Using paradox theory to understand responses to tensions between service and training in general surgery.

CONTEXT: The tension between service and training in pressured health care environments can have a detrimental impact on training quality and job satisfaction. Yet the management literature proposes that competing demands are inherent in organisational settings: it is not the demands as such that lead to negative outcomes but how people and organisations react to opposing tensions. We explored how key stakeholders responded to competing service-training demands in a surgical setting that had recently gone through a highly-publicised organisational crisis. METHODS: This was an explanatory case study of a general surgery unit. Public documents informed the research questions and the data were triangulated with semi-structured interviews (n = 14) with key stakeholders. Data coding and analysis were initially inductive but, after the themes emerged, we used a paradox lens to group themes into four contextual dimensions: performing, organising, belonging and learning. RESULTS: Tensions were apparent in the data, with managers, surgeons and trainees or residents in conflict with each other because of different goals or priorities and divergent perspectives on the same issue of balancing service and training (performing). This adversely impacted on relationships across and within groups (belonging, learning) and led to individuals prioritising their own goals rather than working for the 'greater good' (performing, belonging). Yet although relationships and communication improved, the approach to getting a better balance maintained the 'compartmentalisation' of training (organising) rather than acknowledging that training and service cannot be separated. DISCUSSION: Stakeholder responses to the tensions provided temporary relief but were unlikely to lead to real change if the tension between service and training was considered to be an interdependent and persistent paradox. Reframing the service-training paradox in this way may encourage adjusting responses to create effective working partnerships. Our findings add to the body of knowledge on this topic, and will resonate with all those engaged in surgical and other postgraduate training.

A qualitative systematic review on the application of the normalization of deviance phenomenon within high-risk industries.

INTRODUCTION: The concept of normalization of deviance describes the gradual acceptance of deviant observations and practices. It is founded upon the gradual desensitization to risk experienced by individuals or groups who recurrently deviate from standard operating procedures without encountering negative consequences. Since its inception, normalization of deviance has seen extensive, but segmented, application across numerous high-risk industrial contexts. The current paper describes a systematic review of the existing literature on the topic of normalization of deviance within high-risk industrial settings. METHOD: Four major databases were searched in order to identify relevant academic literature, with 33 academic papers meeting all inclusion criteria. Directed content analysis was used to analyze the texts. RESULTS: Based on the review, an initial conceptual framework was developed to encapsulate identified themes and their interactions; key themes linked to the normalization of deviance included risk normalization, production pressure, culture, and a lack of negative consequences. CONCLUSIONS: While preliminary, the present framework offers relevant insights into the phenomenon that may help guide future analysis using primary data sources and aid in the development of intervention methods. PRACTICAL APPLICATIONS: Normalization of deviance is an insidious phenomenon that has been noted in several high-profile disasters across a variety of industrial settings. A number of organizational factors allow for and/or propagate this process, and as such, the phenomenon should be considered as an aspect of safety evaluations and interventions.

Medical students' views of clinical environments.

BACKGROUND: Monitoring the quality of clinical learning environments (CLEs) is immensely important in medical education. Objective indicators of the quality of the CLE can be used to measure learner perceptions and to inform educational improvements; however, many established tools were not designed for use in clinical settings and are not theoretically grounded. Our aim was to apply a new tool to the new context of a UK setting to explore the perceptions of senior medical students in a number of different CLEs. Monitoring the quality of clinical learning environments is immensely important in medical education METHODS: The four-factor Undergraduate Clinical Education Environment Measure (UCEEM) was translated into English, and used to gather final-year medical students' perceptions of four different specialties they had rotated through: Emergency Medicine (EM), General Surgery (GS), Medicine for the Elderly (ME), and Obstetrics and Gynaecology (O&G). The UCEEM was distributed in paper form. Students were asked to complete it in relation to two of the four specialties. RESULTS/FINDINGS: Year-5 medical students (n = 132) returned a completed UCEEM. For opportunities to learn in and through work experience EM was reported the most positively. ME was perceived to be the most prepared for student entry. Students reported being well received by staff and made to feel part of the team within GS, EM and ME, but less so in O&G. DISCUSSION: UCEEM appears to be a useful tool for evaluating medical student perceptions of CLEs. Theoretically robust, UCEEM is straightforward to administer and to score. It has the potential to be used by time-pressured educators to collect baseline and comparative data for evaluation and improvement purposes.

Staying in the zone: offshore drillers' situation awareness.

OBJECTIVE: The aim of this study was to identify the cognitive components required for offshore drillers to develop and maintain situation awareness (SA) while controlling subsea hydrocarbon wells. BACKGROUND: SA issues are often identified as contributing factors to drilling incidents, most recently in the Deepwater Horizon blowout. Yet, there is a limited body of research investigating SA in the offshore drilling environment. METHOD: In the first study, critical incident interviews were conducted with 18 experienced drilling personnel. Transcripts were subjected to theory-driven thematic analysis, producing a preliminary cognitive framework of how drillers develop and maintain SA during well control. In the second study, 24 hr of observations (in vivo and video) of drillers managing a high fidelity well-control simulator were analyzed to further develop the framework. RESULTS: The cognitive components that enable drillers to build up an understanding of what is happening in the wellbore and surrounding environment, to predict how this understanding may develop, were identified. These components included cue recognition, interpretation of information in conjunction with the current mental model, and projection through mental simulation. Factors such as distracters, expectations, and information sharing between crew members can both positively and negatively influence the drillers' SA. CONCLUSION: The findings give a preliminary understanding into the components of drillers' SA, highlighting the importance of SA for safe and effective performance and indicating that Endsley's model of SA can be applied to drilling. APPLICATION: The results have consequences for training, task management, and work design recommendations.