Archetypes of incomplete stories in chronic illness medical encounters.

OBJECTIVE: During encounters, patients and practitioners engage in conversations to address health concerns. Because these interactions are time-pressured events, it may be inevitable that any story exchanged during these encounters will be incomplete in some way, potentially jeopardizing how quality and safety of care is delivered. In this study, we explored how and why incomplete stories might arise in health interactions. METHODS: Constructivist grounded theory methodology was used to explore how patients and practitioners approach their interactions during encounters. In this two-phase study, we interviewed patients (n = 21) then practitioners (n = 12). RESULTS: We identified three distinct archetypes of incomplete storytelling - the hidden story, the interpreted story, and the tailored story. Measured information sharing, triadic encounters and pre-planned agendas influenced these storylines, respectively. CONCLUSION: Both patient and practitioner participants focused on what each considered important, appropriate, and useful for productive encounters. While incomplete stories may be a reality, educating practitioners about how incomplete stories come about from both sides of the conversation creates new opportunities to optimize interactions at medical encounters for in-depth patient practitioner storytelling.

Collaboration and entanglement: An actor-network theory analysis of team-based intraprofessional care for patients with advanced heart failure.

Despite calls for more interprofessional and intraprofessional team-based approaches in healthcare, we lack sufficient understanding of how this happens in the context of patient care teams. This multi-perspective, team-based interview study examined how medical teams negotiated collaborative tensions. From 2011 to 2013, 50 patients across five sites in three Canadian provinces were interviewed about their care experiences and were asked to identify members of their health care teams. Patient-identified team members were subsequently interviewed to form 50 "Team Sampling Units" (TSUs), consisting of 209 interviews with patients, caregivers and healthcare providers. Results are gathered from a focused analysis of 13 TSUs where intraprofessional collaborative tensions involved treating fluid overload, or edema, a common HF symptom. Drawing on actor-network theory (ANT), the analysis focused on intraprofessional collaboration between specialty care teams in cardiology and nephrology. The study found that despite a shared narrative of common purpose between cardiology teams and nephrology teams, fluid management tools and techniques formed sites of collaborative tension. In particular, care activities involved asynchronous clinical interpretations, geographically distributed specialist care, fragmented forms of communication, and uncertainty due to clinical complexity. Teams 'disentangled' fluid in order to focus on its physiological function and mobilisation. Teams also used distinct 'framings' of fluid management that created perceived collaborative tensions. This study advances collaborative entanglement as a conceptual framework for understanding, teaching, and potentially ameliorating some of the tensions that manifest during intraprofessional care for patients with complex, chronic disease.

Constructions of self: ethical overtones in surprising locations.

Little discussion has occurred in the health profession literature with respect to how the "self" is constructed, despite the imagination and attention it has garnered from philosophers and theorists in various other disciplines. Yet this subject has surprisingly ethical overtones for health professional education and practice. In this paper notions of the self are briefly considered and it is suggested that a narrative and dialogic view of self can contribute to insights about ethical practice in the health professions. Subtle issues with respect to how relationship and language may be used to wield power are revealed and discussed; and awareness about how such power is used in practice is highlighted as a crucial issue. The assumptions practitioners make with respect to constructions of self are ethically important and this topic warrants consideration in the medical humanities.

Reflections on reflective practice.

In recent years, a wide range of professions have adopted 'reflective practice' as an approach to professional development, and many professions have made it a mandatory dimension of their membership credentialling process. Despite the fact that it has been widely taken up in the professional world, there are many different conceptualizations and ideas about what it is. In this paper, six theoretical underpinnings of reflective practice are considered, and suggestions are made about how we can begin to incorporate reflection into our own practices.

Cognitive orientation to daily occupational performance (CO-OP): part III--the protocol in brief.

Parts I and II of this series introduced the Cognitive Orientation to daily Occupational Performance (CO-OP), a new approach to intervention that is based on the premise that cognition plays an important role in the acquisition of occupational skills and the development of occupational competency. Developed for use with children who have occupational performance deficits, CO-OP is an individualized, client-centred approach focused on strategy-based skill acquisition. This third paper in this series presents a brief description of the actual CO-OP protocol including its objectives, prerequisites and key features.