Creating synergies among education/research, practice, and policy environments to build capacity for the scholar role in occupational therapy and physiotherapy in the Canadian context.

Scholarly practice (SP) is considered a key competency of occupational therapy and physiotherapy. To date, the three sectors-education/research, practice, and policy/regulation-that support SP have been working relatively independently. The goals of this project were to (a) understand how representatives of the three sectors conceptualize SP; (b) define each sector's individual and collective roles in supporting SP; (c) identify factors influencing the enactment of SP and the specific needs of how best to support SP; and (d) co-develop goals and strategies to support SP across all sectors. We used interpretive description methodology. Consistent with an integrated knowledge translation approach, partners representing the three sectors across Canada recruited individuals from each sector, developed the content and questions for three focus groups, and collected and analyzed the data. Inspired by the Consolidated Framework for Implementation Research, we developed the questions for the second focus group. We analyzed the data using an inductive thematic analysis method. Thirty-nine participants from the three sectors participated. Themes related to participants' conceptualization of SP included (a) ongoing process, (b) reflective process, (c) broad concept, and (d) collective effort. Themes describing factors influencing and supporting SP were (a) recognition, (b) appropriate conceptualization, (c) social network, (d) accessibility to resources, and (e) forces outside of practitioners' effort. Goals to support SP included (a) further recognizing SP, (b) sustaining SP competency, and (c) ensuring access to information. SP requires collaborative and integrated intersectoral support and further recognition of its importance through the collaboration of multiple stakeholders.

What scholarly practice means to respiratory therapists: An interpretive description study.

RATIONALE: Engagement in scholarly practice has been associated with professional empowerment, role satisfaction and improvements in care delivery and patient outcomes across many healthcare professions. However, in evolving professions like respiratory therapy, scholarly practice is excluded from competency frameworks, resulting in a gap in education and subsequent application of this competency in practice. An exploration of scholarly practice in respiratory therapy may provide insights into evolving professions that face tensions between meeting competency requirements as outlined in frameworks and providing quality healthcare to the populations they serve. AIMS AND OBJECTIVES: The aim of the study was to explore what scholarly practice means, and how it manifests in practice from respiratory therapists' (RTs) perspectives. METHODS: We used interpretive description methodology. We purposively sampled participants to obtain varied perspectives of scholarly practice in respiratory therapy. We conducted 26 semistructured interviews with RTs in different roles (clinicians, educators, researchers, leaders and managers) across Canada and analysed the data using inductive analysis. Data collection and analysis proceeded concurrently. RESULTS: We developed five main themes: (i) the identity of a scholarly practitioner in RTs; (ii) factors influencing scholarly practice; (iii) one's impression of their professional self-image; (iv) scholarly practice as a vehicle for changing practice and (v) the complex interconnections between knowledges and practices. CONCLUSION: Scholarly practice appears to be a multifaceted phenomenon encompassing a wide range of activities and skills including conducting research, reflective practice, application of research to practice, and contributing to the advancement of the profession and healthcare. Scholarly practice is influenced by organisational context and culture, available resources, intrinsic motivation and external political context. We identified similarities between professional identity and the description of the scholarly practitioner, suggesting that these two phenomena may be interconnected. Furthermore, participants believed that scholarly practice could enhance the image, credibility, legitimacy and professionalisation of the profession.

Health System-Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis.

BACKGROUND: Living donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure and offers significant medical and economic advantages for both patients and health systems. Despite this, rates of LDKT in Canada have stagnated and vary significantly across Canadian provinces, the reasons for which are not well understood. Our prior work has suggested that system-level factors may be contributing to these differences. Identifying these factors can help inform system-level interventions to increase LDKT. OBJECTIVE: Our objective is to generate a systemic interpretation of LDKT delivery across provincial health systems with variable performance. We aim to identify the attributes and processes that facilitate the delivery of LDKT to patients, and those that create barriers and compare these across systems with variable performance. These objectives are contextualized within our broader goal of increasing rates of LDKT in Canada, particularly in lower-performing provinces. METHODS: This research takes the form of a qualitative comparative case study analysis of 3 provincial health systems in Canada that have high, moderate, and low rates of LDKT performance (the percentage of LDKT to all kidney transplantations performed). Our approach is underpinned by an understanding of health systems as complex adaptive systems that are multilevel and interconnected, and involve nonlinear interactions between people and organizations, operating within a loosely bounded network. Data collection will comprise semistructured interviews, document reviews, and focus groups. Individual case studies will be conducted and analyzed using inductive thematic analysis. Following this, our comparative analysis will operationalize resource-based theory to compare case study data and generate explanations for our research question. RESULTS: This project was funded from 2020 to 2023. Individual case studies were carried out between November 2020 and August 2022. The comparative case analysis will begin in December 2022 and is expected to conclude in April 2023. Submission of the publication is projected for June 2023. CONCLUSIONS: By investigating health systems as complex adaptive systems and making comparisons across provinces, this study will identify how health systems can improve the delivery of LDKT to patients with kidney failure. Our resource-based theory framework will provide a granular analysis of the attributes and processes that facilitate or create barriers to LDKT delivery across multiple organizations and levels of practice. Our findings will have practice and policy implications and help inform transferrable competencies and system-level interventions conducive to increasing LDKT. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44172.

Living Donor Kidney Transplantation in Quebec: A Qualitative Case Study of Health System Barriers and Facilitators.

Background: Patients with kidney failure represent a major public health burden, and living donor kidney transplantation (LDKT) is the best treatment option for these patients. Current work to optimize LDKT delivery to patients has focused on microlevel interventions and has not addressed interdependencies with meso and macro levels of practice. Objective: We aimed to learn from a health system with historically low LDKT performance to identify facilitators and barriers to LDKT. Our specific aims were to understand how LDKT delivery is organized through interacting macro, meso, and micro levels of practice and identify what attributes and processes of this health system facilitate the delivery of LDKT to patients with kidney failure and what creates barriers. Design: We conducted a qualitative case study, applying a complex adaptive systems approach to LDKT delivery, that recognizes health systems as being made up of dynamic, nested, and interconnected levels, with the patient at its core. Setting: The setting for this case study was the province of Quebec, Canada. Participants: Thirty-two key stakeholders from all levels of the health system. This included health care professionals, leaders in LDKT governance, living kidney donors, and kidney recipients. Methods: Semi-structured interviews with 32 key stakeholders and a document review were undertaken between February 2021 and December 2021. Inductive thematic analysis was used to generate themes. Results: Overall, we identified strong links between system attributes and processes and LDKT delivery, and more barriers than facilitators were discerned. Barriers that undermined access to LDKT included fragmented LDKT governance and expertise, disconnected care practices, limited resources, and regional inequities. Some were mitigated to an extent by the intervention of a program launched in 2018 to increase LDKT. Facilitators driven by the program included advocacy for LDKT from individual member(s) of the care team, dedicated resources, increased collaboration, and training opportunities that targeted LDKT delivery at multiple levels of practice. Limitations: Delineating the borders of a "case" is a challenge in case study research, and it is possible that some perspectives may have been missed. Participants may have produced socially desirable answers. Conclusions: Our study systematically investigated real-world practices as they operate throughout a health system. This novel approach has cross-disciplinary methodological relevance, and our findings have policy implications that can help inform multilevel interventions to improve LDKT.

Contexte: Les patients atteints d'insuffisance rénale représentent un lourd fardeau pour la santé publique, et la transplantation rénale provenant d'un donneur vivant (TRDV) est la meilleure option de traitement pour ces patients. Les travaux actuels visant à optimiser la TRDV chez les patients ont été limités à des interventions de niveau micro et n'ont pas abordé les interdépendances avec les niveaux méso et macro de la pratique. Objectifs: Notre objectif était d'apprendre d'un système de santé présentant un taux historiquement bas de TRDV pour arriver à déterminer les facteurs qui constituent un facilitateur ou un frein à la TRDV. Plus précisément, nous souhaitions, par le biais d'interactions entre les niveaux macro, méso et micro de la pratique, comprendre la façon dont la TRDV est organisée. Nous souhaitions également déterminer quels attributs et processus du système de santé constituent des facilitateurs ou des freins à la TRDV pour les patients atteints d'insuffisance rénale. Conception: Nous avons appliqué une approche de systèmes adaptatifs complexes à la TRDV pour mener une étude de cas qualitative qui reconnaît que les systèmes de santé sont constitués de niveaux dynamiques, imbriqués et interconnectés, où le patient est au cœur des interventions. Cadre: Cette étude de cas avait pour cadre la province de Québec (Canada). Participants: 32 intervenants clés de tous les niveaux du système de santé, notamment des professionnels de la santé, des leaders impliqués dans la gestion de la TRDV, des donneurs vivants d'un rein et des receveurs de rein. Méthodologie: Des entrevues semi-structurées avec 32 intervenants clés et un examen des documents ont été entrepris entre février 2021 et décembre 2021. L'analyse thématique inductive a servi à générer les thèmes. Résultats: De façon générale, nous avons constaté qu'il existait des liens solides entre la TRDV et les attributs et processus du système, et que les obstacles étaient plus nombreux que les facilitateurs. Les obstacles freinant l'accès à la TRDV comprenaient la gouvernance et l'expertise fragmentées en lien avec la TRDV, les pratiques de soins déconnectées, les ressources limitées et les inégalités régionales. Certains de ces obstacles ont été atténués dans une certaine mesure par l'intervention d'un programme lancé en 2018 pour accroître la TRDV. Les facilitateurs soutenus par le programme comprenaient la promotion de la TRDV par des membres individuels de l'équipe de soins, la disponibilité de ressources dédiées, une collaboration accrue et les possibilités de formation ciblant la TRDV à plusieurs niveaux de pratique. Limites: La délimitation des frontières de ce que constitue un « cas ¼ est un défi dans la recherche d'études de cas; il est ainsi possible que certaines perspectives aient été manquées. Les participants pourraient avoir donné des réponses socialement souhaitables. Conclusion: Notre étude a examiné systématiquement les pratiques en contexte réel, tel qu'elles fonctionnent dans l'ensemble d'un système de santé. Cette nouvelle approche présente une pertinence méthodologique interdisciplinaire et nos conclusions ont des implications politiques qui pourraient aider à orienter des interventions à plusieurs niveaux pour améliorer la TRDV.

Health system barriers and facilitators to living donor kidney transplantation: a qualitative case study in British Columbia.

BACKGROUND: In patients with kidney failure, living donor kidney transplantation (LDKT) is the best treatment option; yet, LDKT rates have stagnated in Canada and vary widely across provinces. We aimed to identify barriers and facilitators to LDKT in a high-performing health system. METHODS: This study was conducted using a qualitative exploratory case study of British Columbia. Data collection, conducted between October 2020 and January 2021, entailed document review and semistructured interviews with key stakeholders, including provincial leadership, care teams and patients. We recruited participants via purposive sampling and snowballing technique. We generated themes using thematic analysis. RESULTS: After analysis of interviews conducted with 22 participants (5 representatives from provincial organizations, 7 health care providers at transplant centres, 8 health care providers from regional units and 2 patients) and document review, we identified the following 5 themes as facilitators to LDKT: a centralized infrastructure, a mandate for timely intervention, an equitable funding model, a commitment to collaboration and cultivating distributed expertise. The relationship between 2 provincial organizations (BC Transplant and BC Renal Agency) was identified as key to enabling the mandate and processes for LDKT. Five barriers were identified that arose from silos between provincial organizations and manifested as inconsistencies in coordinating LDKT along the spectrum of care. These were divided accountability structures, disconnected care processes, missed training opportunities, inequitable access by region and financial burden for donors and recipients. INTERPRETATION: We found strong links between provincial infrastructure and the processes that facilitate or impede timely intervention and referral of patients for LDKT. Our findings have implications for policy-makers and provide opportunities for cross-jurisdictional comparative analyses.

Embedding Identity and How Clinical Teachers Reconcile Their Multiple Professional Identities to Meet Overlapping Demands at Work.

PHENOMENON: Clinical teachers perform overlapping tasks in education and patient care. They are therefore expected to juggle many professional identities such as educator and clinician. Yet little is known about how clinical teachers negotiate their professional identities. The present research examined the lived experiences of clinical teachers as they manage and make sense of their professional identities in the context of a faculty development program. APPROACH: This study adopted interpretative phenomenological analysis, which is an idiographic and inductive methodological approach that enables an in-depth examination of how people conceptualize their personal and social worlds. In-depth semi-structured individual interviews were conducted with six purposively sampled Brazilian clinical teachers who were attending a faculty development program. Each participant's lived experience was analyzed independently. Then, these individual analyses were compared against each other to identify convergence and divergence. FINDINGS: Participants recognized one identity, which was labeled as embedding identity, containing other identities and roles. Participants integrated their professional identities in agreement with their personal identities, values, and beliefs, striving thus for identity consonance. Participants understood their craft as a relational process by which they wove themselves into their context and entangled their experience with that of others. They, however, diverged when recognizing who their peers were; whereas some named a single professional group (i.e., family physicians), others had a more comprehensive view and considered as peers healthcare professionals, students, and even patients. Finally, participants identified time constraints and lower prestige of family medicine as a medical discipline vis-à-vis other specialties as challenges posed by their contexts. INSIGHTS: Clinical teachers have multifaceted identities, to which they give a sense, manage, and integrate into their daily practice. Participants recognized an embedding identity and looked for common points between the identities it contained, which allowed them to meaningfully reconcile the different demands from their overlapping professional identities. Thus, this research introduces the notion of embedding identity as a strategy to make sense of many professional identities. Variability in the embedding identities depicted in this investigation suggests the fluid and contextualized character of professional identity development. How participants saw themselves also influenced how they behaved and interacted with others accordingly. Understanding clinical teacher identity development enriches current perspectives of what it is like to be one of these medical professionals. Faculty development programs ought to consider these perspectives to better support clinical teachers in meeting the overlapping demands in education and patient care.

Conceptual foundations of organizational structure: re-structuring of women's health services.

PURPOSE: Researchers often debate health service structure. Understanding of the practical implications of this debate is often limited by researchers' neglect to integrate participants' views on structural options with discourses those views represent. As a case study, this paper aims to discern the extent to which and how conceptual underpinnings of stakeholder views on women's health contextualize different positions in the debate over the ideal structure of health services. DESIGN/METHODOLOGY/APPROACH: The researchers chose a self-standing, comprehensive women's health service facing the prospect of being dispersed into "mainstream" health services. The researchers gathered perspectives of 53 professional and consumer stakeholders in ten focus groups and seven semi-structured interviews, analyzed through inductive thematic analysis. FINDINGS: "Women's marginalization" was the core theme of the debate over structure. The authors found clear patterns between views on the function of women's health services, women's health needs, ideal client group, ideal health service structure and particular feminist discourses. The desire to re-organize services into separate mainstream units reflected a liberal feminist discourse, conceiving marginalization as explicit demonstration of its effects, such as domestic abuse. The desire to maintain a comprehensive women's health service variously reflected post-structural feminism's emphasis on plurality of identities, and a radical feminist discourse, holding that womanhood itself constituted a category of marginalization - that is, merely being at risk of unmet health needs. ORIGINALITY/VALUE: As a contribution to health organizational theory, the paper shows that the discernment of discursive underpinnings of particular stakeholder views can clarify options for the structure of health services.

Exploring the professionalization of respiratory therapy in Canada.

INTRODUCTION: A recurrent challenge facing respiratory therapists (RTs) is their legitimacy as professionals. RTs are often referred to as technologists, vocationalists, or technicians and must often justify their status as full professionals rather than "professional technicians". There is currently little exploration of what it means to be a profession and the process of professionalization in respiratory therapy. APPROACH: Drawing from sociological theory, the purpose of this paper is to discuss the professionalization of respiratory therapy in Canada using Andrew Abbott's theory, the "system of professions". We will use this theory as a lens to propose areas of consideration for professional development regarding two pervasive themes in the respiratory therapy community, RTs' specialized body of knowledge and professional autonomy. FINDINGS: Abstract knowledge is believed to be essential in the evolution from occupation to profession and is valuable to a profession in three ways: it can influence the profession's legitimacy, it can be used for conducting research, and it promotes higher education. RTs possess jurisdictional professional autonomy within Canada. The privilege of self-regulation allows RTs to act according to their knowledge and judgement without direct oversight from other professions. CONCLUSION: Based on Abbott's theoretical position, RTs can rightly justify their position as professionals. However, RTs need to acknowledge that professionalization is a dynamic and continuous process that requires creative changes to innovate within the profession and support future efforts to reinforce their position as professionals. Throughout this paper, we offer suggestions for how RTs can contribute to the ongoing professionalization of respiratory therapy.

Telehealth in Primary Healthcare: A Portrait of its Rapid Implementation during the COVID-19 Pandemic.

OBJECTIVE: This study documents the adoption of telehealth by various types of primary healthcare (PHC) providers working in teaching PHC clinics in Quebec during the COVID-19 pandemic. It also identifies the perceived advantages and disadvantages of telehealth. METHOD: A cross-sectional study was conducted between May and August 2020. The e-survey was completed by 48/50 teaching primary care clinics representing 603/1,357 (44%) PHC providers. RESULTS: Telephone use increased the most, becoming the principal virtual modality of consultation, during the pandemic. Video consultations increased, with variations by type of PHC provider: between 2% and 16% reported using it "sometimes." The main perceived advantages of telehealth were minimizing the patient's need to travel, improved efficiency and reduction in infection transmission risk. The main disadvantages were the lack of physical exam and difficulties connecting with some patients. CONCLUSION: The variation in telehealth adoption by type of PHC provider may inform strategies to maximize the potential of telehealth and help create guidelines for its use in more normal times.

Decontamination effectiveness and the necessity of innovation in a large-scale disaster simulation.

BACKGROUND: Chemical, biological, radiologic, nuclear, and explosive (CBRNE) events threaten the health and integrity of human populations across the globe. Effective decontamination is a central component of CBRNE disaster response. OBJECTIVE: This paper provides an objective determination of wet decontamination effectiveness through the use of a liquid-based contaminant proxy and describes the mobilization and adaptation of easily available materials for the needs of decontamination in pediatric victims. METHODS: In this in-situ disaster simulation conducted at a pediatric hospital, decontamination effectiveness was determined through a liquid-based contaminant proxy, and standard burn charts to systematically estimate affected total body surface area (TBSA) in 39 adult simulated patients. Two independent raters evaluated TBSA covered by the contaminant before and after decontamination. RESULTS: On average, simulated patients had 59 percent (95 percent CI [53, 65]) of their TBSA covered by the simulated contaminant prior to decontamination. Following a wet decontamination protocol, the average reduction in TBSA contamination was 81 percent (95 percent CI [74, 88]). There was high inter-rater reliability for TBSA assessment (intraclass correlation coefficient = 0.83, 95 percent CI [0.68, 0.92]. A modified infant bath was tested during the simulated decontamination of infant mannequins and thereafter integrated to the local protocol. CONCLUSION: Wet decontamination can remove more than 80 percent of the initial contaminant found on adult simulated patients. The use of a liquid-based visual tool as a contaminant proxy enables the inexpensive evaluation of decontamination performance in a simulated setting. This paper also describes an innovative, low-cost adaptation of a local decontamination protocol to better meet pediatric needs.

Seeking coherence between 'mobile learning' applications and the everyday lives of medical residents.

INTRODUCTION: The role of technology in health professions education has received increased research attention. Research has examined the interaction between humans and technology, focusing on the mutual influence between people and technology. Little attention has been given to the role of motivation and incentives in how learning technologies are used in relation to daily activities. This research aims to understand the relationship between medical-learning technology and its users. METHODS: A mixed-method case study of a new medical-learning mobile application (app) for family medicine residents was undertaken at a Canadian university hospital. The Information Assessment Method is a custom-made app to help residents prepare for the College of Family Physicians of Canada licensing examination. Residents' use of the app was tracked over a 7-month period and individual, semi-structured interviews were conducted with users. Data were thematically analyzed and correlated with app use data. RESULTS: Factors identified as shaping residents' mobile app use for learning, included: efficiency, mobility and resonance with life context; credibility of information retrieved; and relevance of content. Most influential was stage of residency. Second-year residents were more selective and strategic than first-year residents in their app use. DISCUSSION: An emphasis on coherence between self-directed learning and externally dictated learning provides a framework for understanding the relationship between users and mobile-learning technology. This framework can guide the design, implementation and evaluation of learning interventions for healthcare professionals and learners.

Re-structuring the negotiated order of the hospital.

Researchers continue to lament the lack of organisational focus in the sociology of health and illness. Although studies have increasingly focused on boundaries between organizations, little such research has focused on the formal boundaries within the hospital itself. Given its dramatic compartmentalisation, and continuing prevalence in health systems, the lack of organisational perspective in hospital research limits insights into the effects (as well as the construction) of the order of health work and care. With a greater emphasis on 'ordering' in the concept of negotiated order, the aim of this study is to examine the manifestation and consequences of the formal boundaries of hospital departments. Fieldwork featured 12 months of ethnography, including formal and informal observations, 80 audio-recorded, semi-structured interviews, and 56 field interviews, in the Emergency Departments (EDs) of two tertiary referral hospitals. Compared with in-patient hospital departments, the ED has limited legitimacy claims of organ-specific knowledge to transfer patients out of the ED. The manifestation of specialised knowledge hierarchies in organisational structures disadvantages patients who are older and who have chronic conditions, underpinning the argument that effects as well as the negotiation of stable organisational orders deserve increased attention in the sociology of health and illness.

Community Preceptors' Motivations and Views about Their Relationships with Medical Students During a Longitudinal Family Medicine Experience: A Qualitative Case Study.

Phenomenon: Although current evidence emphasizes various benefits of community-oriented programs, little is still known about the nature of the relationships that students and family physicians develop in this educational setting. Our aim in this study was twofold: to identify family physicians' motivations to enroll as preceptors in a longitudinal undergraduate family medicine program and to explore the nature of the student-preceptor relationships built during the course. Approach: This was a qualitative exploratory case study. The case was the first edition of a longitudinal family medicine experience (LFME), a course that makes up part of the novel Medicinae Doctor et Chirurgiae Magister curriculum in place in a Canadian medical school since August 2013. All 173 family physician community preceptors of the academic year 2013-2014 were considered key informants in the investigation. Forty-three preceptors finally participated in one of six focus groups conducted in the spring of 2014. Several organizational documents relative to the LFME course were also gathered. Inductive semantic thematic analysis was performed on verbatim interview transcripts. Documents helped contextualize the major themes emerging from the focus groups discussions. Findings: Enjoying teaching, promoting family medicine, and improving medical education where salient motivations for family physicians to become LFME preceptors. The findings also pointed out the complexity of the student-preceptor exchanges that unfolded over the academic year, and the ambiguous and changing nature of the role that LFME preceptors adopted in their relationships with students: from simply being facilitators of students' clinical observership to behaving as their mentors. Insights: Family physicians were highly motivated to become LFME preceptors of 1st-year medical students. Whereas they consistently valued the relationships built during the academic year with the students assigned to them, they also considered that exchanges did not always happen without difficulties, and gauged the roles they played as complex, ambiguous, and necessarily evolving over time.

Interdisciplinary Crisis Resource Management Training: How Do Otolaryngology Residents Compare? A Survey Study.

OBJECTIVE: Emergent medical crises, such as acute airway obstruction, are often managed by interdisciplinary teams. However, resident training in crisis resource management traditionally occurs in silos. Our objective was to compare the current state of interdisciplinary crisis resource management (IDCRM) training of otolaryngology residents with other disciplines. METHODS: A survey study examining (1) the frequency with which residents are involved in interdisciplinary crises, (2) the current state of interdisciplinary training, and (3) the desired training was conducted targeting Canadian residents in the following disciplines: otolaryngology, anesthesiology, emergency medicine, general surgery, obstetrics and gynecology, internal medicine, pediatric emergency medicine, and pediatric/neonatal intensive care. RESULTS: A total of 474 surveys were completed (response rate, 12%). On average, residents were involved in 13 interdisciplinary crises per year. Only 8% of otolaryngology residents had access to IDCRM training, as opposed to 66% of anesthesiology residents. Otolaryngology residents reported receiving an average of 0.3 hours per year of interdisciplinary training, as compared with 5.4 hours per year for pediatric emergency medicine residents. Ninety-six percent of residents desired more IDCRM training, with 95% reporting a preference for simulation-based training. DISCUSSION: Residents reported participating in crises managed by interdisciplinary teams. There is strong interest in IDCRM and crisis resource management training; however, it is not uniformly available across Canadian residency programs. Despite their pivotal role in managing critical emergencies such as acute airway obstruction, otolaryngology residents received the least training. IMPLICATION: IDCRM should be explicitly taught since it reflects reality and may positively affect patient outcomes.

New ways to get policy into practice.

PURPOSE: Health service effectiveness continues to be limited by misaligned objectives between policy makers and frontline clinicians. While capturing the discretion workers inevitably exercise, the concept of "street-level bureaucracy" has tended to artificially separate policy makers and workers. The purpose of this paper is to understand the role of social-organizational context in aligning policy with practice. DESIGN/METHODOLOGY/APPROACH: This mixed-method participatory study focuses on a locally developed tool to implement an Australia-wide strategy to engage and respond to mental health services for parents with mental illness. Researchers: completed 69 client file audits; administered 64 staff surveys; conducted 24 interviews and focus groups (64 participants) with staff and a consumer representative; and observed eight staff meetings, in an acute and sub-acute mental health unit. Data were analyzed using content analysis, thematic analysis and descriptive statistics. FINDINGS: Based on successes and shortcomings of the implementation (assessment completed for only 30 percent of clients), a model of integration is presented, distinguishing "assimilist" from "externalist" positions. These depend on the degree to which, and how, the work environment affords clinicians the setting to coordinate efforts to take account of clients' personal and social needs. This was particularly so for allied health clinicians and nurses undertaking sub-acute rehabilitative-transitional work. ORIGINALITY/VALUE: A new conceptualization of street-level bureaucracy is offered. Rather than as disconnected, it is a process of mutual influence among interdependent actors. This positioning can serve as a framework to evaluate how and under what circumstances discretion is appropriate, and to be supported by managers and policy makers to optimize client-defined needs.

Localizing Global Medicine: Challenges and Opportunities in Cervical Screening in an Indigenous Community in Ecuador.

This participatory research study examines the tensions and opportunities in accessing allopathic medicine, or biomedicine, in the context of a cervical cancer screening program in a rural indigenous community of Northern Ecuador. Focusing on the influence of social networks, the article extends research on "re-appropriation" of biomedicine. It does so by recognizing two competing tensions expressed through social interactions: suspicion of allopathic medicine and the desire to maximize one's health. Semistructured individual interviews and focus groups were conducted with 28 women who had previously participated in a government-sponsored cervical screening program. From inductive thematic analysis, the article traces these women's active agency in navigating coherent paths of health. Despite drawing on social networks to overcome formidable challenges, the participants faced enduring system obstacles-the organizational effects of the networks of allopathic medicine. Such obstacles need to be understood to reconcile competing knowledge systems and improve health care access in underresourced communities.

Leadership in crisis situations: merging the interdisciplinary silos.

Purpose Complex clinical situations, involving multiple medical specialists, create potential for tension or lack of clarity over leadership roles and may result in miscommunication, errors and poor patient outcomes. Even though copresence has been shown to overcome some differences among team members, the coordination literature provides little guidance on the relationship between coordination and leadership in highly specialized health settings. The purpose of this paper is to determine how different specialties involved in critical medical situations perceive the role of a leader and its contribution to effective crisis management, to better define leadership and improve interdisciplinary leadership and education. Design/methodology/approach A qualitative study was conducted featuring purposively sampled, semi-structured interviews with 27 physicians, from three different specialties involved in crisis resource management in pediatric centers across Canada: Pediatric Emergency Medicine, Otolaryngology and Anesthesia. A total of three researchers independently organized participant responses into categories. The categories were further refined into conceptual themes through iterative negotiation among the researchers. Findings Relatively "structured" (predictable) cases were amenable to concrete distributed leadership - the performance by micro-teams of specialized tasks with relative independence from each other. In contrast, relatively "unstructured" (unpredictable) cases required higher-level coordinative leadership - the overall management of the context and allocations of priorities by a designated individual. Originality/value Crisis medicine relies on designated leadership over highly differentiated personnel and unpredictable events. This challenges the notion of organic coordination and upholds the validity of a concept of leadership for crisis medicine that is not reducible to simple coordination. The intersection of predictability of cases with types of leadership can be incorporated into medical simulation training to develop non-technical skills crisis management and adaptive leaderships skills.

Comparing Medical Students' and Preceptors' Views of a Longitudinal Preclerkship Family Medicine Course.

INTRODUCTION: Despite the increasing popularity of longitudinal primary care experiences in North America and beyond, there is a paucity of work assessing these medical undergraduate experiences using reliable and valid questionnaires. Our objective in this study was to evaluate a new preclerkship longitudinal family medicine experience (LFME) course at McGill University by assessing family physician preceptors' self-reported ratings of the perceived effects of this course, and to compare their responses with ratings provided by medical students who completed the course. METHODS: This study is part of a larger evaluative research project assessing the first edition of the LFME. Students (N=187) and preceptors (N=173) of the 2013-2014 cohort were invited to complete separate online questionnaires in the spring through summer of 2014. The preceptor survey contained 53 items, 14 of which were nearly identical to items in the student survey (published elsewhere) and served as the basis for comparing preceptor and student ratings of the LFME. RESULTS: Ninety-nine preceptors (57% response rate; 55% female) and 120 students (64% response rate; 58% female) completed the surveys. Preceptors and students did not significantly differ in their overall ratings of the course, as both groups were satisfied with the quality of the LFME and felt it was an appropriate and valuable educational experience. However, preceptors had more positive ratings regarding their role and the benefits of the course than did medical students. CONCLUSION: This study corroborates prior work showing extensive perceived benefits of longitudinal preclerkship exposure to primary care; however, preceptors were found to report more positive reviews of the course than students. This study also provides new innovative tools to assess students' and preceptors' perceptions of longitudinal, preclerkship family medicine courses available for use over time and in different educational contexts.

How physicians teach in the clinical setting: The embedded roles of teaching and clinical care.

BACKGROUND: Clinical teaching lies at the heart of medical education. However, few studies have explored the embedded nature of teaching and clinical care. The goal of this study was to examine the process of clinical teaching as it naturally, and spontaneously, unfolds in a broad range of authentic contexts with medical students and residents. METHODS: This focused ethnographic study consisted of 160 hours of participant observation and field interviews with three internal medicine teams. Thematic analysis guided data organization and interpretation. FINDINGS: Three overlapping themes emerged: the interconnectedness between clinical work and pedagogy; a multiplicity of teachers; and the influence of space and artifacts on teaching and learning. Clinical teaching, which was deeply embedded in clinical care, was influenced by the acuity of patient problems, learner needs, and the context in which teaching unfolded; it also occurred on a spectrum that included planned, opportunistic, formal, and informal teaching (and learning). CONCLUSIONS: Study findings suggest that clinical teaching, which is marked by an intersection between service and teaching, can be viewed as an example of work-based teaching. They also yield suggestions for the enhancement of clinical teaching in inpatient settings, faculty development, and educational policies that recognize clinical teaching and learning.