What's in a name? Tensions between formal and informal communities of practice among regional subspecialty cancer surgeons.

In 2007 the Cancer Care Ontario Hepatobiliary-Pancreatic (HPB) Community of Practice was formed during the wake of provincial regionalization of HPB services in Ontario, Canada. Despite being conceptualized within the literature as an educational intervention, communities of practice (CoP) are increasingly being adopted in healthcare as quality improvement initiatives. A qualitative case study approach using in-depth interviews and document analysis was employed to gain insight into the perceptions and attitudes of the HPB surgeons in the CoP. This study demonstrates how an engineered formal or idealized structure of a CoP was created in tension with the natural CoPs that HPB surgeons identified with during and after their training. This tension contributed to the inactive and/or marginal participation by some of the surgeons in the CoP. The findings of this study represent a cautionary tale for such future engineering attempts in two distinct ways: (1) a CoP in surgery cannot simply be created by regulatory agencies, rather they need to be supported in a way to evolve naturally, and (2) when the concept of CoPs is co-opted by governing bodies, it does not necessarily capture the power and potential of situated learning. To ensure CoP sustainability and effectiveness, we suggest that both core and peripheral members need to be more directly involved at the inception of the COP in terms of design, organization, implementation and ongoing management.

Towards a sociology of knowledge translation: the importance of being dis-interested in knowledge translation.

Over the last 15 years there has been an increasingly energetic search for theories and definitions in the burgeoning area of knowledge translation (KT) in the health care context. The focus has been on the design and evaluation of KT activities with little attention to developing a considered KT theoretical/methodological approach that takes a more distanced critical inquiry to the studying of KT interventions. As such, what has been overlooked in the health professions KT literature to date is a suitably complex conceptualisation of translation that encompasses the multiplicity of KT interventions, the dynamic environments in which they are occurring, and the production of new knowledge which arises from their interactions. Attending to these epistemological issues; i.e. issues of the type of knowledge and how it is produced, is crucial to developing a relational understanding of the production and emergence of context-specific clinical knowledge and practice in KT processes. Such an approach is compared to the traditional KT evaluations by KT practitioners themselves of the compliance or non-compliance of individual and organisational behaviour change. A Sociology of KT (SKT) is proposed to complement the applied and evaluative research practice of implementing planned action KT activities. The purpose of a SKT basic research agenda is to understand both the context-specific nature of KT interventions and the epistemological premises of the activities of KT implementers themselves, in order to advance the science of KT and inform, complement and add to the success of applied and evaluative KT research in the future.

Protocol for a systematic scoping review of reasons given to justify the performance of randomised controlled trials.

INTRODUCTION: Randomised controlled trials (RCTs) are widely viewed to generate the most reliable medical knowledge. However, RCTs are not always scientifically necessary and therefore not always ethical. Unfortunately, it is not clear when an RCT is not necessary or how this should be established. This study seeks to systematically catalogue justifications offered throughout the medical and ethics literature for performing randomisation within clinical trials. METHODS AND ANALYSIS: We will systematically search electronic databases of the medical literature including MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Clinical Trials Register, Web of Science Proceedings, ClinicalTrials.gov; databases of philosophical literature including Philosopher's Index, Phil Papers, JSTOR, Periodicals Archive Online, Project MUSE, National Reference Centre for Bioethics; the library catalogue at the University of Ottawa; bibliographies of retrieved papers; and the grey literature. We will also pursue suggestions from experts in the fields of medical ethics, philosophy and clinical trial methodology. Article screening, selection and data extraction will be performed by two independent reviewers based on prespecified inclusion/exclusion criteria. A third reviewer will be consulted to resolve any discrepancies. We will then extract the reasons given to justify randomisation using methodology established to extract data in a defensible, systematic manner. We will track the reasons given, their frequency of use and changes over time. Finally, using grounded theory, we will combine the reasons into broader themes. These themes will form the foundation of our subsequent analysis from qualitative and quantitative perspectives. This review will map existing arguments that clinicians, ethicists and philosophers use to ethically justify randomisation in clinical trials. ETHICS AND DISSEMINATION: No research ethics board approval is necessary because we are not examining patient-level data. This protocol complies with the reported guidance for conducting systematic scoping reviews. The findings of this paper will be disseminated via presentations and academic publication. In a subsequent phase of this research, we hope to engage with stakeholders and translate any recommendations derived from our findings into operational guidelines.

Psychosocial and quality of life impact of scars in the surgical, traumatic and burn populations: a scoping review protocol.

INTRODUCTION: Despite the fact that millions of scars affect individuals annually, little is known about their psychosocial impact and overall quality of life (QOL) on individuals. Scars from multiple aetiologies may cause psychiatric and emotional disturbances, can limit physical functioning and increase costs to the healthcare system. The purpose of this protocol is to describe the methodological considerations that will guide the completion of a scoping review that will summarise the extent, range and nature of psychosocial health outcomes and QOL of scars of all aetiologies. METHODS AND ANALYSIS: A modified Arksey and O'Malley (2005) framework will be completed, namely having ongoing consultation between experts from the beginning of the process, then (1) identifying the research question/s, (2) identifying the relevant studies from electronic databases and grey literature, with (3) study selection and (4) charting of data by two independent coders, and (5) collating, summarising and reporting data. Experts will include a health information specialist (TAW), scar expert (JSF), scoping review consultant (SCK), as well as at least two independent coders (NZ, AM). ETHICS AND DISSEMINATION: Ethics approval will not be sought for this scoping review. We plan to disseminate this research through publications, presentations and meetings with relevant stakeholders.

Exploring the experiences and perspectives of substitute decision-makers involved in decisions about deceased organ donation: a qualitative study protocol.

INTRODUCTION: In Canada, deceased organ donation provides over 80% of transplanted organs. At the time of death, families, friends or others assume responsibility as substitute decision-makers (SDMs) to consent to organ donation. Despite their central role in this process, little is known about what barriers, enablers and beliefs influence decision-making among SDMs. This study aims to explore the experiences and perspectives of SDMs involved in making decisions around the withdrawal of life-sustaining therapies, end-of-life care and deceased organ donation. METHODS AND ANALYSIS: SDMs of 60 patients admitted to intensive care units will be enrolled for this study. Ten hospitals across five provinces in Canada in a prospective multicentre qualitative cohort study. We will conduct semistructured telephone interviews in English or French with SDMs between 6 and 8 weeks after the patient's death. Our sampling frame will stratify SDMs into three groups: SDMs who were not approached for organ donation; SDMs who were approached and consented to donate and SDMs who were approached but did not consent to donate. We will use two complementary theoretical frameworks-the Common-Sense Self-Regulation Model and the Theoretical Domains Framework- to inform our interview guide. Interview data will be analysed using deductive directed content analysis and inductive thematic analysis. ETHICS AND DISSEMINATION: This study has been approved by the Centre Hospitalier de l'Université de Montréal Research Ethics Board. The findings from this study will help identify key factors affecting substitute decision-making in deceased organ donation, reasons for non-consent and barriers to achieve congruency between SDM and patient wishes. Ultimately, these data will contribute to the development and evaluation of tools and training for healthcare providers to support SDMs in making decisions about organ donation. TRIAL REGISTRATION NUMBER: NCT03850847.

Bariatric surgery in Australia: who, why and how?

A review of published reports was conducted to identify gaps in the research regarding bariatric surgery. Much of the research that has been conducted is clinical outcome based; however, little research has been conducted in many key areas. Data on the demographics of the bariatric surgery group are patchy at best. The role of best practice and evidence-based medicine in bariatric surgery seems to be poorly understood, and equity issues and the role of clinical pathways in bariatric surgery need to be clarified. Significant gaps were identified in the published reports regarding pathways to bariatric surgery and multidisciplinary team use. Additionally, much of the published report and research data were from US studies, as few Australian studies have been conducted. Further research and policy and practice developments in bariatric surgery are needed, especially with regard to the Australian context.

Managing and avoiding delay in operating theatres: a qualitative, observational study.

RATIONALE, AIMS AND OBJECTIVES: A range of strategies have been proposed to identify and address operating theatre delays, including preoperative checklists, post-delay audits and staff education. These strategies provide a useful starting point in addressing delay, but their effectiveness can be increased through more detailed consideration of sources of surgical delay. METHOD: A qualitative, observational study was conducted at two Australian hospitals, one a metropolitan site and the other a regional hospital. Thirty surgeries were observed involving general, vascular and orthopaedic procedures which ranged in time from 20 minutes to almost 4 hours. Approximately 40 hours of observations were conducted in total. RESULTS: The research findings suggest that there are two key challenges involved in addressing operating theatre delays: unanticipated problems in the clinical condition of patients, and the capacity of surgeons to regulate their own time. These challenges create unavoidable delays due to the contingencies of surgical work and competing demands on surgeons' time. The results also found that surgical staff play a critical role in averting and anticipating delays. Differences in professional authority are significant in influencing how operating theatre time is managed. CONCLUSIONS: Strategies aimed at addressing operating theatre delays are unlikely to achieve their desired aims without a more detailed understanding of medical decision making and work practices, and the intra- as well as inter-professional hierarchies underpinning them. While the nature of surgical work poses some challenges for measures designed to address delays, it is also necessary to focus on surgical practice in devising workable solutions.

(Mis)perceptions of continuing education: insights from knowledge translation, quality improvement, and patient safety leaders.

INTRODUCTION: Minimal attention has been given to the intersection and potential collaboration among the domains of continuing education (CE), knowledge translation (KT), quality improvement (QI), and patient safety (PS), despite their overlapping objectives. A study was undertaken to examine leaders' perspectives of these 4 domains and their relationships to each other. In this article, we report on a subset of the data that focuses on how leaders in KT, PS, and QI define and view the domain of CE and opportunities for collaboration. METHODS: This study is based on a qualitative interpretivist framework to guide the collection and analysis of data in semistructured interviews. Criterion-based, maximum variation, and snowball sampling were used to identify key opinion leaders in each domain. The sample consisted of 15 individuals from the domains KT, QI, and PS. The transcripts were coded using a directed content analysis approach. RESULTS: The findings are organized into 3 thematic subsections: (1) definition and interpretation of CE, (2) concerns about relevance and effectiveness of CE, and (3) opportunities for collaboration among CE and the other domains. While there were slight differences among the data from the leaders of each domain, common themes were generally reported. DISCUSSION: The findings provide CE leaders with information about KT, QI, and PS leaders' (mis)perceptions about CE that can inform future strategic planning and activities. CE leaders can play an important role in building upon initial collaborations among the domains to enable their strengths to complement each other.

Rural surgeons' attitudes towards and usage of evidence-based medicine in rural surgical practice.

INTRODUCTION: Rural and remote surgical practice presents unique barriers to the uptake of the evidence-based medicine (EBM) paradigm. As medical and education institutions around Australia develop practices and support for EBM, there are growing questions about how EBM is situated in the rural and remote context. The Monash University Department of Surgery at Monash Medical Centre implemented a study to explore the current understandings, attitudes and practices of rural surgeons towards the EBM paradigm. METHODS: Descriptive survey of rural surgeons based in a tertiary care environment. RESULTS: The overall results of the survey demonstrate that: (1) rural surgeons have a good understanding of EBM; (2) EBM evidence is somewhat useful but not very important to clinical decision making; and (3) while rural surgeons are relatively confident in most sources listed, they are most confident in their own judgment and clinical practice guidelines, and least confident in telephone contact with colleagues. Rural surgeons' understanding, usage and confidence in EBM purports that rural surgeons have contradictory, ambivalent and complex views of the EBM paradigm and its place in rural surgical practice. DISCUSSION: Professional isolation and context specificity are important to consider when extending the EBM paradigm to rural surgical practice and understanding the EBM uptake in the rural surgery context.

Imagining a continuing interprofessional education program (CIPE) within surgical training.

In recent years increasing attention has been paid to issues of professionalism in surgery and the content and structure of continuing professional development for surgeons; however, little attention has been paid to interprofessional education (IPE) in surgical training. Imagining the form(s) of IPE and/or continuing interprofessional education (CIPE) programs within surgical training requires serious attention to 2 fundamental issues--the discourses of professionalism in surgery and the professional culture of surgery, as shaped and expressed within the clinical setting. We explore the possibility that concepts of professionalism within surgery may be in conflict with the tenets of interprofessionalism held by other health and medical professionals. We believe that if any rapprochement is to occur between the concept of professionalism in surgical training (and within the everyday clinical culture of surgical subspecialties groups and their professional institutions) and broader discourses of interprofessionalism circulating within health care institutions, there is a pressing need to understand and deconstruct this conflict from the point of view of surgery.

Quality in qualitative research.

Qualitative research most commonly involves the systematic collection, ordering, description and interpretation of textual data generated from talk, observation or documentation. A report of qualitative research should address the following criteria: Clarification and justification; Procedural rigour; Representativeness; Interpretative rigour; Reflexivity and evaluative rigour; and Transferability. Because of the limitations on article length for the Medical Journal of Australia, authors should focus on only a couple of aspects of the research, rather than trying to present a simplified description of multiple aspects.