ALLin4IPE- an international research study on interprofessional health professions education: a protocol for an ethnographic multiple-case study of practice architectures in sites of students' interprofessional clinical placements across four universities.

BACKGROUND: The global discourse on future health care emphasises that learning to collaborate across professions is crucial to assure patient safety and meet the changing demands of health care. The research on interprofessional education (IPE) is diverse but with gaps in curricula design and how IPE is enacted in practice. PURPOSE AND AIMS: This research project will identify. 1) how IPE in clinical placements emerges, evolves, and is enacted by students when embedded in local health care practices, 2) factors critical for the design of IPE for students at clinical placements across the four countries. METHODS: A study involving four countries (Sweden, Norway, Australia and New Zealand) using the theory of practice architectures will be undertaken between 2023 and 2027. The project is designed as an international, collaborative multiple-case ethnographic study, using the theoretical framework of practice architectures (TPA). It will include four ethnographic case studies of IPE, one in each country. Data will be collected in the following sequence: (1) participant observation of students during interprofessional placements, (2) interviews with students at clinical placement and stakeholders/professionals, (3) Non-clinical documents may be used to support the analysis, and collection of photos may be use as memory aids for documenting context. An analysis of "sayings, doings and relatings" will address features of the cultural- discursive, material-economic, social-political elements making up the three key dimensions of TPA. Each of the four international cases will be analysed separately. A cross case analysis will be undertaken to establish common learning and critical IPE design elements across the four collaborating universities. DISCUSSION: The use of TPA framework and methodology in the analysis of data will make it possible to identify comparable dimensions across the four research sites, enabling core questions to be addressed critical for the design of IPE. The ethnographic field studies will generate detailed descriptions that take account of country-specific cultural and practice contexts. The study will also generate new knowledge as to how IPE can be collaboratively researched.

Connecting knowledge: First-year health care students' learning in early interprofessional tutorials.

Collaboration across professional boundaries is an essential aspect of health care, and interprofessional education (IPE) is a common way to help increase students' collaborative abilities. Research on how and when IPE should be arranged in a curriculum remains, however, inconclusive. How students actually develop interprofessional competencies have been difficult to demonstrate and is still an under-researched area. Studying IPE in context is therefore important to understand its full complexity. This paper examines how students work with scenarios from professional health care contexts when learning together in interprofessional problem-based learning tutorials during the first year of undergraduate education. The data are video-recorded tutorials of students from medicine, nursing, occupational therapy, speech and language pathology, and physiotherapy programmes. The analysis focuses on students' discussing their readings of the literature. Drawing on "Communities of Practice," findings show that students discuss and connect professional knowledge, with "brokers" (the tutors) and "boundary objects" (scenarios) supporting the emergence of students' professional knowledge. The scenarios, as boundary objects, also enabled the students to turn into brokers themselves. The paper contributes to research on interprofessional learning and offers support for implementing IPE in the early stages of undergraduate education.

Technology-Enhanced Learning of Human Trauma Biomechanics in an Interprofessional Student Context.

Phenomenon: This study aimed to investigate how students can develop their understanding of trauma biomechanics by means of technology-enhanced learning-an interactive visualization tool developed to enhance understanding of the biomechanics underlying an injury via dynamic imaging sequences. Approach: Students were invited to explore the content as a learning resource during an interprofessional clinical placement on an orthopedic ward. Thirty volunteer medical, nursing, and physiotherapy/occupational therapy students participated in 10 interprofessional groups of three participants. They were video recorded while interacting with learning software that was divided into five sections: Work Up, General Information, Biomechanical Case Study, Biomechanical Risk Assessment, and Treatment. Investigators probed students' learning experiences via four focus group discussions. A sociomaterial perspective was adopted, directing the analytical focus to how students' made use of talk, gestures, bodies, and material objects to understand the visualized phenomena. Findings: When connecting the visualization to a patient case, certain features of the technology stood out as important for promoting engagement and understanding trauma mechanisms. Decreased tempo, showing the directions and dynamics of trauma biomechanics in slow-motion, and color coding of the strain on the affected structures were especially important for evoking the emotional responses. The visualization tool also supported students' explorations of causal relationships between external forces and their biomedical effects. These features emphasize the sociomaterial relation between the design of the technology and the student activities. Insights: Dynamic visualization of biomechanical events has the potential to improve the understanding of injury mechanisms and specifically to identify anatomical structures at high risk of injury. Dynamic visualizations for educational purposes seem to promote possibilities for learners to contextualize visual representations relative to one's own body. Educational methods and practice need explicit attention and development in order to use the full potential of the visualization technology for learning for the health care professions.

'In the hospital all is taken care of': a practice-theoretical approach to understand patients' medication use.

Drawing from case examples of medication review implementation in three hospital settings in Sweden, this article examines patients' medication use. Based on a practice theory approach and utilising data from interviews with patients and participant observation, we reconstruct three practices of everyday medication use centring on accepting, challenging or appropriating medication orders. This article argues that patients' medication practices are embedded in wider practice arrangements that afford different modes of agency. Reconceptualising patients' medication use from a practice-based perspective revealed the meaning-making, order-producing and identity-forming features of these practices. Also, we illustrated how different modes of agency were achieved in patients' medication practices, suggesting a fluidity of both the meanings attached to and the identities related to medication use. Our findings have practical implications as these practices of medication use can be transformed when altering the arrangements they are embedded in, thus going beyond the clinical encounter.

Nursing assistants matters-An ethnographic study of knowledge sharing in interprofessional practice.

Interprofessional collaboration involves some kind of knowledge sharing, which is essential and will be important in the future in regard to the opportunities and challenges in practices for delivering safe and effective health care. Nursing assistants are seldom mentioned as a group of health care workers that contribute to interprofessional collaboration in health care practice. The aim of this ethnographic study was to explore how the nursing assistants' knowledge can be shared in a team on a spinal cord injury rehabilitation ward. Using a sociomaterial perspective on practice, we captured different aspects of interprofessional collaboration in health care. The findings reveal how knowledge was shared between professionals, depending on different kinds of practice architecture. These specific cultural-discursive, material-economic, and social-political arrangements enabled possibilities through which nursing assistants' knowledge informed other practices, and others' knowledge informed the practice of nursing assistants. By studying what health care professionals actually do and say in practice, we found that the nursing assistants could make a valuable contribution of knowledge to the team.

Interprofessional student meetings in municipal health service - Mutual learning towards a Community of Practice in patient care.

Mutual engagement is fundamental in interprofessional collaboration. This paper investigated how mutual engagement evolves in interprofessional student meetings when medical, nursing, occupational therapy and physiotherapy students shape their own collaboration and learning in patient care. We conducted a qualitative study with an ethnographic design. The data material consists of 200 hours of observations across nine student groups and two informal conversations with each student group during a two-week clinical placement in the period of 2014-2015. The interprofessional student meetings and the informal conversations were audio recorded, and field notes were prepared from our observations of the student activities. In the data analysis, we relied on an interpretative thematic analysis and used the sociocultural theory of learning as an interpretative framework. The analysis showed that mutuality evolved through three types of mutual engagement: facilitating interactions, actual interactions and clarifying further interactions. In conclusion, complex mutual engagement in patient care evolved and was maintained in interprofessional student meetings when the students had an explicit opportunity to shape their own interprofessional collaboration and learning. The students' opportunity to shape the interprofessional collaborative practice in patient care themselves appeared to be a criterion for success.

International consensus statement on the assessment of interprofessional learning outcomes.

Regulatory frameworks around the world mandate that health and social care professional education programs graduate practitioners who have the competence and capability to practice effectively in interprofessional collaborative teams. Academic institutions are responding by offering interprofessional education (IPE); however, there is as yet no consensus regarding optimal strategies for the assessment of interprofessional learning (IPL). The Program Committee for the 17th Ottawa Conference in Perth, Australia in March, 2016, invited IPE champions to debate and discuss the current status of the assessment of IPL. A draft statement from this workshop was further discussed at the global All Together Better Health VIII conference in Oxford, UK in September, 2016. The outcomes of these deliberations and a final round of electronic consultation informed the work of a core group of international IPE leaders to develop this document. The consensus statement we present here is the result of the synthesized views of experts and global colleagues. It outlines the challenges and difficulties but endorses a set of desired learning outcome categories and methods of assessment that can be adapted to individual contexts and resources. The points of consensus focus on pre-qualification (pre-licensure) health professional students but may be transferable into post-qualification arenas.

Observing of interprofessional collaboration in simulation: A socio-material approach.

Simulation exercises are becoming more common as an educational feature of the undergraduate training of health professionals. Not all students participate in these activities, but are assigned as observers of the actual simulation. This article presents a study that explored how social-material arrangements for observation of interprofessional collaboration in a simulated situation are enacted and how these observations are thematised and made relevant for learning. The empirical data consisted of 18 standardised video recordings of medical and nursing students observing their peer students simulate. Practice theory is used to show how observation is embodied, relational, and situated in social-material relations. The findings show two emerging ways of enacting observation-proximate observation and distant observation. The enactments are characterised by different socio-material arrangements concerning the location where the simulation took place and its material set-up as well as embodied "doings" and "relatings" between the observing students and instructors. The observing students are participating in a passive, normative position as an audience and as judges of what is correct professional behaviour.

Impact of a standardized training program on midwives' ability to assess fetal heart anatomy by ultrasound.

BACKGROUND: Studies of prenatal detection of congenital heart disease (CHD) in the UK, Italy, and Norway indicate that it should be possible to improve the prenatal detection rate of CHD in Sweden. These studies have shown that training programs, visualization of the outflow tracts and color-Doppler all can help to speed up and improve the detection rate and accuracy. We aimed to introduce a more accurate standardized fetal cardiac ultrasound screening protocol in Sweden. METHODS: A novel pedagogical model for training midwives in standardized cardiac imaging was developed, a model using a think-aloud analysis during a pre- and post-course test and a subsequent group reflection. The self-estimated difficulties and knowledge gaps of two experienced and two beginner midwives were identified. A two-day course with mixed lectures, demonstrations and hands-on sessions was followed by a feedback session three months later consisting of an interview and check-up. The long-term effects were tested two years later. RESULTS: At the post-course test the self-assessed uncertainty was lower than at the pre-course test. The qualitative evaluation showed that the color Doppler images were difficult to interpret, but the training seems to have improved their ability to use the new technique. The ability to perform the method remained at the new level at follow-up both three months and two years later. CONCLUSIONS: Our results indicate that by implementing new imaging modalities and providing hands-on training, uncertainty can be reduced and examination time decreased, but they also show that continuous on-site training with clinical and technical back-up is important.

Understanding clinical reasoning: A phenomenographic study with entry-level physiotherapy students.

INTRODUCTION: Entry-level students' conceptualizations of clinical reasoning can provide a starting point for program planning related to clinical reasoning development with a focus on patient-centered care. OBJECTIVE: The aim of the study is to explore how physiotherapy students understand clinical reasoning midway through their education. Nine physiotherapy students were interviewed at the end of their third semester. METHODS: Semi-structured individual interviews were conducted, recorded and transcribed verbatim. A phenomenographic approach to qualitative data analysis, seeking to explore variations in students' conceptions was applied. RESULTS: The students' ways of understanding clinical reasoning could be described as: 1) the cognitive process of the physiotherapist; and 2) the relational process of the collaborative partnership between the physiotherapist and the patient. A contrastive analysis shows how the cognitive and relational perspectives are developed through the relationships among three dimensions of clinical reasoning: 1) problem-solving; 2) context of working; and 3) own learning. CONCLUSION: By identifying the critical variation in students' conceptions of clinical reasoning, focus can be placed on pedagogical arrangements to facilitate students' progression toward a person-centered approach.

Three Principles Informing Simulation-Based Continuing Education to Promote Effective Interprofessional Collaboration: Reorganizing, Reframing, and Recontextualizing.

INTRODUCTION: Shoulder dystocia is a complex birth emergency where patient outcomes remain a concern. This article investigates the detailed processes of simulation-based continuing education in a hospital where evidence over 10 years demonstrates improvements in practitioner knowledge, enacted practices, and maternal and child outcomes. METHODS: Data were collected by video recording teams participating in a shoulder dystocia simulation and debrief. Analysis combined grounded thematic development with purposive coding of enactments of a relevant protocol (the ALSO HELPERR). RESULTS: Three themes were identified (three Rs) that capture how effective interprofessional collaboration is promoted through collectively oriented reflection: Reorganizing roles and responsibilities between team members; Reframing the problem of shoulder dystocia from individuals correctly following a protocol, to a team of professionals who need to attune to, respond to, and support one another; and Recontextualizing by collectively "commingling" theoretical knowledge with practical experience to reflect on actions and judgements. DISCUSSION: The three Rs are relevant to diverse clinical settings and address gaps in knowledge relating to the process of interprofessional simulation. Together, they constitute a set of principles to inform the design and conduct of continuing education for interprofessional practice through simulation.

Employers' views on disability, employability, and labor market inclusion: a phenomenographic study.

Purpose: This study aims to increase our understanding of employers' views on the employability of people with disabilities. Despite employers' significant role in labor market inclusion for people with disabilities, research is scarce on how employers view employability for this group.Methods: This was a qualitative empirical study with a phenomenographic approach using semi-structured interviews with 27 Swedish employers from a variety of settings and with varied experience of working with people with disabilities.Results: The characteristics of employers' views on the employability of people with disabilities can be described as multifaceted. Different understandings of the interplay between underlying individual-, workplace-, and authority-related aspects form three qualitatively different views of employability, namely as constrained by disability, independent of disability, and conditional. These views are also characterized on a meta-level through their association with the cross-cutting themes: trust, contribution, and support.Conclusions: The study presents a framework for understanding employers' different views of employability for people with disabilities as a complex internal relationship between conceived individual-, workplace-, and authority-related aspects. Knowledge of the variation in conceptions of employability for people with disability may facilitate for rehabilitation professionals to tailor their support for building trustful partnerships with employers, which may enhance the inclusion of people with disabilities on the labor market.Implications for rehabilitationEmployers' views on employing people with disabilities vary with respect to individual-, workplace-, and authority-related aspects in relation to trust, contribution and support.Knowledge of the employers' views on the employability of people with disabilities can support professionals in authorities and in vocational rehabilitation.The findings illustrate the importance of analyzing what type of support employers need as a starting point for building trustful partnerships between authority actors and employers.The findings offer a vocabulary that can be used by professionals in authorities and in vocational rehabilitation in tailoring employer-oriented support to increase labor market inclusion of people with disabilities.

Embedding hospital-based medication review.

PURPOSE: The purpose of this paper is to explore the embedding of hospital-based medication review attending to the conflictual and developmental nature of practice. Specifically, this paper examines manifestations of contradictions and how they play out in professional practices and local embedding processes. DESIGN/METHODOLOGY/APPROACH: Using ethnographic methods, this paper employs the activity-theoretic notion of contradictions for analyzing the embedding of medication review. Data from participant observation (in total 290 h over 48 different workdays) and 31 semi-structured interviews with different healthcare professionals in two Swedish hospital-based settings (emergency department, department of surgery) are utilized. FINDINGS: The conflictual and developmental potential related to three interrelated characteristics (contested, fragmented and distributed) of the activity object is shown. The contested nature is illustrated showing different conceptualizations, interests and positions both within and across different professional groups. The fragmented character of medication review is shown by tensions related to the appraisal of the utility of the newly introduced practice. Finally, the distributed character is exemplified through tensions between individual and collective responsibility when engaging in multi-site work. Overall, the need for ongoing "repair" work is demonstrated. ORIGINALITY/VALUE: By using a practice-theoretical approach and ethnographic methods, this paper presents a novel perspective for studying local embedding processes. Following the day-to-day work of frontline clinicians captures the ongoing processes of embedding medication review and highlights the opportunities to learn from contradictions inherent in routine work practices.

Doctors' and nurses' perceptions of military pre-hospital emergency care - When training becomes reality.

The aim of this study was to identify physicians' and nurses' perceptions of military pre-hospital emergency care before and after an international mission. A qualitative empirical study with a phenomenographic approach was used. The results after pre-deployment training can be categorised as (1) learning about military medicine and (2) taking care of the casualty. The results after an international mission can be categorised as (1) collaborating with others, (2) providing general health care and (3) improving competence in military medicine. These results indicate that the training should be developed in order to optimise pre-deployment training for physicians and nurses. This may result in increased safety for the provider of care, while at the same time minimising suffering and enhancing the possibility of survival of the injured.

Co-Producing Interprofessional Round Work: Designing Spaces for Patient Partnership.

Within wide-ranging quality improvement agendas, patient involvement in health care is widely accepted as crucial. Ward rounds that include patients' active participation are growing as an approach to involve patients, ensure safety, and improve quality. An emerging approach to studying quality improvement is to focus on "clinical microsystems," where patients, professionals, and information systems interact. This provides an opportunity to study ward rounds more deeply. A new model of conducting ward rounds implemented through quality improvement work was studied, using the theory of practice architectures as an analytical tool. Practice architecture focuses on the cultural-discursive, social-political, and material-economic conditions that shape what people do in their work. Practice architecture is a sociomaterial theoretical perspective that has the potential to change how we understand relationships between practice, learning, and change. In this study, we examine how changes in practices are accomplished. The results show that practice architecture formed co-productive learning rounds, a possible model integrating quality improvement in daily work. This emerged in the interplay between patients through their "double participation" (as people and as information on screens), and groups of professionals in a ward round room. However, social interplay had to be renegotiated in order to accomplish the goals of all ward rounds.

Method matters: impact of in-scenario instruction on simulation-based teamwork training.

BACKGROUND: The rationale for introducing full-scale patient simulators in training to improve patient safety is to recreate clinical situations in a realistic setting. Although high-fidelity simulators mimic a wide range of human features, simulators differ from the body of a sick patient. The gap between the simulator and the human body implies a need for facilitators to provide information to help participants understand scenarios. The authors aimed at describing different methods that facilitators in our dataset used to provide such extra scenario information and how the different methods to convey information affected how scenarios played out. METHODS: A descriptive qualitative study was conducted to examine the variation of methods to deliver extra scenario information to participants. A multistage approach was employed. The authors selected film clips from a shared database of 31 scenarios from three participating simulation centers. A multidisciplinary research team performed a collaborative analysis of representative film clips focusing on the interplay between participants, facilitators, and the physical environment. After that, the entire material was revisited to further examine and elaborate the initial findings. RESULTS: The material displayed four distinct methods for facilitators to convey information to participants in simulation-based teamwork training. The choice of method had impact on the participating teams regarding flow of work, pace, and team communication. Facilitators' close access to the teams' activities when present in the simulation suite, either embodied or disembodied in the simulation, facilitated the timing for providing information, which was critical for maintaining the flow of activities in the scenario. The mediation of information by a loudspeaker or an earpiece from the adjacent operator room could be disturbing for team communication. CONCLUSIONS: In-scenario instruction is an essential component of simulation-based teamwork training that has been largely overlooked in previous research. The ways in which facilitators convey information about the simulated patient have the potential to shape the simulation activities and thereby serve different learning goals. Although immediate timing to maintain an adequate pace is necessary for professionals to engage in training of medical emergencies, novices may gain from a slower tempo to train complex clinical team tasks systematically.

Incentives for lifestyle changes in patients with coronary heart disease.

AIM: This paper reports a study exploring how patients in the rehabilitation phase of coronary heart disease experience facilitating and constraining factors related to lifestyle changes of importance for wellbeing and prognosis. BACKGROUND: Lifestyle change is important but complex during rehabilitation after a myocardial infarction or angina pectoris. The intentions to perform behaviours and to experience control over facilitators and constraints are important determinants of behaviour. METHODS: A total of 113 consecutive patients below 70 years of age (84 men and 29 women) were interviewed within 6 weeks of a cardiac event and again after 1 year. Interview transcriptions and notes taken by hand were qualitatively analysed using the phenomenographic framework. The distribution of statements among the categories identified was quantitatively analysed. The data were collected in 1998-2000. FINDINGS: Four main categories portrayed patients' experiences of facilitating or constraining incentives for lifestyle changes. 'Somatic incentives' featured bodily signals indicating improvements/illness. 'Social/practical incentives' involved shared concerns, changed conditions including support/demand from social network, and work/social security issues. Practical incentives concerned external environmental factors in the patients' concrete context. 'Cognitive incentives' were characterized by active decisions and appropriated knowledge, passive compliance with limited insights, and routines/habits. 'Affective incentives' comprised fear of and reluctance in the face of lifestyle changes/disease, lessened self-esteem, and inability to resist temptations. Cognitive incentives mostly facilitated physical exercise and drug treatment. Social/practical incentives facilitated physical exercise and diet change. Physical exercise and diet changes were mainly constrained by somatic, social, and affective incentives. CONCLUSION: The results illustrate important incentives that should be considered in contacts with patients and their families to improve the prospects of positively affecting co-operation with suggested treatment and lifestyle changes.