Using cultural historical activity theory to understand how post-graduate residents perform discharge planning at a medical center in Taiwan.

BACKGROUND: Despite the importance of discharge planning in physicians' education, currently in most countries, no identical training is provided. Difficulties in promoting physician discharge planning education in Taiwan are still noted. This study aims to find the physicians' role of discharge planning training in educating post graduate year residents (PGY) in Taiwan. MATERIALS AND METHODS: We took advantage of government and hospital policies that promote the discharge planning program to teach and implement it, beginning with PGY residents by incorporating it into their training program. We recruited 30 PGY residents who were attending their three-month general internal medicine training from 2018 to 2019. They were interviewed at the end of the program using cultural-historical activity theory (CHAT). Qualitative research methods were used to further understand how discharge planning and care was implemented. RESULTS: Trainees initially believed that they did not have any role in discharge planning. Using the cycle of expansive learning, we found that the role of physicians in discharge planning was unclear. There were still some inconsistencies in the teaching and implementation of the discharge planning program for PGY residents that needed to be resolved, but this study also let participants learn through practice to improve their identification of discharge planning. CONCLUSIONS: This study analyzed the impact of a discharge planning program for PGY physicians in Taiwan. It showed that the program affected physicians' practice and medical education, although some contradictions remain.

Enhancing students' agency in learning anatomy vocabulary with a formative intervention design.

One of the major challenges for health science students is the rapid acquisition of a new vocabulary in anatomy comprising several hundred new words. Research has shown that vocabulary learning can be improved when students are directed to vocabulary strategies. This paper reported a study with a formative intervention design inspired by Vygotsky's method of double stimulation. In this design, the students were put in a structured situation that invited them to identify the challenges in learning anatomy and then provided them with active guidance and a range of anatomy vocabulary learning strategies that scaffolded them to work out a solution to the challenge and develop their individualized anatomy learning resources. The data were collected from surveys, pre and postquiz results, and group discussion transcripts. The results revealed students perceived one of the main challenges in learning anatomy was learning, memorizing, and remembering many new words. A key finding in our study was that the formative intervention enhanced students' agency in creating resources for learning anatomy vocabulary. In addition, the development of their understanding showed a recursive form: from concrete experiences to abstract concepts and then to concrete new practices.

Using cultural historical activity theory to reflect on the sociocultural complexities in OSCE examiners' judgements.

Examiners' judgements play a critical role in competency-based assessments such as objective structured clinical examinations (OSCEs). The standardised nature of OSCEs and their alignment with regulatory accountability assure their wide use as high-stakes assessment in medical education. Research into examiner behaviours has predominantly explored the desirable psychometric characteristics of OSCEs, or investigated examiners' judgements from a cognitive rather than a sociocultural perspective. This study applies cultural historical activity theory (CHAT) to address this gap in exploring examiners' judgements in a high-stakes OSCE. Based on the idea that OSCE examiners' judgements are socially constructed and mediated by their clinical roles, the objective was to explore the sociocultural factors that influenced examiners' judgements of student competence and use the findings to inform examiner training to enhance assessment practice. Seventeen semi-structured interviews were conducted with examiners who assessed medical student competence in progressing to the next stage of training in a large-scale OSCE at one Australian university. The initial thematic analysis provided a basis for applying CHAT iteratively to explore the sociocultural factors and, specifically, the contradictions created by interactions between different elements such as examiners and rules, thus highlighting the factors influencing examiners' judgements. The findings indicated four key factors that influenced examiners' judgements: examiners' contrasting beliefs about the purpose of the OSCE; their varying perceptions of the marking criteria; divergent expectations of student competence; and idiosyncratic judgement practices. These factors were interrelated with the activity systems of the medical school's assessment practices and the examiners' clinical work contexts. Contradictions were identified through the guiding principles of multi-voicedness and historicity. The exploration of the sociocultural factors that may influence the consistency of examiners' judgements was facilitated by applying CHAT as an analytical framework. Reflecting upon these factors at organisational and system levels generated insights for creating fit-for-purpose examiner training to enhance assessment practice.

Teaching critical reflection in health professions education with transformative-vygotskian praxis.

Reflective practice is a complex concept to adequately describe, communicate about and, ultimately, teach. Unrelieved tensions about the concept persist within the health professions education (HPE) literature owing to reflection's diverse theoretical history. Tensions extend from the most basic, e.g., what is reflection and what are its contents, to the complex, e.g., how is reflection performed and whether it should be evaluated. Nonetheless, reflection is generally seen as vital to HPE, because it imparts crucial strategies and awareness to learners in their professional practices. In this article, we explore both conceptual and pedagogical dimensions of teaching for reflection. We address the concept of reflection, its application to practice, and how to remain faithful to transformative, critical pedagogy when teaching for it. We present (a) an analysis of two theories of education in HPE: Transformative Learning and Vygotskian Cultural Historical Theory. We (b) outline a pedagogical approach that applies Piotr Gal'perin's SCOBA: schema for the complete orienting basis of an action. We then employ (a) and (b) to provide affordances for developing materials for educational interventions across HPE contexts.

"You gotta give them hope": A structural psychobiography of Harvey Milk (1930-1978).

OBJECTIVE: In this psychobiographical study, we examined the life and times of social change agent Harvey Milk, one of the first openly gay public officials in the United States. Milk is remembered as a gay hero who fought for the rights of marginalized people, often by invoking the importance of hope. Milk was assassinated less than 1 year after his election. METHOD: We adopt a structural psychobiographical approach, foregrounding social, cultural, political, and historical forces that intersect with personal factors to explain Milk's ascension to the status of social change agent. RESULTS: This psychobiography tells the story of a man not destined to become a social change agent but who became one anyway because of shifting tides in the political climate of San Francisco in the 1970s, because of a series of catalytic events that started him down this path, because of a history of persecution as a gay Jew, and because of his enduring need for a stage upon which he could express his generative concern. CONCLUSIONS: Our analysis raises questions about the story that "belongs" to the agent of social change, and the story that "belongs" to the rest of us, as we remember him.

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

PURPOSE: The hope that reliably testing clinicians' competencies would improve patient safety is unfulfilled and clinicians' psychosocial safety is deteriorating. Our purpose was to conceptualise 'mutual safety', which could increase benefit as well as reduce harm. METHODS: A cultural-historical analysis of how medical education has positioned the patient as an object of benefit guided implementation research into how mutual safety could be achieved. RESULTS: Educating doctors to abide by moral principles and use rigorous habits of mind and scientific technologies made medicine a profession. Doctors' complex attributes addressed patients' complex diseases and personal circumstances, from which doctors benefited too. The patient safety movement drove reforms, which reorientated medical education from complexity to simplicity: clinicians' competencies should be standardised and measurable, and clinicians whose 'incompetence' caused harm remediated. Applying simple standards to an increasingly complex, and therefore inescapably risky, practice could, however, explain clinicians' declining psychosocial health. We conducted a formative intervention to examine how 'acting wisely' could help clinicians benefit patients amidst complexity. We chose the everyday task of insulin therapy, where benefit and harm are precariously balanced. 247 students, doctors, and pharmacists used a thought tool to plan how best to perform this risky task, given their current clinical capabilities, and in the sometimes-hostile clinical milieus where they practised. Analysis of 1000 commitments to behaviour change and 600 learning points showed that addressing complexity called for a skills-set that defied standardisation. Clinicians gained confidence, intrinsic motivation, satisfaction, capability, and a sense of legitimacy from finding new ways of benefiting patients. CONCLUSION: Medical education needs urgently to acknowledge the complexity of practice and synergise doctors' and patients' safety. We have shown how this is possible.

Embracing ambiguity: Curriculum design and activity theory.

A curriculum innovation for a new UK medical school - Peninsula, launched in 2002 - was grounded in a period of radical pedagogical innovation in medical education in the UK during the 1990s. Part of this thinking was to include the medical humanities as a medium for re-thinking medical practice, especially how medical students might better learn to communicate with patients and colleagues, and how they might become agents of change in progressing medicine through innovations. In designing the curriculum, Cultural-historical Activity Theory (CHAT) was used as a model to 'think', or reconceptualise, the purposes of a curriculum. The first question asked was: 'what do patients want?' Emphasis was placed on resisting a 'will-to-stability' in adopting safe curriculum process, in favour of adopting a 'possibility knowledge' framework that celebrated dialogue. This operated through three 'spearheads', or radical aims: democratic habits, towards the feminine, and tender-mindedness.

A change laboratory for maternity care in Brazil: Pilot implementation of Mother Baby Friendly Birthing Initiative.

Disrespectful and abusive treatment of women during childbirth is a worldwide problem. This research aimed to develop and implement a Mother Baby-Friendly Hospital Initiative (MBFHI) in an academic maternity hospital in Brazil and evaluate how change could be sustained. Change Laboratory principles guided a process of action research, which was conducted between 2017 and 2019. Clinicians and managers joined the researchers in discussion sessions to redesign routines and care pathways. Observation, interviews, focus groups, and historical and documentary analysis provided information about the existing activity system, which we analysed qualitatively using MBFHI criteria to identify themes. Evidence of inappropriate obstetric interventions and impersonal interactions between clinicians and patients stimulated us to devise innovative solutions. The challenges identified by this exercise included: poor infrastructure and ambience; difficulty adhering to evidence-based protocols; social and professional hierarchies; and clinicians being poorly educated about women's rights. Although challenges remained, positive changes included a friendlier environment, improved patient privacy, and fewer unnecessary procedures. Resources released by these changes allowed us, collaboratively, to track the further implementation and sustainability of change. We conclude that the Change Laboratory can help motivated clinicians and managers humanise patients' experiences, make care more evidence-based, and expand learning of mother-friendly maternity care. Tensions and contradictions between education and patient care reported here may resonate in settings other than maternity care.

Struggling to fit the white coat and the role of contextual factors within a hospital organisation - an ethnographic study on the first months as newly graduated doctors.

BACKGROUND: Despite increased focus on improving the transition from being a medical student to working as a junior doctor, many newly graduated doctors (NGD) report the process of fitting the white coat as stressful, and burnout levels indicate that they might face bigger challenges than they can handle. During this period, the NGDs are in a process of learning how to be doctors, and this takes place in an organisation where the workflow and different priorities set the scene. However, little is known about how the hospital organisation influences this process. Thus, we aimed to explore how the NGDs experience their first months of work in order to understand 1) which struggles they are facing, and 2) which contextual factors within the hospital organisation that might be essential in this transition. METHODS: An ethnographic study was conducted at a university hospital in Denmark including 135 h of participant observations of the NGDs (n = 11). Six semi-structured interviews (four group interviews and two individual interviews) were conducted (n = 21). The analysis was divided into two steps: Firstly, we carried out a "close-to-data" analysis with focus on the struggles faced by the NGDs. Secondly, we reviewed the struggles by using the theoretical lens of Cultural Historical Activity Theory (CHAT) to help us explore, which contextual factors within the hospital organisation that seem to have an impact on the NGDs' experiences. RESULTS: The NGDs' struggles fall into four themes: Responsibility, local knowhow, time management and collaborators. By using the CHAT lens, we were able to identify significant contextual factors, including a physically remote placement, a missing overlap between new and experienced NGDs, a time limited introduction period, and the affiliation to several departments. These struggles and factors were highly intertwined and influenced by one another. CONCLUSION: Contextual factors within the hospital organisation may aggravate the struggles experienced by the NGDs, and this study points to possible elements that could be addressed to make the transition less challenging and overwhelming.

Guiding Engineering Student Teams' Ethics Discussions with Peer Advising.

This study explores how peer advising affects student project teams' discussions of engineering ethics. Peer ethics advisors from non-engineering disciplines are expected to provide diverse perspectives and to help engineering student teams engage and sustain ethics discussions. To investigate how peer advising helps engineering student teams' ethics discussions, three student teams in different peer advising conditions were closely observed: without any advisor, with a single volunteer advisor, and with an advising team working on the ethics advising project. Micro-scale discourse analysis based on cognitive ethnography was conducted to find each team's cultural model of understanding of engineering ethics. Cultural-historical activity theory (CHAT) analysis was also conducted to see what influenced each team's cultural model. In cultural model, the engineering team with an ethics advising team showed broader understanding in social implications of engineering. The results of CHAT analysis indicated that differences in rules, community, and division of labor among three teams influenced the teams' cultural models. The CHAT analysis also indicated that the peer advisors working on the ethics advising project and the engineering team working on engineering design project created a collaborative environment. The findings indicated that collaborative environment supported peer ethics advising to facilitate team discussions of engineering ethics.

Beyond Autism: Introducing the Dialectical Misattunement Hypothesis and a Bayesian Account of Intersubjectivity.

Drawing on sociocultural theories and Bayesian accounts of brain function, in this article we construe psychiatric conditions as disorders of social interaction to fully account for their complexity and dynamicity across levels of description and temporal scales. After an introduction of the theoretical underpinnings of our integrative approach, we take autism spectrum conditions (ASC) as a paradigm example and discuss how neurocognitive hypotheses can be translated into a Bayesian formulation, i.e., in terms of predictive processing and active inference. We then argue that consideration of individuals (even within a Bayesian framework) will not be enough for a comprehensive understanding of psychiatric conditions and consequently put forward the dialectical misattunement hypothesis, which views psychopathology not merely as disordered function within single brains but also as a dynamic interpersonal mismatch that encompasses various levels of description. Moving from a mere comparison of groups, i.e., "healthy" persons versus "patients," to a fine-grained analysis of social interactions within dyads and groups of individuals will open new avenues and may allow to avoid an overly neurocentric scope in psychiatric research as well as help to reduce social exclusion.

"Do you see what I mean?" staff collaboration in eating disorder units during mealtimes.

BACKGROUND: Eating disorders are psychiatric illnesses with potentially life-threatening consequences. Inpatient treatment is typically required for the most severely ill patients, who are often emaciated or significantly malnourished. A core therapeutic objective is to normalize eating patterns and facilitate weight gain. These goals guide the efforts of milieu therapeutic staff working with this patient group, who support renourishment through the positive manipulation of a structured environment, as well via relational aspects. However, there is a lack of empirical research exploring inpatient staff members' perspectives concerning various aspects of this work. This article explore staff's teamwork during mealtimes on inpatient eating disorder units. Specifically, we investigated the collaborative strategies employed to support core therapeutic goals of meal completion and normalized eating behavior, while concurrently maintaining a supportive, friendly atmosphere during mealtimes. METHODS: This was a exploratory qualitative study. Data was collected through 20 semi-structured in-depth interviews with staff members working on a specialized eating disorder unit. The interviews were performed after the conduction of meal time support. Cultural historical activity theory was used as the key theoretical tool for analysis. RESULTS: The analysis revealed three main themes: 1) strategic seating arrangements mediates division of labor, 2) the use of verbal and nonverbal communication as collaborative tools, and 3) the importance of experience as a collaborative resource. CONCLUSIONS: The present study found that mealtime collaborative strategies on inpatient EDUs were mainly of non-verbal nature, with level of experience as an important premise for staff collaboration. Greater awareness about how collegial collaboration is practiced may help staff members to learn routines and regulate scripts for mealtime practices.

Reconceptualizing practice with multilingual children with speech sound disorders: people, practicalities and policy.

BACKGROUND: The speech and language therapy profession is required to provide services to increasingly multilingual caseloads. Much international research has focused on the challenges of speech and language therapists' (SLTs) practice with multilingual children. AIMS: To draw on the experience and knowledge of experts in the field to: (1) identify aspirations for practice, (2) propose recommendations for working effectively with multilingual children with speech sound disorders, and (3) reconceptualize understandings of and approaches to practice. METHODS & PROCEDURES: Fourteen members of the International Expert Panel on Multilingual Children's Speech met in Cork, Ireland, to discuss SLTs' practice with multilingual children with speech sound disorders. Panel members had worked in 18 countries and spoke nine languages. Transcripts of the 6-h discussion were analysed using Cultural-Historical Activity Theory (CHAT) as a heuristic framework to make visible the reality and complexities of SLTs' practice with multilingual children. OUTCOMES & RESULTS: Aspirations and recommendations for reconceptualizing approaches to practice with multilingual children with speech sound disorders included: (1) increased training for working with multilingual children, their families, and interpreters, (2) increased training for transcribing speech in many languages, (3) increased time and resources for SLTs working with multilingual children and (4) use of the International Classification of Functioning, Disability and Health (ICF-CY). CONCLUSIONS & IMPLICATIONS: The reality and complexities of practice identified in this paper highlight that it is not possible to formulate and implement one 'gold standard' method of assessment and intervention for all multilingual children with speech sound disorders. It is possible, however, to underpin practice with a framework that ensures comprehensive assessment, accurate diagnosis and effective intervention. This paper proposes that by working towards the aspirations of the Expert Panel, SLTs can be empowered to facilitate appropriate services for multilingual children regardless of the context in which they live and the languages they speak.

Babies in the Corporeal Turn: The Cognitive Embodiment of Early Motor Development and Exploration in the Brazilian Context of Early Childhood Education.

The corporeal turn in developmental psychology has rekindled interest regarding how early motor development contributes to and enhances cognitive development across the first years of life. By highlighting embodied perceptual-motor engagement with the world, embodied cognitive learning emphasizes the importance of experience and perceptual-motor mechanisms in modulating the development of person-environment systems. The field currently calls for research that combines such conceptual frameworks with the complex everyday material and sociocultural landscapes that resource infants' developmental trajectories. We, therefore, aim to connect the conceptual refinement of bodily-anchored exploration to the contextual reality of everyday settings of early childhood education (ECE)-here situated in the Brazilian context-as relevant social and cultural suppliers and modulators of the developmental trajectories of babies. Secondarily, we ponder on the premises of national pedagogical curricula and their role in mediating the quality of experiences and systems of person-environment relations more closely. Cultural-historical psychology, in dialogue with the principles of Ecological Psychology, constitutes the theoretical framework that underpins the microgenetic analyses conducted. By analyzing episodes of exploratory actions of a focal baby situated in the ECE context, we seek to apprehend motor-perceptual indicators of embodied cognitive processing by considering the modes of appropriation entailed in episodes of embodied exploration. We reflect on pedagogical implications considering official national documents of early childhood education. This work contributes by providing complementary insights into the nature of infants' everyday sociocultural embodied experiences and their development in pedagogically oriented settings.

Between Meanings and Senses-Making Spaces: Agency and Ownership Emergence Formalization from Cultural-Historical Activity Theory Position, for an AI-Friendly Model.

Sense of agency and sense of ownership are considered crucial in autonomous systems. However, drawbacks still exist regarding how to represent their causal origin and internal structure, either in formalized psychological models or in artificial systems. This paper considers that these drawbacks are based on the ontological and epistemological duality in mainstream psychology and AI. By shedding light on the cultural-historical activity theory (CHAT) and dialectical logic, and by building on and extending related work, this paper attempts to investigate how the noted duality affects investigating the self and "I". And by differentiating between the space of meanings and the sense-making space, the paper introduces CHAT's position of the causal emergence of agency and ownership by stressing the twofold transition theory being central to CHAT. Furthermore, a qualitative formalized model is introduced to represent the emergence of agency and ownership through the emergence of the contradictions-based meaning with potential employment in AI.

Intergenerational Storytelling as a Developmental Resource in LGBTQ+ Communities.

LGBTQ+ people continue to be threatened by systemic censorship and erasure in public spaces and discourses, making community-based resources for positive development crucial. In this study, we examined one such developmental resource-LGBTQ+ intergenerational storytelling about cultural-historical events. LGBTQ+ adults (N = 495) ranging in age from 17 to 80 years (M = 39.22, SD = 19.89) responded to an online survey about LGBTQ+ intergenerational storytelling and relationships. Results showed that although LGBTQ+ intergenerational storytelling was reported to occur infrequently, sharing stories across generations was considered important, and LGBTQ+ people desired even greater intergenerational connection. Intergenerational narratives reported by participants were primarily about cultural-historical events involving adversity and oppression (e.g. AIDS crisis), policy and legislation (e.g. marriage equality), and protest, resistance, and activism (e.g. Stonewall uprising). Stories were mostly told by older friends in private or social settings for the purpose of passing on LGBTQ+ history. Lessons learned through storytelling were diverse but tended to focus on appreciation and affirmation. Valuing intergenerational storytelling was associated with positive psychosocial identity. This study suggests that intergenerational storytelling may be an important developmental resource for LGBTQ+ people and other marginalized communities.

Setting the Theater for Creativity: Proposal for Integrating Temporal and Spatial Artificial Mnemonics as a Qualitative Artificial Development of the Autobiographical Naturalistic Mnemonics (AM).

Mnemonics are not only tools that empower memory but also have a significant role in qualitatively transforming mental functions and, hence, consciousness in general. A specific type of mnemonics is autobiographical mnemonics (AM) constructed of spatial, temporal, and semantic dimensions used in a naturalist form by individuals about their own experiences. This paper proposes a spatial-temporal mnemonic that transforms AM from a naturalist level into an artificial one. We consider allowing the intellect and consciousness to grasp the abstract flow of time in the global context of geography will contribute to setting the stage for creativity. By explicitly representing the abstract time-space theater, the intellect (the world view) is more able to reflect the abstract laws of reality (the world), hence, to make the intellect sphere objectively equipped to externalize the emerged meanings (the internalized reality) that reflect the internal content of experience and, hence, make sense of them as a crucial function in creative activity. The paper is a theoretical and methodological step for the empirical part of the proposal when the mnemonic should be used as a training tool to empower creativity factors.

K-nearest neighbor based on exploratory data analysis of curriculum models of Chinese early childhood education.

This research examines the unique Chinese approaches to implementing the Early Childhood Curriculum (ECC) in Shenzhen and Hong Kong, drawing on School-based Curriculum Development (SBCD) studies. A total of 200 administrators and teachers were interviewed in total, and transcripts from those interviews were examined, cross-checked, and assessed using document analysis and classroom observation. Through interviews that have been conducted by administrators and teachers analyzed by document analysis and classroom observation, the influence of Chinese culture on ECC implementation is explored using the Cultural-Historical Activity Theory (CHAT). An exploratory, inferential, and descriptive statistical approach evaluates the sociocultural mechanism of ECC in Chinese society. The proposed framework utilizes K-Nearest Neighbor (KNN) regression analysis to illustrate how social development leads to cultural fusion and conflicts. The overall sociocultural framework promotes cultural growth and inheritance in China's early childhood education settings.

Idealism, materialism, and Vygotsky's cultural historical theory.

Vygotsky straddled the period of the Russian Revolution and found himself facing the Marxist materialist ideology of the Soviet Union with the need for a new method of psychology. Ironically, the Soviet Union's need for a Marxist based method of psychology coincided with Vygotsky's prior research on methods of interpretation which were inspired by Hegel and primarily based on the role of consciousness and culture. As a result of Vygotsky's pre-revolutionary work and inspiration from Hegel clashing with the post-revolutionary need for a new methodology for psychology, Vygotsky developed his Cultural Historical Theory. In presenting his new theory, Vygotsky attempted to resolve a fundamental ideological conflict between idealism and materialism. Furthermore, Vygotsky worked to create an effective new research method by drawing inspiration from Gestalt psychology, Hegel, Marx, and Engels. The result of Vygotsky's efforts was a theory based on psychology of consciousness and mind rather than a biology-based psychology focused entirely on analysis of stimuli and responses. In analyzing Vygotsky's theory, it is useful to draw inspiration from Vygotsky's criticism of pure empiricism, and to be inspired by Vygotsky's demonstration on how deeply rooted differences between societies may be bridged by finding unexpected commonalities within opposing ideologies.

How to form shared objects to enhance university-school collaboration? A cultural-historical activity theory perspective.

Introduction: University-school (U-S) collaboration has proven to be an effective approach for teacher professional development, but it could be hampered by the lack of shared objects. To understand how shared objects are formed in U-S collaboration, this research established a university-school collaborated Change Laboratory in W primary school based on cultural-historical activity theory, which is under the background of Chinese teaching research activity. Methods: Recordings of meetings throughout the year were transcribed into texts and coded, and then analyzed via the method of grounded theory and contradiction analysis. Results: The findings reveal that, in comparison to previous studies regarding shared object formation process, this study identified an special phase named "experimental object," which highlights the significance of experimentation in U-S collaboration. Also, multiple contradictions are recognized as the driving force for shared object formation which would gradually transform into fundamental conflicts between tools. The main contradictions identified include those between scientific and daily concepts, university culture and school culture, as well as new experiment and old routine. Discussion: The current study implicates that U-S collaboration is an expansive learning process to acquire unknown knowledge, which necessitates both parties engaging in exploration and experimentation together. Furthermore, shared object formation within U-S collaboration requires participants to focus on developing teaching tools while consciously undergoing changes in aspects such as logic of thinking, culture and routine.