First-Generation Palestinian Refugees in Jordan: Experiences of Occupational Disruption From an Occupational Justice Perspective.

IMPORTANCE: Only a limited amount of research has investigated the impact of prolonged refugee status of Palestinian refugees who have been displaced for more than 70 yr. OBJECTIVE: To explore lived experiences of Palestinian refugees in Jordan and understand their occupational disruption. DESIGN: Thematic analysis guided by descriptive phenomenology with one-on-one and group interviews. SETTING: An AlBaqa'a community-based rehabilitation center or participants' homes. PARTICIPANTS: First-generation Palestinian refugees who fled Palestine and live in Jordan. RESULTS: Fifteen Palestinians, mainly widowed women in their 70s, participated in this study. Ten completed interviews, and five participated in two group interviews. Four themes emerged: (1) Palestinian pride, (2) trauma leaving one's home country, (3) challenges of living in a host country, and (4) internalized prejudice. CONCLUSIONS AND RELEVANCE: After 70 yr, prolonged refugeeism has led to occupational disruption and negative implications for occupational justice, especially in the absence of social justice. The area most negatively affected was social participation; however, participants still had a great sense of pride about their homeland and their heritage. What This Article Adds: This foundational research explores the occupational injustices of the protracted refugee status of first-generation Palestinians in Jordan and identifies meaningful interventions to promote the alleviation of occupational disruption.

Relationship Between Residents' Physiological Stress and Faculty Leadership Skills in a Department of Surgery.

BACKGROUND: Leadership skills of team leaders can impact the functioning of their teams. It is unknown whether attending surgeons' leadership skills impact residents' physiological stress. This study sought to (1) assess the relationship between attending surgeons' leadership skills and residents' physiological stress and (2) to characterize lifestyle behaviors associated with resident physiological stress. We hypothesized that strong attending leadership skills would be associated with low resident physiological stress. STUDY DESIGN: This prospective observational cohort study was conducted at a single urban, academic medical center in the US, over 12 months. Residents were enrolled during their rotation of 1 to 2 months on the Trauma and ICU services. The primary predictor was the attending surgeons' leadership skills that were measured using a weekly survey filled out by residents, using the Surgeons' Leadership Inventory (SLI). The SLI uses a 4-point Likert scale to measure surgeons' leadership skills across eight domains. The primary outcome was residents' physiological stress, which was measured by their Heart Rate Variability (HRV). We recorded the residents' HRV with a WHOOP strap that was continuously worn on the wrist or the bicep. We used multivariate repeated measures gamma regression to assess the relationship between attending leadership skills and residents' physiological stress, adjusting for hours of sleep, age, and service. RESULTS: Sixteen residents were enrolled over 12 months. The median attending surgeons' leadership score was 3.8 (IQR: 3.2-4.0). The median residents' percent of maximal HRV was 70.8% (IQR: 56.7-83.7). Repeated measure gamma regression model demonstrated a minimal nonsignificant increase of 1.6 % (95% CI: -5.6, 8.9; p-value = 0.65) in the percent of maximal HRV (less resident physiological stress) for every unit increase in leadership score. There was an increase of 2.9% (95% CI= 1.6, 4.2; p-value < 0.001) in the percent of maximal HRV per hour increase in sleep and a significant decrease of 10.9% (95% CI= -16.8, -5.2; < 0.001) in the percent of HRV when working in the ICU compared to the Trauma service. CONCLUSION: This study revealed that more residents' sleep was associated with lower physiological stress. Attending surgeons' leadership skills were not associated with residents' physiological stress.

Which learning experiences support an interprofessional identity? A scoping review.

In recent years, health professions researchers have suggested that a dual identity that includes both a professional and interprofessional identity is essential to interprofessionality. This scoping review sought to describe the learning experiences that may support the development of an interprofessional identity, providing direction for future research. A scoping review was conducted to identify papers published between 2000 and 2020 that provided empiric evidence to support the impact of planned or spontaneous learning experiences involving two or more healthcare professions that fostered the development of an "interprofessional identity," or a sense of belonging to an interprofessional community. Twelve papers were identified for inclusion. Articles varied regarding both the professional groups studied and the developmental levels of their participants. A wide variety of learning experiences were described in the identified studies, including designed activities and programs, as well as those occurring spontaneously in authentic clinical environments. Examples of longitudinal and integrated programs were also identified. The construct of an interprofessional identity and its potential impact on interprofessional practice has yet to be sufficiently studied. The results of this scoping review suggest that a variety of experiences that occur throughout the professional development trajectory may foster an interprofessional identity. Longitudinal, integrated interprofessional learning programs may result in a more long-lasting impact on interprofessional identity and these types of programs should be the focus of future research.

A Newly Developed Interprofessional In-Situ Simulation-Based Training for Airway Management of COVID-19 Patients: Identification of Challenges and Safety Gaps, and Assessment of the Participants' Reaction.

Background: Healthcare providers performing aerosol-generating procedures like airway management are at the highest risk for contamination with coronavirus disease 2019 (COVID-19). We developed an in-situ simulation (ISS) airway management training in confirmed or suspected COVID-19 patients for emergency and anesthesiology staff, evaluated participants' reactions, and identified perceived challenges. Methods: We used a cross-sectional study design incorporating a quantitative questionnaire to describe participants' reaction to the ISS and a qualitative group interview using the plus-delta debriefing modality to explore participants' challenges in acquiring the knowledge and skills required for each learning objective. Data were analyzed using descriptive statistics and deductive content analysis. Results: Two hundred and ninety-nine healthcare providers participated in 62 ISS training sessions. Over 90% of our study participants agreed or strongly agreed that: they understood the learning objectives; the training material appropriately challenged them; the course content was relevant, easy to navigate, and essential; the facilitators' knowledge, teaching, and style were appropriate; the simulation facilities were suitable; and they had ample opportunities to practice the learned skills. The main challenges identified were anticipating difficult airways, preparing intubation equipment, minimizing the number of personnel inside the room, adhering to the proper doffing sequence, preparing needed equipment outside the intubation room, speaking up, and ensuring closed-loop communication. Conclusion: The newly developed ISS training was feasible for busy healthcare practitioners to safely perform airway management procedures for suspected or confirmed COVID-19 patients without affecting bedside care. Anticipation of difficult airways and speaking up were the most frequent challenges identified across all specialties in this study.

Heterogeneity in the evaluation of suspected MIS-C: a cross-sectional vignette-based survey.

BACKGROUND AND OBJECTIVES: Multisystem Inflammatory Syndrome in Children (MIS-C) is an emerging complication of COVID-19 which lacks a definitive diagnostic test and evidence-based guidelines for workup. We sought to assess practitioners' preferences when initiating a workup for pediatric patients presenting with symptoms concerning for MIS-C. METHODS: In a cross-sectional vignette-based survey, providers were presented with clinical vignettes of a patient presenting with 24 h of fever from a community with high rates of COVID-19. Respondents were asked about their general practices in pursuing a workup for potential MIS-C including testing obtained, criteria for diagnosis, and timing to confirm or rule out the diagnosis. RESULTS: Most of the 174 respondents were physicians from the United States at academic medical centers. The majority of providers would not initiate MIS-C workup for fever and non-specific symptoms unless the fever lasted more than 72 h. Skin rash, abdominal pain, and shortness of breath were symptoms that raised greatest concern for MIS-C. Most providers would obtain COVID-19 PCR or antigen testing, plus blood work, in the initial workup. The list of laboratory studies providers would obtain is extensive. Providers primarily rely on cardiac involvement to confirm a MIS-C diagnosis, and establishing a diagnosis takes 24-48 h. CONCLUSIONS: Significant heterogeneity exists amongst providers as to when to initiate the MIS-C workup, the order and content of the workup, and how to definitively diagnose MIS-C. A diagnostic test with high sensitivity and specificity for MIS-C and refined evidence-based guidelines are needed to expedite diagnosis and treatment.

Flexible e-learning video approach to improve fundus examination skills for medical students: a mixed-methods study.

BACKGROUND: Training for the fundus examination using traditional teaching is challenging, resulting in low generalist physicians' confidence in performing the funduscopic examination. There is growing evidence suggesting a flexible e-learning video approach's value in teaching physical examination procedures. However, whether the flexible e-learning video approach is superior to the traditional, face-to-face (F2F) lecture-based teaching for the funduscopic exam and the cognitive processes supporting its effectiveness has not yet been determined. METHODS: We conducted a sequential explanatory mixed-method study to compare the flexible e-learning video approach's effectiveness versus the F2F lecture-based approach for teaching the funduscopic exam to medical students at Chiba University in Japan. Medical students were randomly assigned to either a flexible e-learning video approach group or a F2F lecture approach group. We then quantitatively measured the diagnostic accuracy of funduscopic findings before and after attending the specific classrooms. Next, we conducted student focus groups to explore the students' thinking processes in the flexible e-learning video approach vs. the F2F lecture-based teaching of fundus examination. The qualitative data were analyzed using the qualitative content analysis method. RESULTS: The mean diagnostic accuracy scores in the post-test significantly increased from pre-test in the intervention group (36.6 to 63.4%, p < 0.001). Post-post comparisons across the two groups revealed a significant difference (intervention group 63.4% vs. control group 34.6%, p < 0.001). Six semi-structured focused group interviews were conducted (n = 36). In the flexible e-learning video approach group, we identified ten categories corresponding to four levels of the revised Bloom's taxonomy: remember, understand, apply, analyze. Five categories were identified in the traditional F2F lecture approach group corresponding to three revised Bloom's taxonomy levels: understand, apply, analyze. Interrater reliability was substantial (Cohen's kappa = 0.81). CONCLUSIONS: Teaching medical students funduscopic examination using the flexible e-learning video approach leads to improved diagnostic accuracy of funduscopic examinations. The flexible e-learning video teaching method enabled higher cognitive activity levels than the traditional, lecture-based classroom, as assessed using the revised Bloom's taxonomy. TRIAL REGISTRATION: This study was registered with the University Hospital Medical Information Network Clinical Trials Registry on 08/02/2020 (Unique trial number: UMIN 000039434 ).

Understanding Barriers and Facilitators to Behavior Change After Implementation of an Interdisciplinary Surgical Non-Technical Skills Training Program in Rwanda.

OBJECTIVE: Nontechnical skills, such as situation awareness, decision making, leadership, communication, and teamwork play a crucial role on the quality of care and patient safety in the operating room (OR). In our previous work, we developed an interdisciplinary training program, based on the NOTSS (Non-Technical Skills for Surgeons) taxonomy. The aim of this study was to understand the challenges faced by Rwandan surgical providers, who had undergone NOTSS training, to apply these nontechnical skills during subsequent operative surgery. SETTING DESIGN: A sequential exploratory mixed method study design was used to assess how participants who took the NOTSS in Rwanda applied nontechnical skills in surgical care delivery. The qualitative phase of this study deployed a constructivist grounded theory approach. Findings from the qualitative phase were used to build a quantitative survey tool that explored themes that emerged from the first phase. PARTICIPANTS: Participants were nurses and resident from the departments of Surgery, Anesthesia, Obstetric, and Gynecology, from the University of Rwanda who attended the NOTSS course in March 2018. RESULTS: A total of 25 participants and 49 participants were respectively enrolled in the qualitative phase and quantitative phase. Participants noted that nontechnical skills implementation in clinical practice was facilitated by working with other personnel also trained in NOTSS, anticipation, and preparation ahead of the time; while lack of interdisciplinary communication, hierarchy, work overload, and an inconsistently changing environment compromised nontechnical skills implementation. Nontechnical skills were useful both inside and outside the operating. Participants reported that nontechnical skills implementation resulted in improved team dynamics, safer patient care, and empowerment. CONCLUSION: Surgical care providers who took the NOTSS course subsequently implemented nontechnical skills both inside and outside of the OR. Human and system-based factors affected the implementation of nontechnical skills in the clinical setting.

Correction to: "It is this very knowledge that makes us doctors": an applied thematic analysis of how medical students perceive the relevance of biomedical science knowledge to clinical medicine.

An amendment to this paper has been published and can be accessed via the original article.

"It is this very knowledge that makes us doctors": an applied thematic analysis of how medical students perceive the relevance of biomedical science knowledge to clinical medicine.

BACKGROUND: Intensive study of the biomedical sciences remains a core component of undergraduate medical education with medical students often completing up to 2 years of biomedical science training prior to entering clerkships. While it is generally accepted that biomedical science knowledge is essential for clinical practice because it forms the basis of clinical reasoning and decision-making, whether medical students perceive an expanded role for their biomedical science knowledge remains to be examined. METHODS: We conducted a qualitative research study to explore how medical students in the first clerkship year perceived the relevance of biomedical science knowledge to clinical medicine during this pivotal time as they begin their transition from students to physicians. To identify previously unidentified perspectives and insights, we asked students to write brief essays in response to the prompt: How is biomedical science knowledge relevant to clinical medicine? Ten codes and four themes were interpreted through an applied thematic analysis of students' essays. RESULTS: Analysis of students' essays revealed novel perspectives previously unidentified by survey studies and focus groups. Specifically, students perceived their biomedical science knowledge as contributory to the development of adaptive expertise and professional identity formation, both viewed as essential developmental milestones for medical students. CONCLUSIONS: The results of this study have important implications for ongoing curricular reform efforts to improve the structure, content, delivery, and assessment of the undergraduate medical curriculum. Identifying the explicit and tacit elements of the formal, informal, and hidden curriculum that enable biomedical science knowledge to contribute to the development of adaptive expertise and professional identity formation will enable the purposeful design of innovations to support the acquisition of these critical educational outcomes.

Assessing the hidden curriculum for the care of patients with limited english proficiency: An instrument development.

Background: Patients with limited English proficiency (LEP) are a growing population in the United States at risk for disparities in quality and safety of care. Medical student competency to care for patients with LEP is impacted by a hidden curriculum (HC) that undermines the learning experience; yet to date, there is no way to measure it. Thus, we designed an instrument to assess this HC. Methods: Based on findings from previous qualitative work and input from medical students and experts in LEP and psychometrics, we developed a 23-item survey with four domains. We e-mailed this to 3rd and 4th year students from two medical schools in the US. We conducted principal axis factoring to determine the instrument's construct validity. Only items with a factor loading ≥0.50 were retained. Results: We obtained 111 complete responses. Twenty-two of the 23 original items were retained. Four factors/components emerged, which did not support the original proposed domains. Three factors loaded on a mix of role modeling, and learning environment, structural, and organizational variables, while the fourth factor retained two role modeling items. Based on the factor extraction solution, we restructured the instrument into three domains: role modeling, demonstration of effective systems, and consequences of structural barriers for patients with LEP (Cronbach's alpha: 0.81-0.95, total variance accounted for 53.7%). Discussion: The results led us to reassess the domain structure to create an instrument representing students' perceptions and context. Our instrument, the LEP-HC, will allow medical educators to investigate a specific and important HC and improve teaching about care of patients with LEP.