Public Health Commons^™

The Rules Of The Game: Interprofessional Collaboration On The Intensive Care Unit Team, Lorelei Lingard, Sherry Espin, Cathy Evans, Laura Hawryluck

Lorelei Lingard

BACKGROUND: The intensive care unit (ICU) is a nexus for interspecialty and interdisciplinary tensions because of its pivotal role in the care of the hospital's most critically ill patients and in the management of critical care resources. In an environment charged with temporal, financial and professional tensions, learning how to get results collaboratively is a critical aspect of professional competence. This study explored how team members in the ICU interact to achieve daily clinical goals, delineate professional boundaries and negotiate complex systems issues. METHODS: Seven 1-hour focus groups were conducted with ICU team members in two hospitals. Participants consisted of …

Exploring The Gap Between Knowledge And Behavior: A Qualitative Study Of Clinician Action Following An Educational Intervention, Tara Kennedy, Glenn Regehr, Jay Rosenfield, S. Roberts, Lorelei Lingard

Lorelei Lingard

PURPOSE: Many medical education interventions improve clinicians' knowledge but fail to change behavior. The authors exposed this knowledge-behavior gap through standardized clinical interactions, thus allowing in-depth exploration of the contributing factors. METHOD: A typical evidence-based educational intervention in one clinical domain (early signs of autism) was administered to family medicine residents at the University of Toronto in 2001-02, and change in knowledge was assessed through a multiple-choice test. Six to eight weeks later, participants' relevant knowledge was documented, and their clinical behavior was observed during four interactions with standardized patients. Factors producing a knowledge-behavior discrepancy were then explored using semistructured …

Progressive Independence In Clinical Training: A Tradition Worth Defending?, Tara Kennedy, Glenn Regehr, G. Baker, Lorelei Lingard

Lorelei Lingard

BACKGROUND: Progressive independence is a traditional premise of clinical training. Recently, issues such as managed care, work hours limitation, and patient safety have begun to impact the degree of autonomy afforded to clinical trainees. This article reviews empirical evidence and theory pertaining to the role of progressive autonomy in clinical learning. METHOD: A computerized literature search was performed using Medline, PsycINFO, Social Sciences Citation Index, and Educational Resources Information Center. This article presents a synthetic review of relevant empirical and theoretical concepts from the domains of medicine, psychology, education, kinesiology, and sociology. RESULTS: The clinical psychology and medical education literatures …

Experience And Influence Of Residents' Involvement In Selection Process For Pediatric Residency Program, S. Katz, S. Mehta, Lorelei Lingard, S. Tallett

Lorelei Lingard

No abstract provided.

Making Sense Of Grounded Theory In Medical Education, Tara Kennedy, Lorelei Lingard

Lorelei Lingard

BACKGROUND: Grounded theory is a research methodology designed to develop, through collection and analysis of data that is primarily (but not exclusively) qualitative, a well-integrated set of concepts that provide a theoretical explanation of a social phenomenon.

OBJECTIVE: This paper aims to provide an introduction to key features of grounded theory methodology within the context of medical education research.

OVERVIEW: In this paper we include a discussion of the origins of grounded theory, a description of key methodological processes, a comment on pitfalls encountered commonly in the application of grounded theory research, and a summary of the strengths of grounded …

Learning Oral Presentation Skills A Rhetorical Analysis With Pedagogical And Professional Implications, Richard Haber, Lorelei Lingard

Lorelei Lingard

OBJECTIVE: Oral presentation skills are central to physician-physician communication; however, little is known about how these skills are learned. Rhetoric is a social science which studies communication in terms of context and explores the action of language on knowledge, attitudes, and values. It has not previously been applied to medical discourse. We used rhetorical principles to qualitatively study how students learn oral presentation skills and what professional values are communicated in this process. DESIGN: Descriptive study. SETTING: Inpatient general medicine service in a university-affiliated public hospital. PARTICIPANTS: Twelve third-year medical students during their internal medicine clerkship and 14 teachers. MEASUREMENTS: …

Expert And Trainee Determinations Of Rhetorical Relevance In Referral And Consultation Letters, Lorelei Lingard, Brian Hodges, Helen Macrae, Risa Freeman

Lorelei Lingard

BACKGROUND: Referral and consultation letters ferry patients among providers, negotiating co-operative care. Our study examined how "relevance" is signalled and decoded in these letters, from the perspective of both experts and trainees in three clinical specialties. METHODS: 104 letters were collected from 16 physicians representing family medicine, psychiatry and surgery. Interviews were conducted with 14 of these physicians and 13 residents from the three specialties. All documents and transcripts were analysed for emergent themes. RESULTS: Six rhetorical factors influenced expert physicians' decisions about what material is relevant: educational, professional, audience, system-institutional, medical-legal, and evaluative. Each specialty placed different emphasis on …

Time As A Catalyst For Tension In Nurse-Surgeon Communication, Sherry Espin, Lorelei Lingard

Lorelei Lingard

Carefully studying communication patterns between nurses and surgeons questions popular stereotypes about OR discourse and expands educators' understanding of the factors that motivate team communication, patterns that are habitual among team members, and issues that act as catalysts for tension. This study examines the nature of communication between perioperative nurses and surgeons and identifies patterns and sites of tension. Researchers observed 128 hours of interaction between nurses and surgeons in four surgical divisions at one teaching hospital in Ontario, Canada. Field notes were read, coded, and analyzed independently. Results showed that higher tension in nurse-surgeon communication clusters around particular themes, …

Perceptions Of Operating Room Tension Across Professions: Building Generalizable Evidence And Educational Resources, Lorelei Lingard, Glenn Regehr, Sherry Espin, Isabella Devito, Sarah Whyte, Douglas Buller, Bohdan Sadovy, David Rogers, Richard Reznick

Lorelei Lingard

BACKGROUND: Effective team communication is critical in health care, yet no curriculum exists to teach it. Naturalistic research has revealed systematic patterns of tension and profession-specific interpretation of operating room team communication. Replication of these naturalistic findings in a controlled, video-based format could provide a basis for formal curricula. METHOD: Seventy-two surgeons, nurses, and anesthesiologists independently rated three video-based scenarios for the three professions' level of tension, responsibility for creating tension and responsibility for resolution. Data were analyzed using three-way, mixed-design analyses of variance. RESULTS: The three professions rated tension levels of the various scenarios similarly (F=1.19, ns), but rated …

Childhood Immunization. How Knowledgeable Are We?, Helen Heurter, Karen Breen-Reid, Leya Aronson, Lorelei Lingard, David Manning, E. Ford-Jones

Lorelei Lingard

No abstract provided.

Teaching And Learning Communication In Medicine: A Rhetorical Approach, Lorelei Lingard, R. Haber

Lorelei Lingard

The language people use both makes possible and constrains the thoughts they can have. More than just a vehicle for ideas, language shapes ideas--and the practices that follow from them. Thus, in medical education, teaching students how to talk about medical cases also teaches them how to think about patients and medical work, and how to define their relationships to both. Without a theoretical model, however, teaching efforts in this domain tend to be implicit and ad hoc, which can lead to serious problems. Rhetoric is one science that can deepen understanding of communication and improve teaching of this clinical …

Getting Teams To Talk: Development And Pilot Implementation Of A Checklist To Promote Interprofessional Communication In The Or, Lorelei Lingard, S. Espin, B. Rubin, S. Whyte, M. Colmenares, G. Baker, D. Doran, E. Grober, B. Orser, J. Bohnen, R. Reznick

Lorelei Lingard

BACKGROUND: Pilot studies of complex interventions such as a team checklist are an essential precursor to evaluating how these interventions affect quality and safety of care. We conducted a pilot implementation of a preoperative team communication checklist. The objectives of the study were to assess the feasibility of the checklist (that is, team members' willingness and ability to incorporate it into their work processes); to describe how the checklist tool was used by operating room (OR) teams; and to describe perceived functions of the checklist discussions.

METHODS: A checklist prototype was developed and OR team members were asked to implement …

A Certain Art Of Uncertainty: Case Presentation And The Development Of Professional Identity, Lorelei Lingard, K. Garwood, C. Schryer, M. Spafford

Lorelei Lingard

Healthcare professionals use the genre of case presentation to communicate among themselves the salient patient information during treatment and management. In case presentation, many uncertainties surface, regarding, e.g., the reliability of patient reports, the sensitivity of laboratory tests, and the boundaries of scientific knowledge. The management and portrayal of uncertainty is a critical aspect of professional discourse. This paper documents the rhetorical features of certainty and uncertainty in novice case presentations, considering their pragmatic and problematic implications for students' professional socialization. This study was conducted during the third-year inpatient clerkship at a tertiary care, pediatric hospital in hospital in Canada. …

The Rhetoric Of Rationalization: How Students Grapple With Professional Dilemmas, Lorelei Lingard, K. Garwood, K. Szauter, D. Stern

Lorelei Lingard

No abstract provided.

'You Learn Better Under The Gun': Intimidation And Harassment In Surgical Education, Laura Musselman, Helen Macrae, Richard Reznick, Lorelei Lingard

Lorelei Lingard

BACKGROUND: Medical literature has documented a high prevalence of intimidation and harassment in the educational context. However, the research has failed to adequately delineate the nature of these phenomena as well as the different ways in which diverse actors perceive the behaviours in question.

METHODS: Based on qualitative methodology anchored in a social constructionism framework, how teachers (staff surgeons) and learners (surgical residents) define intimidation and harassment were documented and compared. In addition, teachers' and learners' perceptions of the impact of these behaviours on the learning environment, including their effects on the socialisation of surgeons in training, were examined.

FINDINGS: …

Towards Embracing Clinical Uncertainty: Lessons From Social Work, Optometry And Medicine, Marlee Spafford, Catherine Schryer, Sandra Campbell, Lorelei Lingard

Lorelei Lingard

Summary: The oral transmission and transformation of client information in an apprenticeship setting provides a rich environment in which to observe students and their expert supervisors managing uncertainty. In this Canadian-based study, we examined the communicative features of 12 social work supervisions involving social work students and their supervisors and enriched our observations with subsequent interviews of the participants.

Findings: Social work students viewed the acknowledgement and examination of uncertainty as a touchstone of competent social work. This observation contrasted with our past study of medical and optometry students who focused on personal deficit and a distrust of …

Basing The Evaluation Of Professionalism On Observable Behaviors: A Cautionary Tale, Shiphra Ginsburg, Glenn Regehr, Lorelei Lingard

Lorelei Lingard

PROBLEM STATEMENT AND BACKGROUND: The evaluation of professionalism often relies on the observation and interpretation of students' behaviors; however, little research is available regarding faculty's interpretations of these behaviors.

METHOD: Interviews were conducted with 30 faculty, who were asked to respond to five videotaped scenarios in which students are placed in professionally challenging situations. Behaviors were catalogued by person and by scenario.

RESULTS: There was little agreement between faculty about what students should and should not do in each scenario. Abstracted principles (e.g., honesty, altruism) were defined and applied inconsistently, both between and within individual faculty. There was no apparent …

A Theory-Based Instrument To Evaluate Team Communication In The Operating Room: Balancing Measurement Authenticity And Reliability, Lorelei Lingard, Glenn Regehr, Sherry Espin, Sarah Whyte

Lorelei Lingard

BACKGROUND: Breakdown in communication among members of the healthcare team threatens the effective delivery of health services, and raises the risk of errors and adverse events. AIM: To describe the process of developing an authentic, theory-based evaluation instrument that measures communication among members of the operating room team by documenting communication failures. METHODS: 25 procedures were viewed by 3 observers observing in pairs, and records of events on each communication failure observed were independently completed by each observer. Each record included the type and outcome of the failure (both selected from a checklist of options), as well as the time …

The Rhetorical 'Turn' In Medical Education: What Have We Learned And Where Are We Going?, Lorelei Lingard

Lorelei Lingard

This paper presents a critical reflection on the contributions and challenges associated with one rhetorical approach to studying teaching and learning communication in health professions education. A rhetorical approach treats language as a social act, and attends to the role of language in establishing professional identities and relationships. The research has produced insights into the use of standard communication formats to teach novices, the nature of socialization on clinical teams, and the relationship between communication patterns and patient safety. Challenges and emerging questions include the problem of accounting for the material dimensions of communication in a rhetorical model, grappling with …

Technical Skills In Paediatrics: A Qualitative Study Of Acquisition, Attitudes And Assumptions In The Neonatal Intensive Care Unit, Susan Bannister, Robert Hilliard, Glenn Regehr, Lorelei Lingard

Lorelei Lingard

PURPOSE: While the effective acquisition of technical skills is essential for excellent paediatric care, little is known about how technical skills are learned in the paediatric setting. This study sought to describe and theorise the variables influencing technical skills acquisition in a tertiary care neonatal intensive care unit (NICU) inpatient setting. METHODOLOGY: Using non-participant field methodology, paediatric residents and their teachers (nurses, respiratory therapists, neonatal staff and fellows) were observed at various times in the NICU for 8 weeks. Thirteen semistructured interviews with these teachers and learners and 1 focus group of additional learners were conducted and used to triangulate …