Intraprofessional boundary crossing in acute paediatric care: A rich journey for general practice and paediatric residents.

BACKGROUND: Achieving optimal collaboration between general practitioners and hospital-based critical care doctors is vital yet challenging, necessitating targeted collaborative training during residency. Despite apparent benefits, implementing intraprofessional learning faces constraints. Understanding its occurrence is crucial for engaging and educating residents. Considering boundaries' learning potential, we developed and evaluated an educational programme for general practitioner (GP) and paediatric (P) residents in paediatric emergency care based on Akkerman's Boundary Crossing Theory. The study investigated how intraprofessional learning mechanisms occurred and what learning conditions facilitated or impeded learning of GP and P residents, aiming to optimise educational programme design for intraprofessional collaboration. METHODS: We developed an educational programme with three activities: joint medical assessments of paediatric patients in each other's context, mutually mini-Clinical Evaluation Exercises (mini-CEXs) about intraprofessional collaboration skills and educational meetings about collaborative care. We performed a qualitative study with a constructivist approach to explore experiences of the programme. We conducted focus group interviews and analysed mini-CEXs, utilising Boundary Crossing theory for template analysis. RESULTS: Ten GP and eight P residents participated in our study. Learning mechanisms of identification and coordination dominated the joint medical assessments. Mini-CEXs stimulated reflection. Educational meetings with supervisors about intraprofessional barriers initiated transformation. Facilitated learning conditions were bidirectional crossing, enthusiastic supervisors, residents being familiar with each other, clear mini-CEX design and authentic paediatric cases. Unclear mutual expectations during joint medical assessments impeded learning of residents. CONCLUSIONS: Working in each other's context triggers learning mechanisms of identification, coordination and reflection, forming the basis for intraprofessional learning in paediatric emergency care for GP and P residents. For development of new collaboration practices, supervisors are necessary to translate reflection into transformation. Mutual responsibilities and expectations should be made more explicit to create a safer intraprofessional learning environment. Our findings extend to other medical training contexts, leveraging boundaries for learning.

Reframing selection as a learning experience: Insights from a residency selection assessment.

PURPOSE: Selection for postgraduate medical training is high-stakes and complex. The learning value of assessments for selection has, thus far, been underexplored, limiting their uptake as potentially meaningful learning experiences. The aim of this study was to explore the learning value residency applicants derive from an intelligence, personality, motivation and competency selection assessment and what factors influence the experienced learning value. METHODS: In Autumn 2020 and Spring 2021, we conducted individual semi-structured interviews with sixteen applicants for pediatric residency training. Selection outcomes were unknown at the time of the interview. Interviews were transcribed verbatim and thematically analyzed. RESULTS: Participants reported that the assessment was valuable in fostering self-reflection and self-awareness, embracing self-acceptance, pursuing development goals, assessing professional fit, and harnessing motivational drivers in work. The experienced learning value was influenced by applicants' ability to interpret its results, their focus on the high-stakes selection process and concerns regarding the acceptability and credibility of the selection tool. CONCLUSIONS: While the selection assessment showed learning potential, its learning value was impeded by a preoccupation with the high-stakes nature of the selection procedure. Intentional integration of the selection assessment in the learning curriculum may play a pivotal role in realizing its learning potential.

Unravelling underlying processes in intraprofessional workplace learning in residency.

BACKGROUND: To deliver high-quality collaborative care, residents need to be trained across the boundaries of their medical specialty (intraprofessional learning). The current literature does not provide insights into the underlying processes that influence intraprofessional learning. The aim of this study was to gain insight into the processes that occur during intraprofessional workplace learning in residency training, by exploring everyday intraprofessional interactions experienced by residents, with the ultimate objective of improving collaborative practice. METHOD: We conducted a focused ethnography using field observations and in-depth interviews with residents at an academic children's hospital in the Netherlands. In 2022, nine residents from four different medical specialties were shadowed and/or interviewed. In total, >120 hours of observation and 10 interviews were conducted. Data collection and analysis were conducted iteratively and discussed in a research team with diverse perspectives, as well as with a sounding board group of stakeholders. RESULTS: Residents were involved in numerous intraprofessional interactions as part of their daily work. We identified three themes that shed light on the underlying processes that occur during intraprofessional workplace learning: (1) residents' agency, (2) ingroups and outgroups and (3) communication about intraprofessional collaboration. CONCLUSIONS: Collaborative practice offers many intraprofessional learning opportunities but does not automatically result in learning from, with and about other specialties to improve intraprofessional collaborative care. Overarching the identified themes, we emphasise the pivotal role of the resident-supervisor dyad in facilitating residents' engagement in the learning opportunities of complex intraprofessional care. Furthermore, we propose that promoting deliberate practice and shared responsibility in collaborative care are crucial to better prepare residents for their roles and responsibilities in delivering high-quality collaborative patient care.

Learning for doctor-to-doctor collaboration: a qualitative study exploring the experiences of residents and supervisors with intraprofessional workplace learning in complex tertiary care.

BACKGROUND: To deliver high-quality care for individuals with complex medical conditions, residents need to be trained across the boundaries of their specialties. This study aimed to explore learning activities and influencing factors in intraprofessional workplace learning by residents in complex tertiary care. METHODS: This qualitative study was conducted in a tertiary care children's hospital. In September - December 2017, fourteen individual and two focus group interviews were conducted with a purposive sample of residents and supervisors of various specialties. Transcribed interviews were thematically analyzed to describe learning activities and influencing factors that play a role in intraprofessional workplace learning in complex tertiary care settings during residency training. RESULTS: Respondents described numerous activities that they considered opportunities for intraprofessional learning, both directly and not directly related to patient care. However, deliberate attention to intraprofessional learning often seemed to be lacking in clinical practice. Influencing factors on a system (macro), organization (meso) and personal and interpersonal level (micro) level were identified. Factors on the macro and meso level mainly determined whether intraprofessional learning opportunities arose, while micro level factors mainly influenced whether opportunities were seized. CONCLUSIONS: There are ample opportunities for intraprofessional workplace learning in complex tertiary care for residents. Residents may benefit more from intraprofessional learning opportunities if these are made more intentional and deliberate. Influencing factors at the macro, meso and micro level provide targets for interventions aimed at enhancing intraprofessional workplace learning in postgraduate medical training.

Intraprofessional workplace learning in postgraduate medical education: a scoping review.

BACKGROUND: Residents need to be trained across the boundaries of their own specialty to prepare them for collaborative practice. Intraprofessional learning (i.e. between individuals of different disciplines within the same profession) has received little attention in the postgraduate medical education literature, in contrast to the extensive literature on interprofessional learning between individuals of different professions. To address this gap, we performed a scoping review to investigate what and how residents learn from workplace-related intraprofessional activities, and what factors influence learning. METHODS: The PRISMA guidelines were used to conduct a scoping review of empirical studies on intraprofessional workplace learning in postgraduate medical education published between 1 January 2000 to 16 April 2020 in Pubmed, Embase, PsycINFO, ERIC and Web of Science. This study applied 'best fit' framework-based synthesis to map the existing evidence, using the presage-process-product (3P) model developed by Tynjälä (2013). RESULTS: Four thousand three hundred thirty records were screened, and 37 articles were included. This review identified influencing (presage) factors that derived from the sociocultural environment, learner and learning context. Studies described that complexity of care can both facilitate and hinder learning. Furthermore, intraprofessional learning is threatened by professional stereotyping and negative perceptions, and awareness of learning opportunities and explicit reflection are critical in intraprofessional workplace learning. Studies described a range of informal and formal intraprofessional activities (process) under the headings of collaboration in clinical practice, rotations or placements, formal educational sessions and simulated workplace training. In general, learners responded well and their attitudes and perceptions improved, learners reported increased knowledge and skills and positive behavioural changes (product). Learning outcomes were reported in the domains of patient-centred care, collaborative attitudes and respect, mutual knowledge and understanding, collaborative decision making, communication, leadership, teamwork and reflexivity. CONCLUSIONS: This review gives insight into the high learning potential of intraprofessional activities. Many of the included studies relied on self-reported perceptions of change, therefore, future research should focus on generating more robust evidence including objectively examined outcome measures. This review offers a comprehensive overview of the factors that influence intraprofessional workplace learning in postgraduate medical education. Finally, we provide recommendations for enhancing intraprofessional learning in clinical practice.

The use of SBAR as a structured communication tool in the pediatric non-acute care setting: bridge or barrier for interprofessional collaboration?

SBAR (Situation, Background, Assessment and Recommendation) is a structured method developed for communicating critical information that requires immediate action. In 2016 the SBAR tool was introduced at the Amalia Children's Hospital in the Netherlands to improve communication between healthcare workers. Despite formal training and the introduction of aids to facilitate implementation, observed adherence to the tool was low. A qualitative study was undertaken to study the use of SBAR by pediatric residents and nurses in the non-acute clinical care setting of an academic children's hospital. Semi-structured focus group sessions were conducted and qualitatively analyzed using a constructed coding template to search for facilitators and barriers in the use of SBAR by different professionals. We found professionals' use of SBAR was influenced by departmental, cultural, and individual factors. Important themes for effective implementation and use of SBAR in an interprofessional setting, like situation dependency, learning climate and professional identity had not been addressed during the initial implementation. To facilitate SBAR's use it is important to identify professionals' needs to use the tool effectively, to take into account how tasks and responsibilities are perceived by different professions, and to stimulate interprofessional feedback and role modeling.

Measuring situation awareness and team effectiveness in pediatric acute care by using the situation global assessment technique.

Situation awareness (SA) is an important human factor and necessary for effective teamwork and patient safety. Human patient simulation (HPS) with video feedback allows for a safe environment where health care professionals can develop both technical and teamwork skills. It is, however, very difficult to observe and measure SA directly. The Situation Global Assessment Technique (SAGAT) was developed by Endsley to measure SA during real-time simulation. Our objective was to measure SA among team members during simulation of acute pediatric care scenarios on the medical ward and its relationship with team effectiveness. Twenty-four pediatric teams, consisting of two nurses, one resident, and one consultant, participated in three acute care scenarios, using high-fidelity simulation. Individual SAGAT scores contained shared and complimentary knowledge questions on different levels of SA. Within each scenario, two "freezes" were incorporated to assess SA of each team members' clinical assessment and decision-making. SA overlap within the team (team SA) was computed and compared to indicators of team effectiveness (time to goal achievement, consensus on primary problem, diagnosis, task prioritization, leadership, and teamwork satisfaction). In 13 scenarios (18%), the team failed to reach the primary goals within the prescribed time of 1200 s. There was no significant difference in failure of goal completion between the scripted scenarios; however, there was a significant difference between scenario 3 and the other scenarios in time to goal completion. In all three scenarios, SA overlap level 2 (consensus on primary problem during the first freeze and consensus on diagnosis during the second freeze) leads to significantly faster achievement of the predefined goals. There was a strong relationship between team SA on the primary problem and diagnosis and team SA on task prioritization. Consensus on leadership within the team was low. Teamwork satisfaction was more influenced by knowledge about the importance of the assigned task than outcome of the scenario.Conclusion: The use of SAGAT enables us to measure SA of team members during real-time simulation of acute care scenarios. Although there is no direct connection between team SA and goal achievement, SAGAT provides insight in differences in SA among team members, and the process of shared mental model formation. By measuring SA, issues that may improve team effectiveness (prioritizing tasks, enhancing shared mental models, and providing leadership) can be trained and assessed during medical team simulation, enhancing teamwork in health care settings. What is known? • Teamwork skills such as communication, leadership, and situational awareness have become increasingly recognized as essential for good performance in pediatric resuscitation. However, the assessment of pediatric team performance in these clinical situations has been traditionally difficult. • The Situation Awareness Global Assessment Technique (SAGAT) is a method of objectively and directly measuring SA during a team simulation using "freezes" at predetermined points in time with participants reporting on "what is going on" from their perspective on the situation. What is new? • We assessed SA, and its relationship with team effectiveness, in multidisciplinary pediatric teams performing simulated critical events in critically ill children on the medical ward using the SAGAT model, outside the emergency room setting. • In all three scenarios, consensus on the primary problem (shared mental model) leads to faster achievement of predefined goals. Consensus on leadership was overall low, without a significant impact on goal achievement.

Leading teams during simulated pediatric emergencies: a pilot study.

PURPOSE: Leadership has been identified as a key variable for the functioning of teams and as one of the main reasons for success or failure of team-based work systems. Pediatricians often function as team leaders in the resuscitation of a critically ill child. However, pediatric residents often report having little opportunity to perform in the role of team leader during residency. In order to gain more insight into leadership skills and behaviors, we classified leadership styles of pediatric residents during simulated emergencies. METHODS: We conducted a prospective quantitative study to investigate leadership styles used by pediatric residents during simulated emergencies with clinical deterioration of a child at a pediatric ward. Using videotaped scenarios of 48 simulated critical events among 12 residents, we were able to classify verbal and nonverbal communication into different leadership styles according to the situational leadership theory. RESULTS: The coaching style (mean 54.5%, SD 7.8) is the most frequently applied by residents, followed by the directing style (mean 35.6%, SD 4.1). This pattern conforms to the task- and role-related requirements in our scenarios and it also conforms to the concept of situational leadership. We did not find any significant differences in leadership style according to the postgraduate year or scenario content. CONCLUSION: The model used in this pilot study helps us to gain a better understanding of the development of effective leadership behavior and supports the applicability of situational leadership theory in training leadership skills during residency.

Effectiveness of high fidelity video-assisted real-time simulation: a comparison of three training methods for acute pediatric emergencies.

Background. Video-assisted real-time simulation (VARS) offers the possibility of developing competence in acute medicine in a realistic and safe environment. We investigated the effectiveness of the VARS model and compared it with educational methods like Problem-Based Learning (PBL) and Pediatric Advanced Life Support (PALS). Methods. 45 fourth-year medical students were randomized for three educational methods. Level of knowledge and self-efficacy were measured before and after intervention. Clinical performance was measured by a blinded observer using a video checklist of prescripted scenarios on a high-fidelity simulator. Results. Knowledge test and self-efficacy scores improved significantly (P < 0.001) without differences between educational groups. The VARS group showed significantly (P < 0.05) higher scores on both postintervention scenarios concerning structure and time. Conclusion. VARS training is an effective educational method teaching pediatric acute care skills in the undergraduate curriculum. When compared to PBL and PALS training, VARS training appears to be superior in enhancing short-term clinical performance.