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.

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.

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.

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.

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 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.

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.

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.

Female victims and female perpetrators: medical students' narratives of gender dynamics and professionalism dilemmas.

Medicine is a gendered discipline, in which women, both as patients and practitioners, have often held subordinate positions. The reproduction of dominant gender biases in the medical setting can negatively impact the professional development of medical students and the wellbeing of patients. In this analysis of medical students' narratives of professionalism dilemmas, we explore students' experiences of gender bias in hospital settings. Seventy-one students participated in 12 group interviews, where they discussed witnessing or participating in various activities that they thought were professionalism lapses. Within the dataset, 21 narratives had a distinctly gendered component broadly pertaining to patient dignity and safety dilemmas, informed consent issues, and female student abuse. Interestingly, perpetrators of such acts were commonly female healthcare professionals and educators. Although students recognized such acts as professionalism lapses and often expressed concern for patient wellbeing, students did not intervene or report such acts due to hierarchical cultural contexts, and at times even reproduced the discriminatory behavior they were criticizing. This raises concerns about medical students' professionalism development and the extent to which gender bias is ingrained within particular medical systems. The normalization of disrespectful and abusive treatment of female patients poses immediate and future consequences to the wellbeing and safety of women. Furthermore, the same socio-cultural values that sustain these acts may account for perpetrators often being women themselves as they strive to overcome their subordinate position within medicine.

Supervision training in healthcare: a realist synthesis.

Supervision matters: it serves educational, supportive and management functions. Despite a plethora of evidence on the effectiveness of supervision, scant evidence for the impact of supervision training exists. While three previous literature reviews have begun to examine the effectiveness of supervision training, they fail to explore the extent to which supervision training works, for whom, and why. We adopted a realist approach to answer the question: to what extent do supervision training interventions work (or not), for whom and in what circumstances, and why? We conducted a team-based realist synthesis of the supervision training literature focusing on Pawson's five stages: (1) clarifying the scope; (2) determining the search strategy; (3) study selection; (4) data extraction; and (5) data synthesis. We extracted contexts (C), mechanisms (M) and outcomes (O) and CMO configurations from 29 outputs including short (n = 19) and extended-duration (n = 10) supervision training interventions. Irrespective of duration, interventions including mixed pedagogies involving active and/or experiential learning, social learning and protected time served as mechanisms triggering multiple positive supervisor outcomes. Short-duration interventions also led to positive outcomes through mechanisms such as supervisor characteristics, whereas facilitator characteristics was a key mechanism triggering positive and negative outcomes for extended-duration interventions. Disciplinary and organisational contexts were not especially influential. While our realist synthesis builds on previous non-realist literature reviews, our findings extend previous work considerably. Our realist synthesis presents a broader array of outcomes and mechanisms than have been previously identified, and provides novel insights into the causal pathways in which short and extended-duration supervision training interventions produce their effects. Future realist evaluation should explore further any differences between short and extended-duration interventions. Educators are encouraged to prioritize mixed pedagogies, social learning and protected time to maximize the positive supervisor outcomes from training.

Student dignity during work-integrated learning: a qualitative study exploring student and supervisors' perspectives.

While University students increasingly participate in work-integrated learning (WIL), their dignity is often violated during WIL. The current literature is limited in so far as it typically focuses on student perspectives within healthcare contexts and does not use the concept of 'dignity'. Instead, this study explored student and supervisor perspectives on student dignity during WIL across healthcare and non-healthcare disciplines. Research questions included: What are: (1) types of student dignity experiences and patterns by groups; (2) factors contributing to experiences; (3) consequences of experiences? Sixty-five semi-structured interviews were conducted using narrative interviewing techniques with 30 supervisors and 46 students from healthcare (medicine, nursing and counselling) and non-healthcare (business, law and education) disciplines. Data were analyzed using framework analysis. Nine common narrative types were identified within 344 stories: verbal abuse, right for learning opportunities, care, inclusion, reasonable expectations, right for appropriate feedback, equality, trust, and right to be informed. Factors contributing to dignity experiences and consequences were often at the individual level (e.g. student/supervisor characteristics). We found some salient differences in perceptions of experiences between students and supervisors, but few differences between healthcare and non-healthcare disciplines. This study extends WIL research based on student perspectives in healthcare, and provides practice and further research guidance to enhance student dignity during WIL.

An international study of trainee-trained transitions: Introducing the transition-to-trained-doctor (T3D) model.

Background: Throughout their careers, doctors and other healthcare professionals experience numerous transitions. When supporting transitions, opportunities for development and learning should be maximized, while stressors having negative impacts on well-being should be minimized. Building on our international data, this study aimed to develop a conceptual model of the trainee-trained transition (i.e. the significant transitions experienced by doctors as they complete postgraduate training moving from trainee/resident status to medical specialist roles).Methods: Employing Multiple and Multidimensional Transitions (MMT) theory and current conceptualizations of clinical context, this study undertook secondary analysis of 55 interviews with doctors from three countries (Netherlands, Cananda and the UK) undergoing trainee-trained transitions.Results: Through this analysis, the Transition-To-Trained-Doctor (T3D) conceptual model has been developed. This model takes into consideration the multiple contexts and multiple domains in which transitions take place.Discussion: This model is significant in that it has several uses and is applicable across countries: to remind doctors, managers and medical educators of the complexity of transitions; to frame and facilitate supportive conversations; and as a basis to teach about transitions.

Student and clinician identities: how are identities constructed in interprofessional narratives?

CONTEXT: Although the literature on professional identity formation in medical education is increasing, it is scant by comparison on student and clinician identities within interprofessional contexts. We therefore adopt a novel discursive approach to identities to explore how soon-to-become graduates and workplace-based clinicians construct their own and others' identities in interprofessional student-clinician (IPSC) interaction narratives. METHODS: We conducted a qualitative narrative interview study with 38 students and 23 clinicians representing the fields of medicine, midwifery, nursing, occupational therapy, paramedicine and physiotherapy. Through framework analysis, we identified the breadth of student and clinician identity constructions across 208 IPSC interaction narratives, and explored how common constructions differed by narrative and narrator. Through in-depth positioning analysis, we explored how student and clinician identities are discursively positioned within two selected IPSC interaction narratives. RESULTS: We identified 11 common constructions of student identities and eight common constructions of clinician identities across all 208 narratives. We found differences in identity constructions across positively versus negatively evaluated narratives, and student versus clinician narrators, highlighting the rhetorical nature of narratives. Our in-depth positioning analysis of two narratives illustrates how one student and one clinician discursively positioned theirs and others' identities during interprofessional interactions, and how identities vary depending on narrators' evaluations of their stories. Although both positioning analyses illustrate how the narrators' language serves to reproduce the common societal discourse of interprofessional conflict, the clinician narrative also draws on the competing discourse of interprofessional collaboration. CONCLUSIONS: Although some of the identities support previous uniprofessional research, our findings illustrate greater breadth and depth in terms of student and clinician identities within interprofessional contexts. We encourage educators to embed identities curricula into existing workplace learning for students and clinicians to help them make sense of their developing professional and interprofessional identities. Workplace educators should facilitate meaningful IPSC interactions to promote interprofessional learning and collaboration.

'I will never ever go back': patients' written narratives of health care communication.

CONTEXT: Although communication with patients is essential to health care, education designed to develop patient-centred communication often ignores patients' voices. Patient stories may offer a means to explore patient experiences to inform patient-centred communication skills education design. OBJECTIVES: Our research questions were: (i) What are the features of patients' health care communication narratives? (ii) What differences exist between patient narratives evaluated as positive and those evaluated as negative? (iii) How do patients narrate emotion in their narratives? METHODS: This interpretivist research was underpinned by social constructionism. We employed a narrative approach to design an online questionnaire that was advertised to patients in the community. Analysis of the stories that were generated involved analysis of what was written (i.e. framework analysis) and of how it was written (i.e. attending to linguistic features). RESULTS: Participants shared 180 written narratives about previous health care professional (HCP) communication interactions. Narratives commonly included those of female patients seeking help for musculoskeletal or psychological concerns, which most frequently had occurred within the previous 6 months with male general practitioners in community settings. Framework analysis revealed four key themes: (i) patient actions during consultations; (ii) patient actions afterwards; (iii) lasting legacy, and (iv) interpersonal factors. Patients in narratives evaluated as positive actively engaged during and after interactions, had ongoing positive relationships with HCPs and felt valued in these relationships. Patients in narratives evaluated as negative were either passive or active during the interaction, but mostly failed to return to the HCP and felt devalued in their interaction. Further analysis of the linguistic features of select narratives revealed rich constructions of positive and negative emotions emphasising the lasting legacies of these interactions. CONCLUSIONS: Analysis of patient narratives provides a detailed way of exploring patients' experiences, emotions and behaviours during and after consultations. Educational implications include emphasising the importance of valuing the patient, and of seeking and acting on patient feedback to calibrate HCPs' patient-centred communication practices.

What really matters for successful research environments? A realist synthesis.

CONTEXT: Research environments, or cultures, are thought to be the most influential predictors of research productivity. Although several narrative and systematic reviews have begun to identify the characteristics of research-favourable environments, these reviews have ignored the contextual complexities and multiplicity of environmental characteristics. OBJECTIVES: The current synthesis adopts a realist approach to explore what interventions work for whom and under what circumstances. METHODS: We conducted a realist synthesis of the international literature in medical education, education and medicine from 1992 to 2016, following five stages: (i) clarifying the scope; (ii) searching for evidence; (iii) assessing quality; (iv) extracting data, and (v) synthesising data. RESULTS: We identified numerous interventions relating to research strategy, people, income, infrastructure and facilities (IIF), and collaboration. These interventions resulted in positive or negative outcomes depending on the context and mechanisms fired. We identified diverse contexts at the individual and institutional levels, but found that disciplinary contexts were less influential. There were a multiplicity of positive and negative mechanisms, along with three cross-cutting mechanisms that regularly intersected: time; identity, and relationships. Outcomes varied widely and included both positive and negative outcomes across subjective (e.g. researcher identity) and objective (e.g. research quantity and quality) domains. CONCLUSIONS: The interplay among mechanisms and contexts is central to understanding the outcomes of specific interventions, bringing novel insights to the literature. Researchers, research leaders and research organisations should prioritise the protection of time for research, enculturate researcher identities, and develop collaborative relationships to better foster successful research environments. Future research should further explore the interplay among time, identity and relationships.

"I'd been like freaking out the whole night": exploring emotion regulation based on junior doctors' narratives.

The importance of emotions within medical practice is well documented. Research suggests that how clinicians deal with negative emotions can affect clinical decision-making, health service delivery, clinician well-being, attentiveness to patient care and patient satisfaction. Previous research has identified the transition from student to junior doctor (intern) as a particularly challenging time. While many studies have highlighted the presence of emotions during this transition, how junior doctors manage emotions has rarely been considered. We conducted a secondary analysis of narrative data in which 34 junior doctors, within a few months of transitioning into practice, talked about situations for which they felt prepared or unprepared for practice (preparedness narratives) through audio diaries and interviews. We examined these data deductively (using Gross' theory of emotion regulation: ER) and inductively to answer the following research questions: (RQ1) what ER strategies do junior doctors describe in their preparedness narratives? and (RQ2) at what point in the clinical situation are these strategies narrated? We identified 406 personal incident narratives: 243 (60%) contained negative emotion, with 86 (21%) also containing ER. Overall, we identified 137 ER strategies, occurring prior to (n = 29, 21%), during (n = 74, 54%) and after (n = 34, 25%) the situation. Although Gross' theory captured many of the ER strategies used by junior doctors, we identify further ways in which this model can be adapted to fully capture the range of ER strategies participants employed. Further, from our analysis, we believe that raising medical students' awareness of how they can handle stressful situations might help smooth the transition to becoming a doctor and be important for later practice.

Pre-registration interprofessional clinical education in the workplace: a realist review.

CONTEXT: The inclusion of interprofessional education opportunities in clinical placements for pre-registration learners has recently been proposed as a strategy to enhance graduates' skills in collaborative practice. OBJECTIVES: A realist review was undertaken to ascertain the contexts, mechanisms and outcomes of formal interprofessional clinical workplace learning. METHODS: Initial scoping was carried out, after which Ovid MEDLINE, CINAHL and EMBASE were searched from 2005 to April 2016 to identify formal interprofessional workplace educational interventions involving pre-registration learners. Papers reporting studies conducted in dedicated training wards were excluded, leaving a total of 30 papers to be included in the review. RESULTS: Several educational formats that combined students from medicine, nursing, pharmacy and allied health professions were identified. These included: the use of engagement by student teams with a real patient through interview as the basis for discussion and reflection; the use of case studies through which student teams work to promote discussion; structured workshops; ward rounds, and shadowing. Meaningful interprofessional student discussion and reflection comprised the mechanism by which the outcome of learners acquiring knowledge of the roles of other professions and teamwork skills was achieved. The mechanism of dialogue during an interaction with a real patient allowed the patient to provide his or her perspective and contributed to an awareness of the patient's perspective in health care practice. Medication- or safety-focused interprofessional tasks contributed to improved safety awareness. In the absence of trained facilitators or in the context of negative role-modelling, programmes were less successful. CONCLUSIONS: In the design of workplace education initiatives, curriculum decisions should take into consideration the contexts of the initiatives and the mechanisms for achieving the education-related outcomes of interest.

Shedding the cobra effect: problematising thematic emergence, triangulation, saturation and member checking.

CONTEXT: Qualitative research is widely accepted as a legitimate approach to inquiry in health professions education (HPE). To secure this status, qualitative researchers have developed a variety of strategies (e.g. reliance on post-positivist qualitative methodologies, use of different rhetorical techniques, etc.) to facilitate the acceptance of their research methodologies and methods by the HPE community. Although these strategies have supported the acceptance of qualitative research in HPE, they have also brought about some unintended consequences. One of these consequences is that some HPE scholars have begun to use terms in qualitative publications without critically reflecting on: (i) their ontological and epistemological roots; (ii) their definitions, or (iii) their implications. OBJECTIVES: In this paper, we share our critical reflections on four qualitative terms popularly used in the HPE literature: thematic emergence; triangulation; saturation, and member checking. METHODS: We discuss the methodological origins of these terms and the applications supported by these origins. We reflect critically on how these four terms became expected of qualitative research in HPE, and we reconsider their meanings and use by drawing on the broader qualitative methodology literature. CONCLUSIONS: Through this examination, we hope to encourage qualitative scholars in HPE to avoid using qualitative terms uncritically and non-reflexively.