning outcomes.

Three zones of cultural competency: surface competency, bias twilight, and the confronting midnight zone.

BACKGROUND: Regulatory authorities in healthcare are authorised to develop and assess the cultural competence of their professionals. There remains significant diversity on approaches to cultural competency training and assessment. Little evidence exists about whether existing cultural competency training leads to improved patient health outcomes and reductions in health disparity. DISCUSSION: In this paper I frame cultural competency as analogous to the ocean and consisting of three zones: surface competency zone, bias twilight zone, and the confronting midnight zone. The surface competency zone focuses on deployment of culturally-specific knowledge: what people see, say, and do. The bias twilight zone is where people engage in critical reflection on their inherent/unconscious biases, and how such biases inform their thoughts and practices. The confronting midnight zone is where people engage in critical consciousness and self-awareness. Here they look beyond their biases to interrogate their power and positionality in society (their own privileges and centralisation). This attention is coupled with a commitment to social justice and to working within their means to reduce health disparities. CONCLUSIONS: I suggest surface cultural competency is somewhat easier to see, teach and reach than the bias twilight or confronting midnight zones. But it is these deeper zones that cultural competency training needs to attend to if we are to see systemic cultural changes in healthcare provision. Research assessing the extent by which cultural competency training within each zone informs improved patient outcomes and reductions in health disparity is called for.

Why people donate their brain to science: a systematic review.

The acquisition of brain tissue for research purposes is an important endeavour in research on ageing, pathological diagnosis, and the advancement of treatment of neurological or neurodegenerative diseases. While some tissue samples can be obtained from a living patient, the procurement of a whole brain requires the donation from people after their death. In order to promote positive attitudes towards brain donation, it is essential to understand why people do or do not donate their brain to medical research. In 2018 we undertook a systematic review of the international literature concerning people's attitudes, motivations, and feelings about brain donation. Five electronic databases were searched: Scopus, PsycINFO, Embase, Medline, and Google Scholar. Search terms included: ("brain donor*" OR "brain donation" OR "brain banking" OR "banking on brain") AND (attitude* OR motivation* OR decision*") AND (LIMIT-TO "human") AND (LIMIT-TO (LANGUAGE, "English")). Articles were analysed using the Framework for Assessing Qualitative Evaluations and a meta-ethnographic approach. Fourteen articles were included for review. The findings suggest four universal factors informing a person's decision to donate their brain: (1) contextual knowledge, (2) conceptual understandings, (3) family/friends matter, and (4) personal experience, time and process. The findings also indicate that the way healthcare professionals present themselves can influence people's feelings and attitudes towards brain donation. Healthcare and research professionals who are involved in brain donation processes must be mindful of the complex and multiple factors that influence donation outcomes. Effective and sensitive communication with potential donors and their family/friends is paramount.

Evaluation of a modified 16-item Readiness for Interprofessional Learning Scale (RIPLS): Exploratory and confirmatory factor analyses.

The Readiness for Interprofessional Learning Scale (RIPLS) was developed to assess undergraduate readiness for engaging in interprofessional education (IPE). It has become an accepted and commonly used instrument. To determine utility of a modified 16-item RIPLS instrument, exploratory and confirmatory factor analyses were performed. Data used were collected from a pre- and post-intervention study involving 360 New Zealand undergraduate students from one university. Just over half of the participants were enrolled in medicine (51%) while the remainder were in pharmacy (27%) and nursing (22%). The intervention was a two-day simulation-based IPE course focused on managing unplanned acute medical problems in hospital wards ("ward calls"). Immediately prior to the course, 288 RIPLS were collected and immediately afterwards, 322 (response rates 80% and 89%, respectively). Exploratory factor analysis involving principal axis factoring with an oblique rotation method was conducted using pre-course data. The scree plot suggested a three-factor solution over two- and four-factor solutions. Subsequent confirmatory factor analysis performed using post-course data demonstrated partial goodness-of-fit for this suggested three-factor model. Based on these findings, further robust psychometric testing of the RIPLS or modified versions of it is recommended before embarking on its use in evaluative research in various healthcare education settings.

Clinical learning environments: place, artefacts and rhythm.

CONTEXT: Health care practitioners learn through experience in clinical environments in which supervision is a key component, but how that learning occurs outside the supervision relationship remains largely unknown. This study explores the environmental factors that inform and support workplace learning within a clinical environment. METHODS: An observational study drawing on ethnographic methods was undertaken in a general medicine ward. Observers paid attention to interactions among staff members that involved potential teaching and learning moments that occurred and were visible in the course of routine work. General purpose thematic analysis of field notes was undertaken. RESULTS: A total of 376 observations were undertaken and documented. The findings suggest that place (location of interaction), rhythm (regularity of activities occurring in the ward) and artefacts (objects and equipment) were strong influences on the interactions and exchanges that occurred. Each of these themes had inherent tensions that could promote or inhibit engagement and therefore learning opportunities. Although many learning opportunities were available, not all were taken up or recognised by the participants. CONCLUSIONS: We describe and make explicit how the natural environment of a medical ward and flow of work through patient care contribute to the learning architecture, and how this creates or inhibits opportunities for learning. Awareness of learning opportunities was often tacit and not explicit for either supervisor or learner. We identify strategies through which tensions inherent within space, artefacts and the rhythms of work can be resolved and learning opportunities maximised.

Experiencing integration: a qualitative pilot study of consumer and provider experiences of integrated primary health care in Australia.

BACKGROUND: The terms integration and integrated care describe the complex, patient-centred strategies to improve coordination of healthcare services. Frameworks exist to conceptualise these terms, but these have been developed from a professional viewpoint. The objective of this study was to explore consumers' and providers' concepts, expectations and experience of integrated care. A key focus was whether frameworks developed from a professional perspective are effective models to explore people's experiences. METHODS: A qualitative pilot study was undertaken at one Australian multidisciplinary primary health care centre. Semi-structured interviews were conducted with consumers (N = 19) and staff (N = 10). Data were analysed using a framework analysis approach. RESULTS: Consumers' experience of integrated care tended to be implicit in their descriptions of primary healthcare experiences more broadly. Experiences related to the typologies involved clinical and functional integration, such as continuity of providers and the usefulness of shared information. Staff focused on clinical level integration, but also talked about a cultural shift that demonstrated normative, professional and functional integration. CONCLUSIONS: Existing frameworks for integration have been heavily influenced by the provider and organisational perspectives. They are useful for conceptualising integration from a professional perspective, but are less relevant for consumers' experiences. Consumers of integrated primary health care may be more focussed on relational aspects of care and outcomes of care.

Time and chronic illness: a narrative review.

PURPOSE: This narrative review is concerned with the ways in which the relationships between time and chronic illnesses have been chartered in recent literature. It aims to identify types of time (referred to here as temporal structures) most commonly reported in chronic illness literature and to assess their bearing on people's lived experiences. METHODS: Literature searches of three electronic databases (Google Scholar, MEDLINE, and PubMed) were carried out in November 2014 of articles published between 1970 and 2013 using the following search terms (and derivatives): chronic illness AND time AND (patient OR carer). The review followed four procedural steps: (a) comprehensive search, (b) temporal structure appraisal, (c) synthesis of findings, and (d) critical appraisal. RESULTS: Forty studies met the inclusion criteria and were included for review. Four types of called temporal structures had a strong presence in the literature: calendar and clocked time, biographical time, past-present-future time, and inner time and rhythms. The first three temporal structures are largely understood socially, and the fourth is predominantly understood in and through the body. Several studies reported more than one temporal structure as informing people's chronic illness experiences. A wide array of chronic illnesses were represented in these studies. Few studies reported on the experiences of people with multi-morbid chronic illnesses. CONCLUSION: Chronic illness induces new relationships to time. Drawing on Hyden (Sociol Health Illn 19(1):48-69, 1997), it is suggested that "narrative" storytelling--as a temporally informed analytic device---might prove effective for reconciling the tensions emergent from new and multiple relationships to time that chronic and multiple illnesses create. Opportunities exist for healthcare practitioners and health services to offer patients illness support that is cognisant of their relationships to time.

Perceptions of purpose, value, and process of the mini-Clinical Evaluation Exercise in anesthesia training.

INTRODUCTION: Workplace-based assessment is integral to programmatic assessment in a competency-based curriculum. In 2013, one such assessment, a mini-Clinical Evaluation Exercise (mini-CEX) with a novel "entrustability scale", became compulsory for over 1,200 Australia and New Zealand College of Anaesthetists (ANZCA) trainees. We explored trainees' and supervisors' understanding of the mini-CEX, their experience with the assessment, and their perceptions of its influence on learning and supervision. METHODS: We conducted semi-structured telephone interviews with anesthesia supervisors and trainees and performed an inductive thematic analysis of the verbatim transcripts. RESULTS: Eighteen supervisors and 17 trainees participated (n = 35). Interrelated themes concerned the perceived purpose of the mini-CEX, its value in trainee learning and supervision, and the process of performing the assessment. While few participants saw the mini-CEX primarily as an administrative burden, most focused on its potential for facilitating trainee improvement and reported positive impacts on the quantity and quality of feedback, trainee learning, and supervision. Finding time to schedule assessments and deliver timely feedback proved to be difficult in busy clinical workplaces. Views on case selection were divided and driven by contrasting goals - i.e., receiving useful feedback on challenging cases or receiving a high score by choosing lenient assessors or easy cases. Whether individual mini-CEXs were summative or formative was subject to intense debate, while the intended summative use of multiple mini-CEXs in programmatic assessment was poorly understood. CONCLUSION: Greater clarity of purpose and consistency of time commitment are necessary to embed the mini-CEX in the culture of the workplace, to realize the full potential for trainee learning, and to reach decisions on trainee progression.

Time to manage: patient strategies for coping with an absence of care coordination and continuity.

This paper examines how people with chronic illnesses respond to absences of continuity and coordination of care. Little work has been done on how the ill person might mitigate flaws in a less than optimal system. Our qualitative research, carried out among 91 participants in Australia, reveals that people with chronic illnesses create strategies to facilitate the management of their care. These strategies included efforts to improve communication between themselves and their health care practitioners; keeping personal up-to-date medication lists; and generating their own specific management plans. While we do not submit that it is patients' responsibility to attend to gaps in the health system, our data suggests that chronically ill people can, in and through such strategies, exert a measure of agency over their own care; making it effectively more continuous and coordinated. Participants crafted strategies according to the particular social and bodily rhythms that their ongoing illnesses had lent to their lives. Our analysis advances the view that the ill body itself is capable of enfolding the health system into the rhythms of illness - rather than the ill body always fitting into the overarching structural tempo. This entails an agent-centric view of time in illness experience. A Virtual Abstract of this paper can be found at: https://youtu.be/UwbxlEJOTx8.

What motivates Australian health service users with chronic illness to engage in self-management behaviour?

CONTEXT: Health policy in Australia emphasizes the role of health service users (HSU) in managing their own care but does not include mechanisms to assist HSUs to do so. OBJECTIVE: To describe motivation towards or away from self-management in a diverse group of older Australians with diabetes, chronic heart failure (CHF) or chronic obstructive pulmonary disease (COPD) and suggest policy interventions to increase patient motivation to manage effectively. DESIGN: Content and thematic analyses of in-depth semi-structured interviews. Participants were asked to describe their experience of having chronic illness, including experiences with health professionals and health services. Secondary analysis was undertaken to expose descriptions of self-management behaviours and their corresponding motivational factors. PARTICIPANTS: Health service users with diabetes, COPD and/or CHF (N=52). RESULTS: Participant descriptions exposed internal and external sources of motivation. Internal motivation was most often framed positively in terms of the desire to optimize health, independence and wellness and negatively in terms of avoiding the loss of those attributes. External motivation commonly arose from interactions with family, carers and health professionals. Different motivators appeared to work simultaneously and interactively in individuals, and some motivators seemed to be both positive and negative drivers. CONCLUSION: Successful management of chronic illness requires recognition that the driving forces behind motivation are interconnected. In particular, the significance of family as an external source of motivation suggests a need for increased investment in the knowledge and skill building of family members who contribute to care.

Measuring the added value of virtual communities of practice for developing the educator role of critical care professionals.

In healthcare settings, workplace learning is often supported by clinicians who strive to combine service provision and educator roles. We evaluated an international 12-month programme that supports widely distributed critical care health professional educators (HPEs) through a virtual community of practice (vCoP). Specifically, we evaluate if and how the vCoP approach affects learning experiences using an innovative evaluation framework in medical education-the value-creation framework (VCF). We used a mixed-methods approach to evaluation, including an anonymous survey and semistructured interviews. Themes from data sources were identified using the VCF as the common thread. Themes discussed by at least two-thirds of interview participants were analysed using narrative inquiry. 27 of 66 participants responded to the survey, and 15 participated in interviews. Positive and negative indicators of value creation were extracted and organised according to the framework's eight value cycles. Framework analysis made value-creation and potential flow-on effects in one value-creation cycle to another visible, offering insight into relationships. Themes from narrative inquiry elaborated on the results of the framework analysis. Using the VCF to evaluate the Incubator programme brings to bear the complexity of boundary-crossing HPE faculty development for critical care educators. The framework can be a valuable tool for evaluating a vCoP associated with faculty development programmes.

Interprofessional Learning in Multidisciplinary Healthcare Teams Is Associated With Reduced Patient Mortality: A Quantitative Systematic Review and Meta-analysis.

OBJECTIVE: The aim of the study is to identify quantitative evidence for the efficacy of interprofessional learning (IPL) to improve patient outcomes. METHODS: We conducted a systematic review and meta-analysis of quantitative patient outcomes after IPL in multidisciplinary healthcare teams reported in the Medline, Scopus, PsycInfo, Embase, and CINAHL databases. RESULTS: In 2022, we screened 15,248 reports to include 20 and extracted rates of mortality and primary outcomes in conventional care groups and intervention groups (involving initiatives to promote IPL in multidisciplinary teams). The meta-analysis of the 13 studies reporting mortality outcomes demonstrated that the 7166 patients in the intervention group had a significant 28% (95% confidence interval [CI], 40%-14%; P < 0.0003) reduced risk of dying compared with the 6809 patients in the conventional care group. The meta-analysis of the 14 studies reporting other treatment-related adverse outcomes demonstrated that the 4789 patients in the intervention group had a significant 23% (95% CI, 33%-12%; P < 0.0001) reduced risk of experiencing an adverse outcome during care compared with the 4129 patients in the conventional care group. Sensitivity analysis, involving the exclusion of the 20% of individual studies with the widest 95% CIs, confirmed the precision and reliability of our findings. CONCLUSIONS: We believe that our results are the first to demonstrate significant quantitative evidence for the efficacy of IPL to translate into changes in clinical practice and improved patient outcomes. Our results reinforce earlier qualitative work of the value of IPL, but further prospective quantitative and mixed-methods research is needed to better define such benefits.