Towards equitable learning environments for medical education: Bias and the intersection of social identities.

CONTEXT: Medical educators are increasingly paying attention to how bias creates inequities that affect learners across the medical education continuum. Such bias arises from learners' social identities. However, studies examining bias and social identities in medical education tend to focus on one identity at a time, even though multiple identities often interact to shape individuals' experiences. METHODS: This article examines prior studies on bias and social identity in medical education, focusing on three social identities that commonly elicit bias: race, gender and profession. By applying the lens of intersectionality, we aimed to generate new insights into intergroup relations and identify strategies that may be employed to mitigate bias and inequities across all social identities. RESULTS: Although different social identities can be more or less salient at different stages of medical training, they intersect and impact learners' experiences. Bias towards racial and gender identities affect learners' ability to reach different stages of medical education and influence the specialties they train in. Bias also makes it difficult for learners to develop their professional identities as they are not perceived as legitimate members of their professional groups, which influences interprofessional relations. To mitigate bias across all identities, three main sets of strategies can be adopted. These strategies include equipping individuals with skills to reflect upon their own and others' social identities; fostering in-group cohesion in ways that recognise intersecting social identities and challenges stereotypes through mentorship; and addressing intergroup boundaries through promotion of allyship, team reflexivity and conflict management. CONCLUSIONS: Examining how different social identities intersect and lead to bias and inequities in medical education provides insights into ways to address these problems. This article proposes a vision for how existing strategies to mitigate bias towards different social identities may be combined to embrace intersectionality and develop equitable learning environments for all.

From ideal to real: a qualitative study of the implementation of in situ interprofessional simulation-based education.

BACKGROUND: Despite the widespread adoption of interprofessional simulation-based education (IPSE) in healthcare as a means to optimize interprofessional teamwork, data suggest that IPSE may not achieve these intended goals due to a gap between the ideals and the realities of implementation. METHODS: We conducted a qualitative case study that used the framework method to understand what and how core principles from guidelines for interprofessional education (IPE) and simulation-based education (SBE) were implemented in existing in situ IPSE programs. We observed simulation sessions and interviewed facilitators and directors at seven programs. RESULTS: We found considerable variability in how IPSE programs apply and implement core principles derived from IPE and SBE guidelines with some principles applied by most programs (e.g., "active learning", "psychological safety", "feedback during debriefing") and others rarely applied (e.g., "interprofessional competency-based assessment", "repeated and distributed practice"). Through interviews we identified that buy-in, resources, lack of outcome measures, and power discrepancies influenced the extent to which principles were applied. CONCLUSIONS: To achieve IPSE's intended goals of optimizing interprofessional teamwork, programs should transition from designing for the ideal of IPSE to realities of IPSE implementation.

Exploring the role of power during debriefing of interprofessional simulations.

Interprofessional simulation aims to improve teamwork and patient care by bringing participants from multiple professions together to practice simulated patient care scenarios. Yet, power dynamics may influence interprofessional learning during simulation, which typically occurs during the debriefing. This issue has received limited attention to date but may explain why communication breakdowns and conflicts among healthcare teams persist despite widespread adoption of interprofessional simulation. This study explores the role of power during interprofessional simulation debriefings. We collected data through observations of seven interprofessional simulation sessions and debriefings, four focus groups with simulation participants, and four interviews with simulation facilitators. We identified ways in which power dynamics influenced discussions during debriefing and sometimes limited participants' willingness to share feedback and speak up. We also found that issues related to power that arose during interprofessional simulations often went unacknowledged during the debriefing, leaving healthcare professionals unprepared to navigate power discrepancies with other members of healthcare teams in practice. Given that the goal of interprofessional simulation is to allow professionals to learn together about each other, explicitly addressing power in debriefing after interprofessional simulation may enhance learning.

Embracing or relinquishing sources of power in interprofessional communication: implications for patient-centered speaking up.

Health professionals working in an interprofessional work environment are entrusted to speak up on behalf of patients. However, that environment is comprised of dynamic intra- and interprofessional hierarchies, characterized by power differentials that affect speaking up behaviors. Drawing on the social bases of power and on power/interaction theory, we analyzed focus group and interview transcripts of 62 health professionals' accounts of speaking up. We focused on their primary sources of power, and described factors associated with health professionals' embracing power to speak up for patient safety, as well as those associated with relinquishing power and remaining silent. Nurses primarily employed direct patient information as a source of power to advocate for patients. Senior nurses and attending physicians exercised their legitimate power through titles or expertise, and when embracing that power, often influenced the healthcare team's speaking up behaviors and the team environment. Physician trainees perceived to have limited sources of power. Participants reported using hospital policies, relationships, and humor for engaging in speaking up behavior. Relinquishing power and remaining silent were associated with fear, anxiety, and lack of confidence. Given the complex, hierarchical environment in healthcare, leaders' inclusive behaviors for setting a culture for speaking up, including modeling speaking up, are critical.

The impact of interprofessional perspective-taking on moral distress in the pediatric intensive care unit.

Moral distress arises when constraints outside of healthcare professionals' control prohibit them from acting according to the ethically sound course of action. It can be triggered by poor communication and different perspectives between professionals. We examined whether and how taking the perspective of the other profession reduces moral distress among pediatric intensive care nurses and physicians. Using elements of a previously published scale, we created a Vignette-based Moral Distress Rating Scale (V-MDRS). Study participants from three sites included 105 nurses and 34 physicians who read a patient vignette with their own profession's perspective, completed the V-MDRS, then received the other profession's perspective and completed the V-MDRS again. We conducted semi-structured interviews with nine nurses and nine physicians who completed the V-MDRS to explore how interprofessional perspective-taking impacts moral distress. Nurses experienced higher baseline moral distress than physicians (mean ± standard deviation 31.1 ± 6.9 vs 26.4 ± 5, P < .001), and at two study sites nurses' moral distress declined after reading the physician's perspective. Findings from interviews suggest that physicians were already sensitized to nurses' perspective and that perspective-taking may be particularly beneficial to cohesive teams with strong relationships. Thus, encouraging interprofessional perspective-taking may mitigate moral distress in healthcare professionals.

Does the single-item self-rated health measure the same thing across different wordings? Construct validity study.

PURPOSE: The self-rated health (SRH) item is frequently used in health surveys but variations of its form (wording, response options) may hinder comparisons between versions over time or across surveys. The objectives were to determine (a) whether three SRH forms are equivalent, (b) the form with the best construct validity and (c) the best coding scheme to maximize equivalence across forms. METHODS: We used data from 58,023 respondents of the Swiss Health Survey. Three SRH forms were used. Response options varied across forms and we explored four coding schemes (two considering SRH as continuous, two as dichotomous). Construct validity of the SRH was assessed using 34 health predictors to estimate the explained variance. RESULTS: Distributions of response options were similar across SRH forms, except for the "good" and "very good" options ("good" in form 1: 58.6%, form 2: 65.0% and form 3: 44.1%). Explained variances differed across SRH forms, with form 3 providing the best overall explained variance, regardless of coding schemes. The linear coding scheme maximised the equivalence across SRH forms. CONCLUSION: The three SRH forms were not equivalent in terms of construct validity. Studies examining the evolution of SRH over time with surveys using different forms should use the linear coding scheme to maximise equivalence between SRH forms.

Learning to manage uncertainty: supervision, trust and autonomy in residency training.

Sociologists have debated whether and how medical trainees are socialised to deal with uncertainty for decades. Recent changes in the structure of medical education, however, have likely affected the ways that resident physicians learn to manage uncertainty. Through ethnographic case studies of academic medical centres in Switzerland and the United States, this article provides new insights into the processes through which residents learnt to manage uncertainty. These processes included working under supervision, developing relationships of trust with supervisors and gaining autonomy to practise independently. As a result, residents developed different attitudes towards uncertainty. Residents at the Swiss medical centre tended to develop a more pragmatic attitude and viewed uncertainty as something to be addressed and controlled. On the other hand, residents at the American medical centre tended to develop an acceptive attitude towards uncertainty. More broadly, residents learnt to reproduce their supervisors' attitudes towards uncertainty. This article therefore provides new perspectives on continuity and the reproduction of social phenomena in medical education.

Intra versus interprofessional conflicts: implications for conflict management training.

Interprofessional collaboration and conflict management training are necessary in health sciences curricula. Characteristics of conflicts occurring within intraprofessional or between interprofessional teams can vary and are poorly understood. We sought to compare and contrast characteristics of intra- versus interprofessional conflicts to inform future training programs. An exploratory study was conducted through semi-structured interviews with 82 healthcare professionals working in a tertiary hospital. Interviews focused on sources, consequences, and responses to conflicts. Conflict situations were analyzed with conventional content analysis. Participants shared more intra- than interprofessional situations. Intraprofessional conflicts were caused by poor relationships, whereas interprofessional conflicts were associated with patient-related tasks and social representations. Avoiding and forcing were the most commonly mentioned responses to intraprofessional conflicts. The theme of power impacted all aspects of conflict both intra- and interprofessional. Intraprofessional conflicts were found to be as important as interprofessional conflicts. Differences in the sources of conflict and similarities regarding consequences of and responses to conflicts support integration of authentic clinical situations in interprofessional training. Understanding similarities and differences between intra- and interprofessional conflicts may help educators develop conflict management training that addresses the sources, consequences, and responses to conflicts in clinical settings.

Exploring group boundaries and conflicts: a social identity theory perspective.

CONTEXT: In the clinical environment, health care professionals self-categorise into different groups towards which they develop positive attitudes, whereas they view other groups less favourably. Social identity theory purports that these attitudes influence group processes and may foster conflicts that impede collaborative practice, although this relationship is poorly understood. This study used concepts from social identity theory to examine the interplay between group processes and conflicts, as well as the consequences of these conflicts, with the goal of identifying educational strategies to favour teamwork. METHODS: Semi-structured interviews with 82 randomly selected physicians and nursing professionals working at a Swiss academic medical centre explored participants' experiences of conflicts. Data analysis was informed by social identity theory and focused on interviews where group processes were highlighted by participants. The analysis sought to uncover how group processes were intertwined with conflicts and how they affected health care professionals. RESULTS: A total of 42 participants out of the initial pool of 82 interviews shared 52 stories of conflicts involving group processes. Most of these stories were shared by physicians and involved groups of physicians at different hierarchical levels. Conflicts and group processes were linked in two ways: (i) through processes of group membership when individuals struggled to join a relevant group, and (ii) through intergroup boundaries, such as when participants perceived that power differentials disadvantaged their own groups. Conflicts could lead to difficult experiences for clinicians who questioned their abilities, became disillusioned with their professional ideals and developed negative perceptions of other groups. CONCLUSIONS: This study suggests that conflicts involving group processes may lead to stronger intergroup boundaries, challenging current educational efforts to favour teamwork in health care. Taking steps to create more inclusive groups and to encourage perspective taking may help manage intergroup conflict.

Discussing teamwork in health care: from interprofessional collaboration to coordination and cooperation.

This doctoral research investigates teamwork, specifically collaboration, at two different hospitals both of which were highly involved in the promotion of interprofessional collaboration. The analysis of the field observations and data collected revealed that this concept did not accurately reflect daily interactions between health care professionals, but that other forms of interaction such as coordination and cooperation were more frequent. Furthermore, the use of these more specific concepts to discuss teamwork in health care enabled important differences to be observed between the clinical settings. The impact of this research in practice suggests that adopting more specific concepts would make it easier to identify relevant literature and to design policies and educational programmes that address teamwork in health care. FJ.

Are role perceptions of residents and nurses translated into action?

BACKGROUND: Effective interprofessional collaboration (IPC) has been shown to depend on clear role definitions, yet there are important gaps with regard to role clarity in the IPC literature. The goal of this study was to evaluate whether there was a relationship between internal medicine residents' and nurses' role perceptions and their actual actions in practice, and to identify areas that would benefit from more specific interprofessional education. METHODS: Fourteen residents and 14 nurses working in internal medicine were interviewed about their role perceptions, and then randomly paired to manage two simulated clinical cases. The authors adopted a general inductive approach to analyze the interviews. They identified 13 different role components that were then compared to data from simulations. Descriptive and kappa statistics were used to assess whether there was a relationship between role components identified in interviews and those performed in simulations. Results from these analyses guided a further qualitative evaluation of the relationship between role perceptions and actions. RESULTS: Across all 13 role components, there was an overall statistically significant, although modest, relationship between role perceptions and actions. In spite of this relationship, discrepancies were observed between role components mentioned in interviews and actions performed in simulations. Some were more frequently performed than mentioned (e.g. "Having common goals") while others were mentioned but performed only weakly (e.g. "Providing feedback"). CONCLUSIONS: Role components for which perceptions do not match actions point to role ambiguities that need to be addressed in interprofessional education. These results suggest that educators need to raise residents' and nurses' awareness of the flexibility required to work in the clinical setting with regard to role boundaries.

Individual, interpersonal, and organisational factors of healthcare conflict: A scoping review.

Unresolved conflicts among healthcare professionals can lead to difficult patient care consequences. This scoping review examines the current healthcare literature that reported sources and consequences of conflict associated with individual, interpersonal, and organisational factors. We identified 99 articles published between 2001 and 2015 from PubMed, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medical Database. Most reviewed studies relied on healthcare professionals' perceptions and beliefs associated with conflict sources and consequences, with few studies reporting behavioural or organisational change outcomes. Individual conflict sources included personal traits, such as self-focus, self-esteem, or worldview, as well as individuals' conflict management styles. These conflicts posed threats to one's physical, mental, and emotional health and to one's ability to perform at work. Interpersonal dynamics were hampered by colleagues' uncivil behaviours, such as low degree of support, to more destructive behaviours including bullying or humiliation. Perceptions of disrespectful working environment and weakened team collaboration were the main interpersonal conflict consequences. Organisational conflict sources included ambiguity in professional roles, scope of practice, reporting structure, or workflows, negatively affecting healthcare professionals' job satisfactions and intent to stay. Future inquiries into healthcare conflict research may target the following: shifting from research involving single professions to multiple professions; dissemination of studies via journals that promote interprofessional research; inquiries into the roles of unconscious or implicit bias, or psychological capital (i.e., resilience) in healthcare conflict; and diversification of data sources to include hospital or clinic data with implications for conflict sources.

A Scoping Review of Interprofessional Simulation-Based Team Training Programs.

SUMMARY STATEMENT: Interprofessional simulation-based team training (ISBTT) is promoted as a strategy to improve collaboration in healthcare, and the literature documents benefits on teamwork and patient safety. Teamwork training in healthcare is traditionally grounded in crisis resource management (CRM), but it is less clear whether ISBTT programs explicitly take the interprofessional context into account, with complex team dynamics related to hierarchy and power. This scoping review examined key aspects of published ISBTT programs including (1) underlying theoretical frameworks, (2) design features that support interprofessional learning, and (3) reported behavioral outcomes. Of 4854 titles identified, 58 articles met inclusion criteria. Most programs were based on CRM and related frameworks and measured CRM outcomes. Only 12 articles framed ISBTT as interprofessional education and none measured all interprofessional competencies. The ISBTT programs may be augmented by integrating theoretical concepts related to power and intergroup relations in their design to empower participants to navigate complex interprofessional dynamics.

Development and validity evidence for the intraprofessional conflict exercise: An assessment tool to support collaboration.

BACKGROUND: Effective collaboration is the foundation for delivering safe, high quality patient care. Health sciences curricula often include interprofessional collaboration training but may neglect conflicts that occur within a profession (intraprofessional). We describe the development of and validity evidence for an assessment of intraprofessional conflict management. METHODS AND FINDINGS: We designed a 22-item assessment, the Intraprofessional Conflict Exercise, to evaluate skills in managing intraprofessional conflicts based on a literature review of conflict management. Using Messick's validity framework, we collected evidence for content, response process, and internal structure during a simulated intraprofessional conflict from 2018 to 2019. We performed descriptive statistics, inter-rater reliability, Cronbach's alpha, generalizability theory, and factor analysis to gather validity evidence. Two trained faculty examiners rated 82 trainees resulting in 164 observations. Inter-rater reliability was fair, weighted kappa of 0.33 (SE = 0.03). Cronbach's alpha was 0.87. The generalizability study showed differentiation among trainees (19.7% person variance) and was highly reliable, G-coefficient 0.88, Phi-coefficient 0.88. The decision study predicted that using one rater would have high reliability, G-coefficient 0.80. Exploratory factor analysis demonstrated three factors: communication skills, recognition of limits, and demonstration of respect for others. Based on qualitative observations, we found all items to be applicable, highly relevant, and helpful in identifying how trainees managed intraprofessional conflict. CONCLUSIONS: The Intraprofessional Conflict Exercise provides a useful and reliable way to evaluate intraprofessional conflict management skills. It provides meaningful and actionable feedback to trainees and may help health educators in preparing trainees to manage intraprofessional conflict.

Using Simulation to Teach Learners in Health Care Behavioral Skills Related to Diversity, Equity, and Inclusion: A Scoping Review.

SUMMARY STATEMENT: Bias is commonplace in the health care environment and can negatively impact patients and their health outcomes. Simulation has long been shown to be an effective teaching tool for communication skills in health care, but it has rarely been used to deliver concrete behavioral skills that address issues of diversity, equity, and inclusion (DEI). This scoping review examines 23 published articles surrounding the use of simulation in health care education to impart behavioral skills that reduce bias and promote DEI. Included articles described various behavioral skills including communication, history-taking, and system/community-level advocacy. The most commonly used simulation modality to teach these skills included the use of simulated participants (16 articles, 70%). The main DEI topics addressed in the trainings included sexual orientation/gender identity, language, and culture/ethnicity. Based on findings from this review, the authors suggest recommendations for educators who are considering teaching DEI-related skills through simulation.

Developing a Community for Patients With Cancer Through Longer-Term Art Therapy.

PURPOSE: Art therapy (AT) improves quality of life and symptoms in patients with cancer. However, previous studies that have demonstrated these effects focused on time-limited interventions. The benefits of longer-term AT interventions for patients with cancer remain unexplored. We aimed to delineate the benefits of one such intervention for patients with cancer. METHODS: The Art for Recovery open art studio (OAS) is a weekly experience that provides patients the opportunity to express themselves through art and discussion. In April 2019, we sent a cross-sectional survey with closed- and open-ended components to all patients attending the OAS. We analyzed the closed-ended results using descriptive statistics and the open-ended results using directed content analysis through the theoretical framework of community-based development (CBD). RESULTS: The response rate was 82% (18 of 22 patients). The median duration of OAS attendance was 2 years, and the median frequency of attendance was three times per month. All respondents found the OAS very helpful, and 17 (94%) of 18 believed that the friendships they had made were very valuable. Directed content analysis revealed three themes: togetherness, active engagement, and familiar surroundings. These themes and our closed-ended results aligned well with the CBD framework. CONCLUSION: Longer-term AT experiences may provide benefits, such as community development, that briefer interventions lack. Medical centers should consider providing longer-term AT experiences for patients with cancer to give them access to these benefits.

Training Residents in Advance Care Planning: A Task-Based Needs Assessment Using the 4-Component Instructional Design.

BACKGROUND: Residents may learn how to perform advance care planning (ACP) through informal curriculum. Task-based instructional designs and recent international consensus statements for ACP provide opportunities to explicitly train residents, but residents' needs are poorly understood. OBJECTIVE: We assessed residents' training needs in ACP at the Geneva University Hospitals in Geneva, Switzerland. METHODS: Qualitative data were collected and analyzed iteratively between December 2017 and September 2019. Transcripts were coded using both a deductive content analysis based on the 4-Component Instructional Design (4C/ID) model and an inductive thematic analysis. RESULTS: Out of 55 individuals contacted by email, 49 (89%) participated in 7 focus groups and 10 individual interviews, including 19 residents, 18 fellows and attending physicians, 4 nurses, 1 psychologist, 1 medical ethics consultant, 3 researchers, and 3 patients. Participants identified 3 tasks expected of residents (preparing, discussing, and documenting ACP) and discussed why training residents in ACP is complex. Participants described knowledge (eg, prognosis), skills (eg, clinical and ethical reasoning), and attitudes (eg, reflexivity) that residents need to become competent in ACP and identified needs for future training. In terms of the 4C/ID, these needs revolved around: (1) learning tasks (eg, workplace practice, simulated scenarios); (2) supportive information (eg, videotaped worked examples, cognitive feedback); (3) procedural information (eg, ACP pocket-sized information sheet, corrective feedback); and (4) part-task practice (eg, rehearsal of communication skills, simulation). CONCLUSIONS: This study provides a comprehensive description of tasks and competencies to train residents in ACP.

The Role of Power in Health Care Conflict: Recommendations for Shifting Toward Constructive Approaches.

PURPOSE: The combination of power and conflict is frequently reported to have a detrimental impact on communication and on patient care, and it is avoided and perceived negatively by health care professionals. In view of recent recommendations to explicitly address power and conflict in health professions education, adopting more constructive approaches toward power and conflict may be helpful. This study examined the role of power in conflicts between health care professionals in different cultural contexts to make recommendations for promoting more constructive approaches. METHOD: The authors used social bases of power (positional, expert, informational, reward, coercive, referent) identified in the literature to examine the role of power in conflicts between health care professionals in different cultural settings. They drew upon semistructured interviews conducted from 2013 to 2016 with 249 health care professionals working at health centers in the United States, Switzerland, and Hungary, in which participants shared stories of conflict they had experienced with coworkers. The authors used a directed approach to content analysis to analyze the data. RESULTS: The social bases of power tended to be comparable across sites and included positional, expert, and coercive power. The rigid hierarchies that divide health care professionals, their professions, and their specialties contributed to negative experiences in conflicts. In addition, the presence of an audience, such as supervisors, coworkers, patients, and patients' families, prevented health care professionals from addressing conflicts when they occurred, resulting in conflict escalation. CONCLUSIONS: These findings suggest that fostering more positive approaches toward power and conflict could be achieved by using social bases of power such as referent power and by addressing conflicts in a more private, backstage, manner.

Patient Safety Over Power Hierarchy: A Scoping Review of Healthcare Professionals' Speaking-up Skills Training.

Communication failures in healthcare constitute a major root cause of adverse events and medical errors. Considerable evidence links failures to raise concerns about patient harm in a timely manner with errors in medication administration, hygiene and isolation, treatment decisions, or invasive procedures. Expressing one's concern while navigating the power hierarchy requires formal training that targets both the speaker's emotional and verbal skills and the receiver's listening skills. We conducted a scoping review to examine the scope and components of training programs that targeted healthcare professionals' speaking-up skills. Out of 9,627 screened studies, 14 studies published between 2005 and 2018 met the inclusion criteria. The majority of the existing training exclusively relied on one-time training, mostly in simulation settings, involving subjects from the same profession. In addition, most studies implicitly referred to positional power as defined by titles; few addressed other forms of power such as personal resources (e.g., expertise, information). Almost none addressed the emotional and psychological dimensions of speaking up. The existing literature provides limited evidence identifying effective training components that positively affect speaking-up behaviors and attitudes. Future opportunities include examining the role of healthcare professionals' conflict engagement style or leaders' behaviors as factors that promote speaking-up behaviors.