Exploring adaptive expertise in residency: the (missed) opportunity of uncertainty.

Preparing novice physicians for an unknown clinical future in healthcare is challenging. This is especially true for emergency departments (EDs) where the framework of adaptive expertise has gained traction. When medical graduates start residency in the ED, they must be supported in becoming adaptive experts. However, little is known about how residents can be supported in developing this adaptive expertise. This was a cognitive ethnographic study conducted at two Danish EDs. The data comprised 80 h of observations of 27 residents treating 32 geriatric patients. The purpose of this cognitive ethnographic study was to describe contextual factors that mediate how residents engage in adaptive practices when treating geriatric patients in the ED. Results showed that all residents fluidly engaged in both adaptive and routine practices, but they were challenged when engaging in adaptive practices in the face of uncertainty. Uncertainty was often observed when residents' workflows were disrupted. Furthermore, results highlighted how residents construed professional identity and how this affected their ability to shift between routine and adaptive practices. Residents reported that they thought that they were expected to perform on par with their more experienced physician colleagues. This negatively impacted their ability to tolerate uncertainty and hindered the performance of adaptive practices. Thus, aligning clinical uncertainty with the premises of clinical work, is imperative for residents to develop adaptive expertise.

Clinical decision-making and adaptive expertise in residency: a think-aloud study.

Clinical decision-making (CDM) is the ability to make clinical choices based on the knowledge and information available to the physician. It often refers to individual cognitive processes that becomes more dependent with the acquisition of experience and knowledge. Previous research has used dual-process theory to explain the cognitive processes involved in how physicians acquire experiences that help them develop CDM. However, less is known about how CDM is shaped by the physicians' situated cognition in the clinical environment. This is especially challenging for novice physicians, as they need to be adaptive to compensate for the lack of experience. The adaptive expert framework has been used to explain how novice physicians learn, but it has not yet been explored, how adaptive expertise is linked to clinical decision-making amongst novice physicians.This study aimed to analyse how residents utilize and develop adaptive expert cognition in a natural setting. By describing cognitive processes through verbalization of thought processes, we sought to explore their CDM strategies considering the adaptive expert framework.We used concurrent and retrospective think-aloud interviews in a natural setting of an emergency department (ED) at a university hospital, to query residents about their reasoning during a patient encounter. We analysed data using protocol analysis to map cognitive strategies from these verbalizations. Subsequently in a narrative analysis, we compared these strategies with the literature on adaptive expertise.Fourteen interviews were audio recorded over the course for 17 h of observation. We coded 78 informational concepts and 46 cognitive processes. The narrative analysis demonstrated how epistemic distance was prevalent in the initial CDM process and self-regulating processes occurred during hypothesis testing. However, residents who too quickly moved on to hypothesis testing tended to have to redirect their hypothesis more often, and thus be more laborious in their CDM. Uncertainty affected physicians' CDM when they did not reconcile their professional role with being allowed to be uncertain. This allowance is an important feature of orientation to new knowledge as it facilitates the evaluation of what the physician does not know.For the resident to learn to act as an adaptive decision-maker, she relied on contextual support. The professional role was crucial in decisional competency. This supports current literature, which argues that role clarification helps decisional competency. This study adds that promoting professional development by tolerating uncertainty may improve adaptive decisional competency.

Using simulation-based training during hospital relocation: a controlled intervention study.

BACKGROUND: During hospital relocations, it is important to support healthcare professionals becoming familiar with new settings. Simulation-based training seems promising and in situ simulation has been suggested as a beneficial educational tool to prepare healthcare professionals for relocation. This study aimed to investigate the impact of a simulation-based training intervention on health professionals´ readiness to work in their new environment, as well as investigate sick leave before and after relocation. METHODS: The study was a controlled intervention study implemented at a university hospital in Denmark. Simulation was used to prepare employees for workflows prior to relocation. Before relocation, 1199 healthcare professionals participated in the in situ simulation-based training program. Questionnaires on readiness to perform were distributed to participants at pre-, post-, and follow-up (6 months) measurement. In addition, data on participants' sick leave was gathered from a business intelligence portal. To compare dependent and independent groups, paired and unpaired t tests were performed on mean score of readiness to perform and sick leave. RESULTS: Compared to the control group, healthcare professionals participating in the intervention felt significantly more ready to work in a new hospital environment. As a measure of psychological wellbeing, register data indicated no difference in sick leave, when comparing intervention and control groups before and after participating in the in situ simulation-based training program. CONCLUSIONS: Healthcare professionals felt significantly more ready to work in a new environment, after participating in the in situ simulation-based training program, indicating that the intervention supported healthcare professionals during relocations. This may mitigate feelings of uncertainty; however, further research is needed to explore such effects. TRIAL REGISTRATION: The study was approved by The Regional Ethics Committee (no. 1-16-02-222-22).

Balancing closure and discovery: adaptive expertise in the workplace.

Residents must develop knowledge, skills, and attitudes to handle a rapidly developing clinical environment. To address this need, adaptive expertise has been suggested as an important framework for health professions education. However, research has yet to explore the relationship between workplace learning and adaptive expertise. This study sought to investigate how clinical supervision might support the development of adaptive expertise. The present study used a focused ethnography in two emergency departments. We observed 75 supervising situations with the 27 residents resulting in 116 pages of field notes. The majority of supervision was provided by senior physicians, but also included other healthcare professionals. We found that supervision could serve two purposes: closure and discovery. Supervision aimed at discovery included practices that reflected instructional approaches said to promote adaptive expertise, such as productive struggle. Supervision aimed at closure-included practices with instructional approaches deemed important for efficient and safe patient care, such as verifying information. Our results suggest that supervision is a shared practice and responsibility. We argue that setting and aligning expectations before engaging in supervision is important. Furthermore, results demonstrated that supervision was a dynamic process, shifting between both orientations, and that supervision aimed at discovery could be an an appropriate mode of supervision, even in the most demanding clinical situations.

Preparing an orthopedic department for COVID-19.

Background and purpose - The COVID-19 pandemic has disrupted healthcare services around the world. We (1) describe the organizational changes at a level 1 trauma center, (2) investigate how orthopedic healthcare professionals perceived the immense amount of information and educational activities, and (3) make recommendations on how an organization can prepare for disruptive situations such as the COVID-19 pandemic in the future. Methods - We conducted a retrospective survey on the organizational restructuring of the orthopedic department and the learning outcomes of a needs-driven educational program. The educational activities were evaluated by a non-validated, 7-item questionnaire. Results - The hospital established 5 COVID-19 clusters, which were planned to be activated in sequential order. The orthopedic ward comprised cluster 4, where orthopedic nursing staff were teamed up with internal medicine physicians, while the orthopedic team were redistributed to manage minor and major injuries in the emergency department (ED). The mean learning outcome of the educational activities was high-very high, i.e., 5.4 (SD 0.7; 7-point Likert scale). Consequently, the staff felt more confident to protect themselves and to treat COVID-19 patients. Interpretation - Using core clinical competencies of the staff, i.e., redistribution of the orthopedic team to the ED, while ED physicians could use their competencies treating COVID-19 patients, may be applicable in other centers. In-situ simulation is an efficient tool to enhance non-technical and technical skills and to facilitate organizational learning in regard to complying with unforeseen changes.

Conceptualizations of clinical decision-making: a scoping review in geriatric emergency medicine.

BACKGROUND: Clinical decision-making (CDM) is an important competency for young doctors especially under complex and uncertain conditions in geriatric emergency medicine (GEM). However, research in this field is characterized by vague conceptualizations of CDM. To evolve and evaluate evidence-based knowledge of CDM, it is important to identify different definitions and their operationalizations in studies on GEM. OBJECTIVE: A scoping review of empirical articles was conducted to provide an overview of the documented evidence of findings and conceptualizations of CDM in GEM. METHODS: A detailed search for empirical studies focusing on CDM in a GEM setting was conducted in PubMed, ProQuest, Scopus, EMBASE and Web of Science. In total, 52 publications were included in the analysis, utilizing a data extraction sheet, following the PRISMA guidelines. Reported outcomes were summarized. RESULTS: Four themes of operationalization of CDM emerged: CDM as dispositional decisions, CDM as cognition, CDM as a model, and CDM as clinical judgement. Study results and conclusions naturally differed according to how CDM was conceptualized. Thus, frailty-heuristics lead to biases in treatment of geriatric patients and the complexity of this patient group was seen as a challenge for young physicians engaging in CDM. CONCLUSIONS: This scoping review summarizes how different studies in GEM use the term CDM. It provides an analysis of findings in GEM and call for more stringent definitions of CDM in future research, so that it might lead to better clinical practice.