Dignity during work-integrated learning: Piloting an online learning resource for placement students and supervisors.

What was the educational challenge?Medical student abuse within work-integrated learning (WIL) is well-reported, with negative consequences for wellbeing, motivation, and learning. Conversely, workplace dignity, described as respecting the worth of others and self, has positive impacts on wellbeing, learning, and relationships for WIL students and supervisors. Stakeholders often struggle to articulate what workplace dignity means, and can downplay or do nothing in the face of WIL indignities.What was the solution and how was this implemented?We created an innovative research-informed online learning resource about WIL dignity to improve stakeholders' understandings and help them get the best from WIL placements ensuring these are dignified, safe, and educationally productive. The resource included three topics: (a) workplace dignity and why it matters; (b) upholding dignity; and (c) strengthening dignity.What lessons were learned?We conducted a pilot qualitative evaluation involving 13 semi-structured interviews with students and supervisors to elicit their views and experiences of the resource. Our key findings across three overarching categories were: (1) perceived benefits (motivations to complete the resource; content of the resource; online pedagogies); (2) potential applications of learning (reinforcing existing knowledge; developing new knowledge; promoting reflection; changing workplace practices); and (3) suggested improvements (barriers to resource use; resource content; online pedagogies; timing of resource implementation; embedding the resource in broader learning).What are the next steps?Although we identified numerous perceived benefits, and applications of learning, the findings suggested opportunities for further development, especially improving the resource's social interactivity. We recommend that further resource implementation includes student-educator and student-peer interactivity to maximise learning, and longitudinal evaluation of the resource.

A roadmap to realist interviews in health professions education research: Recommendations based on a critical analysis.

CONTEXT: Realist evaluation is increasingly employed in health professions education research (HPER) because it can unpack the extent to which complex educational interventions work (or not), for whom under what circumstances and how. While realist evaluation is not wedded to particular methods, realist interviews are commonly the primary, if not only, data collection method in realist evaluations. While qualitative interviewing from an interpretivist standpoint has been well-articulated in the HPER literature, realist interviewing differs substantially. The former elicits participants' views and experiences of a topic of inquiry, whereas realist interviewing focuses on building, testing and/or refining programme theory. Therefore, this article aims to help readers better understand, conduct, report and critique realist interviews as part of realist evaluations. METHODS: In this paper, we describe what realist approaches are, what realist interviewing is and why realist interviewing matters. We outline five stages to realist interviewing (developing initial programme theory, realist sampling/samples, the interview itself, realist analysis and reporting realist interviews), drawing on two illustrative cases from our own realist evaluations employing interviewing to bring theory to life. We provide a critical analysis of 12 realist evaluations employing interviewing in the HPER literature. Alongside reporting standards, and our own realist interviewing experiences, this critical analysis of published articles serves to foreground our recommendations for realist interviewing. CONCLUSIONS: We encourage HPE researchers to consider realist interviews as part of realist evaluations of complex interventions. Our critical analysis reveals that realist interviews can provide unique insights into HPE, but authors now need to report their sampling approach, type of interviewing and interview questions more explicitly. Studies should also more explicitly draw on existing realist interviewing literature and follow reporting guidelines for realist evaluations. We hope this paper provides a useful roadmap to conducting, reporting and critically appraising realist interviews in HPER.

The graduate dietitian experience of employment and employability: A longitudinal qualitative research study from one Australian university.

AIMS: Diet-related chronic disease contributes significantly to the global burden of disease. Dietitians are best placed to address this disease burden, yet graduate dietitians may struggle to find employment. This study aimed to explore dietetics graduates' experiences of employment and employability, up to 6-month post-degree completion. METHODS: Secondary data analysis of in-depth qualitative interview data and longitudinal audio-diaries was undertaken. An interpretivist approach was employed whereby knowledge was viewed as subjective and multiple realities exist. A total of five entrance interviews, 31 audio-diaries and three exit interviews, from nine graduates were included in the analysis. This comprised 12 h of longitudinal audio data. Thematic analysis was undertaken using a framework analysis method. RESULTS: Four key themes were identified: (1) The tumultuous process of applying for jobs demonstrated that graduates struggled with repeated rejections. (2) The uncertain journey to employment indicated that job-seeking was a limbo stage marked by uncertainty. (3) Feeling the pressure showed that graduates experienced pressure from multiple sources. (4) Enhancing employability explained that graduates were not prepared for available employment opportunities, but utilised resources to increase their employability. CONCLUSION: Diverse placement experiences may better prepare graduates for available employment opportunities. To enhance employability, it may be beneficial to assist students to develop job-seeking skills, and to engage in networking and volunteering experiences during their education.

Leadership during airway management in the intensive care unit: A video-reflexive ethnography study.

Effective leadership is crucial to team performance within the intensive care unit. This novel study aimed to explore how staff members from an intensive care unit conceptualize leadership and what facilitators and barriers to leadership exist within a simulated workplace. It also aimed to identify factors that intersect with their perceptions of leadership. This study was underpinned by interpretivism, and video-reflexive ethnography was chosen as the methodology for the study. The use of both video recording (to capture the complex interactions occurring in the ICU) and team reflexivity allowed repeated analysis of those interactions by the research team. Purposive sampling was used to recruit participants from an ICU in a large tertiary and private hospital in Australia. Simulation groups were designed to replicate the typical clinical teams involved in airway management within the intensive care unit. Twenty staff participated in the four simulation activities (five staff per simulation group). Each group simulated the intubations of three patients with hypoxia and respiratory distress due to severe COVID-19. All 20 participants who completed the study simulations were invited to attend video-reflexivity sessions with their respective group. Twelve of the 20 participants (60%) from the simulations took part in the reflexive sessions. Video-reflexivity sessions (142 min) were transcribed verbatim. Transcripts were then imported into NVivo software for analysis. The five stages of framework analysis were used to conduct thematic analysis of the video-reflexivity focus group sessions, including the development of a coding framework. All transcripts were coded in NVivo. NVivo queries were conducted to explore patterns in the coding. The following key themes regarding participants' conceptualizations of leadership within the intensive care were identified: (1) leadership is both a group/shared process and individualistic/hierarchical; (2) leadership is communication; and (3) gender is a key leadership dimension. Key facilitators identified were: (1) role allocation; (2) trust, respect and staff familiarity; and (3) the use of checklists. Key barriers identified were: (1) noise and (2) personal protective equipment. The impact of socio-materiality on leadership within the intensive care unit is also identified.

Identities and roles through clinician-educator transitions: A systematic narrative review.

OBJECTIVE: To synthesise the literature exploring nurse and other clinicians' conceptualisations and experiences of roles and identities as they transition to educator positions and to identify facilitators/barriers to, and consequences of, successful transitions. DESIGN: A systematic narrative review of empirical research reporting clinician-educator transitions was conducted from database inception to December 2020. DATA SOURCES: Our search employed ERIC, CINAHL, PsycINFO, Scopus, Ovid MEDLINE® Plus, ERIC (ProQuest), and Sociological Abstracts (ProQuest). We used search terms and synonyms relating to 'identity', 'role' and 'transitions'. REVIEW METHODS: Using the PRISMA protocol for systematic reviews, we reviewed titles and abstracts for inclusion, then used the Critical Appraisal Skills Program tool to evaluate article quality. We extracted evidence from included articles, synthesising data thematically by exploring similarities and differences between studies. RESULTS: We screened 2753 articles. 23 studies (across 25 articles) matched our inclusion criteria, 20 of which included nursing clinician-educator transitions. We identified four themes describing clinician-educator transitions: (i) multiple ways of conceptualising roles and identities, (ii) clinician-educator transitions as complex, emotion-laden processes, (iii) personal, interpersonal, and organisational facilitators and barriers of clinician-educator transitions, and (iv) positive and negative consequences of clinician-educator transitions. CONCLUSION: Our review supports deeper understandings of transition processes that can be used by organisations to better support clinicians as they adapt to their new educator roles and identities.

Gender Matters: Understanding Transitions in Surgical Education.

Introduction: Diverse transitions are elemental to medical career trajectories. The effective navigation of such transitions influences a sense of belonging and wellbeing, positive relationships, and good engagement and attainment within new contexts. Using Multiple and Multidimensional Transitions (MMT) theory as an analytical lens, this paper aims to answer the research question: "What gendered transitions do female surgeons experience, and how do these gendered transitions impact them?" Methods: We conducted a qualitative study drawing on narrative inquiry, with face-to-face and online semi-structured interviews with 29 female surgeons across nine surgical specialities in Ireland and Scotland. This paper is part of a larger study including male surgeons, other colleagues and patients of female surgeons. The female surgeons in this paper were purposively sampled using maximum variation sampling across several levels (consultants, trainees and middle-grade doctors), as well as six who had transitioned out of surgery. Framework analysis was employed to interrogate the interview data. Results: Five overarching types of transitions were identified across surgical education but only three of these transitions-work, culture and health-were primarily experienced by female surgeons (not male surgeons so were considered gendered), thereby impacting social, academic, and psychological domains. The remaining two types of transition-education and geography-were seemingly experienced equally by female and male surgeons, so are beyond the scope of this paper focused on female surgeons' gendered experiences. Conclusion: This novel qualitative study drawing on MMT theory illustrates how multiple gendered transitions interact and impact female surgeons across the surgical education continuum. Aligned with MMT theory, family members and others are also purportedly affected by female surgeons' transitions. Healthcare educators, leaders and policymakers need to better understand gendered transitions and their impacts to improve support for female surgical trainees on their educational journeys.

What Really Matters for Supervision Training Workshops? A Realist Evaluation.

PURPOSE: Supervision training supports health care supervisors to perform their essential functions. Realist evaluations are increasingly popular for evaluating complex educational interventions, but no such evaluations exist appraising supervision workshops. Building on an earlier realist synthesis of supervision training, the authors evaluated whether supervision workshops work, for whom and under what circumstances, and why. METHOD: The authors conducted a 2-stage realist evaluation during 2018-2019 to refine and develop program theory. The intervention involved half-day, face-to-face supervision workshops as part of an Australian state-wide government-funded program for health care and human services supervisors. Data collection involved realist interviews with 10 workshop developers (stage 1) and 43 supervisors (stage 2). The authors employed team-based data analysis using realist logic to refine and develop program theory by identifying contexts, mechanisms, outcomes, and context-mechanism-outcome configurations. RESULTS: Despite their brevity, the supervision workshops had many reported benefits for supervisors (e.g., improved satisfaction) through various perceived mechanisms pertaining to pedagogy (e.g., mixed pedagogies), workshops (e.g., optimal duration), and individuals (e.g., supervisor engagement). However, they also yielded negative reported outcomes (e.g., suboptimal knowledge gains) brought about by assorted perceived mechanisms related to pedagogy (e.g., suboptimal peer learning), workshops (e.g., content irrelevance), and individuals (e.g., suboptimal facilitator competence). Such mechanisms were thought to be triggered by diverse contexts including supervisors' levels of experience, sector, and workplace supervision cultures. CONCLUSIONS: While the findings partly support the realist synthesis of supervision training and previous realist evaluations of faculty development, this realist evaluation extends this literature considerably. Health care educators should employ mixed pedagogies (e.g., didactic teaching, peer learning), relevant content, optimal workshop duration, and competent/engaging facilitators. Educators also need to tailor workshops according to supervisors' contexts including the sectors and supervision cultures in which supervision is practiced, and supervisors' levels of experience (e.g., experienced supervisors appreciated workshop brevity).

Balancing the effectiveness and cost of online education: A preliminary realist economic evaluation.

PURPOSE: While online learning for faculty development has grown substantially over recent decades, it has been further accelerated in the face of the worldwide pandemic. The effectiveness of online learning has been repeatedly established through systematic reviews and meta-analyses, yet questions remain about its cost-effectiveness. This study evaluates how synchronous online supervision training workshops and their cost-effectiveness might work, and in what contexts. METHODS: We conducted preliminary realist economic evaluation including qualitative (13 realist interviews), and quantitative approaches (cost Ingredients method). We developed a cost-optimised model based on identified costs and cost-sensitive mechanisms. RESULTS: We identified 14 recurring patterns (so-called demi-regularities) illustrating multiple online workshop outcomes (e.g. satisfaction, engagement, knowledge), generated by various mechanisms (e.g. online technology, mixed pedagogies involving didactic and active/experiential learning, peer learning), and triggered by two contexts (supervisor experience levels, and workplace location). Each workshop cost $302.92 per learner, but the optimised model including senior facilitators cost $305.70. CONCLUSIONS: Our initial realist program theories were largely supported and refined. Although findings were largely concordant with previous literature, we illustrate how online workshop costs compare favourably with face-to-face alternatives. We encourage program developers to consider synchronous online learning for faculty development especially for remote learners, and in resource-constrained environments.

The effectiveness of extended-duration supervision training for nurses and allied health professionals: A realist evaluation.

BACKGROUND: Training helps maintain high-quality supervision and its associated benefits (e.g. reduced burnout, improved care). While studies have previously evaluated extended-duration supervision training programmes, none have treated these as complex interventions so have not employed realist approaches. OBJECTIVES: Building on a previous realist synthesis, this evaluation tests and develops programme theory for extended-duration supervision training to answer the question: to what extent does the supervision training programme work, for whom, under what circumstances and why? DESIGN: We conducted a realist evaluation of a novel state-wide Victorian 3-month supervision training programme including one or two 3.5-h workshops followed by weekly reflexive longitudinal audio diaries (LADs) for up to 12 weeks. METHODS: Realist evaluation data comprised 25 entrance interviews with nurses and allied health professionals, 176 LADs (and 29 written diaries), and 23 exit interviews. We employed team-based realist analysis to identify context-mechanism-outcome configurations (CMOCs) to test and develop programme theory. RESULTS: We refined four recurring CMOCs from the realist synthesis programme theory, found insufficient evidence for two, and established five new recurring CMOCs. We identified multiple positive outcomes from our extended-duration supervision training programme (e.g. improved supervisor practices) through various mechanisms relating to pedagogy (e.g. weekly reflexivity), supervisors (e.g. engagement), and workplaces (e.g. enabling supervision cultures). Some negative outcomes were reported (e.g. decreased engagement) through various mechanisms (e.g. suboptimal training design). Such mechanisms were thought to come about by diverse contexts including supervisors (e.g. inexperienced/experienced), professions (nursing/allied health), and organisations (supervision-enabled/non-enabled cultures). CONCLUSIONS: Our findings extend the realist synthesis programme theory by highlighting various contexts triggering outcome-generating mechanisms. Programme outcomes are maximised through ongoing supervisor reflexivity paying attention to facilitator-supervisor relationships, as well as protected time for supervisors to translate learning into practice.

Unpacking economic programme theory for supervision training: Preliminary steps towards realist economic evaluation.

INTRODUCTION: Cost studies are increasingly popular given resource constraints. While scholars stress the context-dependent nature of cost, and the importance of theory, cost studies remain context-blind and atheoretical. However, realist economic evaluation (REE) privileges context and the testing/refinement of economic programme theory. This preliminary REE serves to test and refine economic programme theory for supervision training programmes of different durations to better inform future programme design/implementation. METHODS: Our preliminary REE unpacked how short (half-day) and extended (12 week) supervision training programmes in Victoria, Australia, produced costs and outcomes. We employed mixed methods: qualitative realist and quantitative cost methods. Economically optimised programme models were developed guided by identified cost-sensitive mechanisms and contexts. RESULTS: As part of identified context-mechanism-outcome configurations (CMOCs) for both training programmes, we found a wider diversity of positive outcomes but greater costs for the extended programme (11 outcomes; AU$3069/learner) compared with the short programme (7 outcomes; $385/learner). We identified four shared cost-sensitive mechanisms for both programmes (training duration, learner protected time, learner engagement, and facilitator competence) and one shared cost-sensitive context (learners' supervisory experience). We developed two economically optimised programme models: (1) short programme for experienced supervisors facilitated by senior educators ($406/learner); and (2) extended programme for inexperienced supervisors facilitated by junior educators ($2104/learner). DISCUSSION: Our initial economic programme theory was somewhat supported, refuted and refined. Results were partly consistent with previous research, but also extended it through unpacking cost-sensitive mechanisms and contexts. Although our preliminary REE fills a pressing gap in the methodology literature, conducting REE was challenging given our desire to integrate economic and realist analyses fully, and remain faithful to realist principles. Attention to training duration and experience levels of the facilitator-learner dyad may help to balance the cost and outcomes of training programmes.

Understanding Health Care Graduates' Conceptualizations of Transitions: A Longitudinal Qualitative Research Study.

PURPOSE: Although transitions have been defined in various ways in the higher education literature (e.g., inculcation, development, becoming), little research exists exploring health care learners' conceptualizations of transitions across their transition from final year to new graduate. How they understand transitions is important because such conceptualizations will shape how they navigate their transitions and vice versa. METHOD: The authors conducted a 3-month longitudinal qualitative research study with 35 health care learners from 4 disciplines (medicine, dietetics, nursing, and pharmacy) across their final year to new graduate transition to explore how they conceptualized transitions. Data collection occurred between July 2019 and April 2020 at Monash University in Victoria, Australia. The authors employed framework analysis to interrogate the interview and longitudinal audio diary data cross-sectionally and longitudinally. RESULTS: The authors found 10 different conceptualizations of transitions broadly categorized as time bound and linear (one-off events, systems, linear, adaptation, linked to identities), ongoing and complex (ongoing processes, multifaceted, complex), or related to transition shock (labor, linked to emotions). The adaptation conceptualization increased in dominance over time, the linear conceptualization was more apparent in the interviews (time points 1 and 3), and the multifaceted and emotion-linked conceptualizations were more dominant in the longitudinal audio diaries (time point 2). CONCLUSIONS: This novel study illustrates conceptualizations of transitions as broadly consistent with existing higher education literature but extends this research considerably by identifying differences in conceptualizations across time. The authors encourage health care learners, educators, and policy makers to develop expanded and more sophisticated understandings of transitions to ensure that health care learners can better navigate often challenging graduate transitions. Further research should explore stakeholders' transition conceptualizations over lengthier durations beyond the new graduate transition.

The relationship between feedback and evaluative judgement in undergraduate nursing and midwifery education: An integrative review.

AIM: This integrative review aims to explore the relationship between feedback and evaluative judgement in undergraduate nursing and midwifery education. BACKGROUND: Research in higher education has shown that feedback practices can lead to students' developing evaluative judgement; thought critical for performance improvement and life-long learning. While literature in nursing and midwifery education has not yet employed the term 'evaluative judgement' explicitly, there might be similar concepts and practices that seek to develop students' judgement of performance that sustain learning beyond the immediate task. DESIGN: An integrative review of the nursing and midwifery feedback literature. METHODS: In February 2020, six online databases (CINAHL, ProQuest, Scopus, ERIC, PsycINFO, Ovid MEDLINE) were systematically searched for literature published between January 1989-February 2020. Synonyms for feedback and evaluative judgement were used to inform our search. This review included a rigorous team-based, five-stage approach: (1) identifying the problem; (2) conducting the search; (3) evaluating the data; (4) analysing the data; and (5) presenting the integrative review. RESULTS: A total of 1408 studies were initially retrieved with 543 duplicates. 865 abstracts were screened using eligibility criteria, resulting in the exclusion of 835 studies. Thirty full-text studies were appraised for quality. Eighteen studies with diverse methodologies achieved a medium-high quality score for inclusion in data analysis. Conceptions of feedback and evaluative judgement were identified in all studies; despite none using the term 'evaluative judgement' explicitly. Thematic analysis of the studies resulted in seven themes: conceptions of feedback, purposes of feedback, sources of feedback, modes of feedback, conceptions of evaluative judgement, purposes of evaluative judgement and relationships between feedback and evaluative judgement. CONCLUSIONS: While our findings supported contemporary higher education research, the feedback-evaluative judgement relationship is novel in nursing education. We encourage educators to design feedback activities privileging students' active engagement through dialogic feedback, reflection and self-assessment, to develop their evaluative judgement of practice.

Internal coherence matters: Lessons for nutrition and dietetics research.

AIM: Internal coherence in research refers to the alignment between ontology (nature of reality), epistemology (nature of knowledge), axiology (values), methodology and methods and is an important but often overlooked element of research quality. We therefore aimed to illustrate the concept of internal coherence in nutrition and dietetics research, and its importance beyond individual elements of study quality. METHOD: A targeted literature search in Nutrition and Dietetics was used to identify research illustrating one example of three main approaches to research (scientific, interpretive and critical inquiry) published between November 2017 and November 2020. Studies were included if they related to education research based on the expertise of the authors, and illustrated diverse points about internal coherence. The authors independently critiqued included studies for internal coherence and synthesised their findings. RESULTS: From 76 manuscripts, 14 were identified as describing education research. Of the three selected studies that were critiqued, all had elements of internal coherence, in particular alignment between epistemology and methodology. However, each had elements of misalignment too, specifically between epistemology, axiology and method. The results point to the profession's historical groundings privileging the scientific approach, showing how this can yield misalignments, particularly when describing the limitations of interpretive and critical inquiry approaches. CONCLUSION: This review demonstrates the importance of internal coherence as a marker of quality, over and above existing quality assessment checklists for qualitative and quantitative methodologies. As such, it can help authors, reviewers and editors to improve the quality of nutrition and dietetics research and its reporting.

Materials matter: Understanding the importance of sociomaterial assemblages for OSCE candidate performance.

INTRODUCTION: The OSCE is a sociomaterial assemblage-a meshing together of human and material components producing multiple effects. Materials matter because they shape candidate performance, with potentially calamitous career consequences if materials influence performance unjustly. Although the OSCE literature refers to materials, few papers study the sociomateriality of OSCEs. Therefore, we explored OSCE stakeholders' talk about sociomaterial assemblages to better understand their importance for candidate performance. METHODS: We conducted 15 focus groups with OSCE candidates (n = 42), examiners (n = 20) and simulated patients (n = 17) after an Australian postgraduate nursing OSCE. Sociomateriality informed our team-based framework analysis of data. RESULTS: Participants identified a multiplicity of OSCE materials (objects, technologies and spaces) thought to matter for candidate performance. Candidates' unfamiliarity with materials and missing or malfunctioning materials were reported to yield numerous negative impacts (eg cognitive overload, negative affect, time-wasting), thereby adversely affecting candidate performance. Both examiners and candidates made micro-adjustments to sociomaterial assemblages during the OSCE in order to make it work (eg candidates saying what they would do rather than doing it). Sometimes, such tinkering extended so far that sociomaterial assemblages were ruptured (eg examiners ignoring rubrics to help pass candidates), potentially influencing OSCE standardisation. DISCUSSION: Our novel empirical study extends previous conceptual work by illustrating wide-ranging sociomaterial assemblages influencing OSCE candidate performance. Further research is now needed employing sociomaterial approaches to further elucidate sociomaterial entanglements in diverse OSCEs. We encourage OSCE stakeholders to become more attuned to the productive nature of materials within all stages of OSCE design and implementation.

Exploring health care graduates' conceptualisations of preparedness for practice: A longitudinal qualitative research study.

INTRODUCTION: Although preparedness for practice (P4P) has been variously described, little shared understanding exists about what P4P is across the health professions. How P4P is conceptualised matters, because this shapes how stakeholders think, talk about and act towards it. Further, multiple understandings can result in diverse expectations for graduate performance. This study therefore explores health care learners' solicited and unsolicited conceptualisations of P4P over their early graduate transition. METHODS: We conducted longitudinal qualitative research including individual and group entrance interviews (phase 1: n = 35), longitudinal audio-diaries (phase 2: n = 30), and individual and group exit interviews (phase 3: n = 22) with learners from four disciplines (dietetics, medicine, nursing and pharmacy). We employed framework analysis to interrogate data cross-sectionally and longitudinally. RESULTS: We found 13 conceptualisations of P4P (eg knowledge, confidence), broadly similar across the disciplines. We found some conceptualisations dominant in both solicited and unsolicited talk (eg skills), some dominant only in solicited talk (eg competence) and others dominant only in unsolicited talk (eg experience). Although most conceptualisations appeared relatively stable across time, some appeared to dominate at certain time points only (eg employability and skills in phases 1 and 2, and competence in phase 3). DISCUSSION: This novel study extends previous uniprofessional work by illustrating a broader array of conceptualisations, differences between professions, solicited versus unsolicited talk and longitudinal cohort patterns. We encourage health care educators to discuss these different P4P understandings in graduate transition interventions. Further research is needed to explore other stakeholders' conceptualisations, and over a duration beyond the early graduate transition.

The applicability of generalisability and bias to health professions education's research.

CONTEXT: Research in health professions education (HPE) spans an array of topics and draws from a diversity of research domains , which brings richness to our understanding of complex phenomena and challenges us to appreciate different approaches to studying them. To fully appreciate and benefit from this diversity, scholars in HPE must be savvy to the hallmarks of rigour that differ across research approaches. In the absence of such recognition, the valuable contributions of many high-quality studies risk being undermined. METHODS: In this article, we delve into two constructs---generalisability and bias--that are commonly invoked in discussions of rigour in health professions education research. We inspect the meaning and applicability of these constructs to research conducted from different paradigms (i.e., positivist and constructivist) and orientations (i.e., objectivist and subjectivist) and then describe how scholars can demonstrate rigour when these constructs do not align with the assumptions underpinning their research. CONCLUSIONS: A one-size-fits-all approach to evaluating the rigour of HPE research disadvantages some approaches and threatens to reduce the diversity of research in our field. Generalisability and bias are two examples of problematic constructs within paradigms that embrace subjectivity; others are equally problematic. As a way forward, we encourage HPE scholars to inspect their assumptions about the nature and purpose of research-both to defend research rigour in their own studies and to ensure they apply standards of rigour that align with research they read and review.

Exploring the impact of education on preclinical medical students' tolerance of uncertainty: a qualitative longitudinal study.

Tolerance of uncertainty, a construct describing individuals' responses to perceived uncertainty, has relevancy across healthcare systems, yet little work explores the impact of education on medical students' tolerance of uncertainty. While debate remains as to whether tolerance of uncertainty is changeable or static, the prevailing conceptual healthcare tolerance of uncertainty model (Hillen et al. in Soc Sci Med 180:62-75, 2017) suggests that individuals' tolerance of uncertainty is influenced by so-called moderators. Evidence regarding education's role as a moderator of tolerance of uncertainty is, however, lacking. Preliminary work exploring medical students' professional identity formation within anatomy learning identified tolerance of uncertainty as a theme warranting further exploration. Extending from this work, our research question was: How does the anatomy education learning environment impact medical students' tolerance of uncertainty? To address this question, qualitative data were collected longitudinally across two successive cohorts through online discussion forums during semester and end of semester interviews. Framework analysis identified five stimuli of uncertainty, four moderators of uncertainty, and cognitive, emotional and behavioral responses to uncertainty with variable valency (positive and/or negative). Longitudinal data analyses indicated changes in stimuli, moderators and responses to uncertainty over time, suggesting that tolerance of uncertainty is changeable rather than static. While our findings support the Hillen et al. (Soc Sci Med 180:62-75, 2017) model in parts, our data extend this model and the previous literature. Although further research is needed about students' development of tolerance of uncertainty in the clinical learning environment, we encourage medical educators to incorporate aspects of tolerance of uncertainty into curricular and learning environments.

Leadership in intensive care: A review.

An integrative review of the literature specific to leadership within the intensive care unit was planned to guide future research. Four databases were searched. Study selection was based on predetermined inclusion and exclusion criteria and a quality check was done. Data extraction and synthesis involved developing a preliminary thematic coding framework based on a sample of papers. The coding framework and all selected papers were entered into NVivo software. All papers were then coded to the previously identified themes. Themes were summarised and presented with illustrative quotes highlighting key findings. In total, 1102 relevant quotations were coded across the 28 included papers. Four themes pertaining to leadership were described and analysed: (a) leadership dimensions and discourses; (b) leadership experiences; (c) facilitators and/or barriers to leadership; and (d) leadership outcomes. The literature was found to focus on leader behaviours, as well as the leader dimensions of role allocation, clinical and communication skills and traditional hierarchies. Positive behaviours mentioned included good decision-making, staying calm under pressure and being approachable. Leadership experiences (and outcomes) are typically reported to be positive. Personal individual factors seem the biggest enablers and barriers to leadership within the intensive care unit. Training is considered to be a facilitator of leadership within the intensive care unit. This study highlights the current literature on leadership in intensive care medicine and provides a basis for future research on interventions to improve leadership in the intensive care unit.

Doctors' identity transitions: Choosing to occupy a state of 'betwixt and between'.

CONTEXT: During transitions, doctors engage in identity work to adapt to changes in multiple domains. Accompanied by this are dynamic 'liminal' phases. Definitions of liminality denote a state of being 'betwixt and between' identities. From a social constructionist perspective, being betwixt and between professional identities may either involve a sense of disrupted self, requiring identity work to move through and out of being betwixt and between (ie, temporary liminality), or refer to the experiences of temporary workers (eg, locum doctors) or those in dual roles (eg, clinician-managers) who find themselves perpetually betwixt and between professional identities (ie, perpetual liminality) and use identity work to make themselves contextually relevant. In the health care literature, liminality is conceptualised as a linear process, but this does not align with current notions of transitions that are depicted as multiple, complex and non-linear. METHODS: We undertook a longitudinal narrative inquiry study using audio-diaries to explore how doctors experience liminality during trainee-to-trained transitions. In three phases, we: (a) interviewed 20 doctors about his or her trainee-to-trained transitions; (b) collected longitudinal audio-diaries from 17 doctors for 6-9 months, and (c) undertook exit interviews with these 17 doctors. Data were analysed thematically, both cross-sectionally and longitudinally, using identity work theory as an analytical lens. RESULTS: All participants experienced liminality. Our analysis enabled us to identify temporary and perpetual liminal experiences. Furthermore, fine-grained analysis of participants' identity talk enabled us to identify points in participants' journeys at which he or she rejected identity grants associated with his or her trained status and instead preferred to remain in and thus occupy liminality (ie, neither trainee nor trained doctor). CONCLUSIONS: This paper is the first to explore longitudinally doctors' liminal experiences through trainee-to-trained transitions. Our findings also make conceptual contributions to the health care literature, as well as the wider interdisciplinary liminality literature, by adding further layers to conceptualisations and introducing the notion of occupying liminality.