"Juggle the different hats we wear": enacted strategies for negotiating boundaries in overlapping relationships.

Despite agreement that teaching on professional boundaries is needed, the design of health profession curricula is challenged by a lack of research on how boundaries are maintained and disagreement on where boundaries should be drawn. Curricula constrained by these challenges can leave graduates without formal preparation for practice conditions. Dual role or overlapping relationships are an example: they continue to be taught as boundary crossings amidst mounting evidence that they must be routinely navigated in small, interconnected communities. In this study, we examined how physicians are navigating overlapping personal (non-sexual) and professional relationships with the goal to inform teaching and curricula on professional boundaries. Following constructivist grounded theory methodology, 22 physicians who had returned to their rural, northern and/or remote hometown in British Columbia, Canada or who had lived and practised in a such a community for decades were interviewed in iterative cycles informed by analysis. We identified four strategies described by physicians for regulating multiple roles within overlapping relationships: (a) signalling the appropriate role for the current context; (b) separating roles by redirecting an interaction to an appropriate context; (c) switching roles by pushing the appropriate role forward into the context and pulling other roles into the background; and (d) suspending an interfering role by ending a relationship. Negotiating boundaries within overlapping relationships may involve monitoring role clarity and role alignment, while avoiding role conflict. The enacted role regulation strategies could be critically assessed within teaching discussions on professional boundaries and also analyzed through further ethics research.

Urban ideals and rural realities: Physiotherapists navigating paradox in overlapping roles.

OBJECTIVES: Rural practitioners who develop a sense of belonging in their community tend to stay; however, belonging means neighbours become patients and non-clinical encounters with patients become unavoidable. Rural clinical experiences expose students to overlapping personal and professional relationships, but students cannot be duly prepared to navigate them because ethical practice standards primarily reflect urban, and not rural, contexts. To inform such educational activities, this study examines rural physiotherapists' strategies for navigating overlapping relationships. METHODS: Constructivist grounded theory guided iterative recruitment of 22 physiotherapists (PTs) living and practising in rural, northern or remote (RNR) communities in British Columbia, Canada, and analysis of their experiences navigating overlapping relationships. RESULTS: PTs routinely navigate overlapping relationships while mindful of practice standards, neighbourly and community expectations, personal well-being and patient welfare. While off-duty, they balance opposing expectations and manage various responsibilities to achieve contradictory goals such as being a professional who protects patient confidentiality while being an active and cordial community member. While on-duty, they face ethical dilemmas where deciding not to treat acquaintances potentially denies access to care but allows for clearer personal-professional boundaries and deciding to treat contravenes (urban) practice standards but could allow for customised patient care based on knowledge gained through both clinical and social interactions. CONCLUSION: Overlapping relationships are a rural norm. Urban ethical practice standards imposed on rural contexts put RNR practitioners in a paradoxical situation where clinical and social interactions must be but cannot be partitioned. Examining the identified strategies through the lens of paradox theory shows sophisticated cognitive framing of the conflicting and interrelated aims inherent to living and practising in RNR communities. Consequently, introducing a paradox mindset in educational activities could be explored as a way to prepare students for the ethically complex overlapping relationships that they will need to navigate during RNR clinical experiences.

Context-dependent bioactivity of versican fragments.

Versican (VCAN) proteolysis and the accumulation of VCAN fragments occur in many developmental and disease processes, affecting extracellular matrix (ECM) structure and cell phenotype. Little is known about the significance of proteolysis and the roles of fragments, or how this ECM remodeling affects the microenvironment and phenotype of diseased cells. G1-DPEAAE fragments promote aspects of epithelial-mesenchymal transitioning in developing and diseased cells, resulting in cell migration. Enhanced proliferation and invasion of tumor and endothelial cells is directly associated with G1 domain deposition and G1-DPEAAE localization respectively. These tumorigenic and angiogenic roles could explain the disease exacerbating effect often associated with G1-containing fragments, however, the pathogenicity of G1 fragments depends entirely upon the context. Overall, VCAN fragments promote tumorigenesis and inflammation; however, the specific cleavage site, the extent of cleavage activity and the microenvironment in which cleavage occurs collectively determine how this pleiotropic molecule and its fragments influence cells.

The Healthcare Travelling Roadshow: a qualitative study of a rural community engagement initiative in Canada.

INTRODUCTION: Youth from rural communities face significant challenges in the pursuit of healthcare training. Healthcare trainees with a rural background are more likely than those without to practice rurally as healthcare professionals. The Healthcare Travelling Roadshow (HCTRS) is an initiative in Canada that provides rural youth with exposure to healthcare careers, while providing healthcare students with exposure to rural opportunities, and an interprofessional education experience. To the authors' knowledge, this is the first description of an initiative for rural university-high school healthcare career outreach that involves near-peer teaching, highly interactive sessions, and an interprofessional focus. METHODS: Ten HCTRSs took place throughout northern rural and remote British Columbia between 2010 and 2017. Questionnaires were delivered to youth in a pilot research project in 2010. Healthcare students and community members completed questionnaires for ongoing program evaluation from 2010 to 2017. Quantitative elements were graded on a five-point Likert scale. Qualitative elements were analyzed thematically. RESULTS: Participants indicated that the program was very successful (4.71, 95% confidence interval (CI) 4.63-4.79), would likely encourage healthcare students to consider rural practice (4.12, 95%CI 3.98-4.26), and that it inspired local youth to consider careers in health care much or very much (4.45, 95%CI 4.35-4.55). Qualitative analysis led to description of four themes: (1) sincerity and interactivity sparking enthusiasm, (2) learning through rural exposure and community engagement, (3) healthcare student personal growth and (4) interprofessional collaboration and development. Open-ended feedback identified successes outside of the primary goals and illustrated how this program could act in a multi-faceted way to promote healthcare recruitment and retention. Constructive comments emphasized the importance of taking a balanced approach to planning the HCTRS, ensuring the goals of the HCTRS are best met, while meeting the needs of the host communities as much as possible. CONCLUSIONS: The HCTRS is an interdisciplinary experience that successfully engages rural youth, healthcare students, and community stakeholders. Participants consistently indicated that it encouraged rural youth towards healthcare careers and healthcare students towards rural practice. Success of the program requires meaningful engagement with multiple academic and community stakeholders.

Versican: a novel modulator of hepatic fibrosis.

Little is known about the deposition and turnover of proteoglycans in liver fibrosis, despite their abundance in the extracellular matrix. Versican plays diverse roles in modulating cell behavior in other fibroproliferative diseases, but remains poorly described in the liver. Hepatic fibrosis was induced by carbon tetrachloride treatment of C57BL/6 mice over 4 weeks followed by recovery over a 28-day period. Primary mouse hepatic stellate cells (HSCs) were activated in culture and versican was transiently knocked down in human (LX2) and mouse HSCs. Expression of versican, A Disintegrin-like and Metalloproteinase with Thrombospondin-1 motifs (ADAMTS)-1, -4, -5, -8, -9, -15, and -20, and markers of fibrogenesis were studied using immunohistochemistry, real-time quantitative PCR, and western blotting. Immunohistochemistry showed increased expression of versican in cirrhotic human livers and the mouse model of fibrosis. Carbon tetrachloride treatment led to significant increases in versican expression and the proteoglycanases ADAMTS-5, -9, -15, and -20, alongside TNF-α, α-smooth muscle actin (α-SMA), collagen-1, and TGF-ß expression. During recovery, expression of many of these genes returned to control levels. However, expression of ADAMTS-5, -8, -9, and -15 showed delayed increases in expression at 28 days of recovery, which corresponded with decreases in versican V0 and V1 cleavage products (G1-DPEAAE(1401) and G1-DPEAAE(441)). Activation of primary HSCs in vitro significantly increased versican, α-SMA, and collagen-1 expression. Transient knockdown of versican in HSCs led to decreases in markers of fibrogenesis and reduced cell proliferation, without inducing apoptosis. Versican expression increases during HSC activation and liver fibrosis, and proteolytic processing occurs during the resolution of fibrosis. Knockdown studies in vitro suggest a possible role of versican in modulating hepatic fibrogenesis.

Inspiring rural youth to consider healthcare careers through an interprofessional healthcare traveling roadshow.

There are well-documented shortages of healthcare providers in rural and remote communities worldwide, and these shortages correlate with inequitable health outcomes for rural peoples. Despite a wide array of efforts to remedy the issue, these shortages persist to this day. The Healthcare Traveling Roadshow (HCTRS) is a grassroots initiative that began in 2010 to help address the shortage of healthcare providers in rural communities throughout British Columbia. Since its inception, the HCTRS has been predicated on three evidence-based guiding principles which have been shown to markedly increase the rate at which healthcare students choose to practice rurally. These principles are: (1) to showcase healthcare careers as viable and realistic options for rural youth (high school students) using interactive stations and near-peer teaching; (2) to expose healthcare students to rural communities and showcase them as a potential opportunity for their future practice; and (3) to provide a unique interprofessional experience to healthcare students from diverse healthcare careers and backgrounds. Through the synergy of these three principles the HCTRS aims to increase the longitudinal recruitment and retention of healthcare workers in underserved rural communities. This paper will share our experience from 15 years of running this initiative, for those hoping to implement similar programs in other areas of the world.