Changes in residents’ opportunities for experiential learning over time

Medical Education 2012: 46 : 1189–1193 Context Learning in the clinical environment is believed to be a crucial component of residency training. However, it remains unclear whether recent changes to postgraduate medical education, including the implementation of work hour limitations, have significantly impacted opportunities for experiential learning. Therefore, we sought to quantify opportunities to gain clinical experience within medical‐surgical intensive care units (ICUs) over time. Methods Data on the numbers of patients admitted and invasive procedures performed per day between 1 July 2001 and 30 June 2010 within three academic medical‐surgical ICUs in Calgary, Alberta, Canada were obtained from electronic medical records. These data were matched to resident doctor on‐call schedules and residents’ opportunities to admit patients and participate in procedures were calculated and compared over time using Spearman’s rho. Results We found that over a 9‐year period, the opportunities afforded to residents (n = 1156) to admit patients (n = 17 189) and perform procedures (n = 52 827) during ICU rotations decreased by 32% (p < 0.001) and 34% (p < 0.001), respectively. Conclusions Our results suggest that there has been a significant decrease in residents’ clinical experiences in the ICU over time. Further investigations to better understand these changes and how they may impact on performance as residents become independent practising doctors are warranted.     

Patterns of direct observation and their impact during residency: general practice supervisors’ views

Context

Direct observation (DO) of residents’ performance, despite the importance that is ascribed to it, does not readily fit in with the practice of postgraduate medical education (PGME); it is infrequent and the quality of observation may be poor in spite of ongoing efforts towards improvement. In recent literature, DO is mostly portrayed as a means to gather information on the performance of residents for purposes of feedback and assessment. The role of DO in PGME is likely to be more complex and poorly understood in the era of outcome‐based education. By exploring the possible complexity of DO in workplace learning, our research aims to contribute to a better use of DO in the practice of PGME.

Methods

Constructivist grounded theory informed our data collection and analysis. Data collection involved focus group sessions with supervisors in Dutch general practice who were invited to discuss the manifestations, meanings and effects of DO of technical skills. Theoretical sufficiency was achieved after four focus groups, with a total of 28 participants being included.

Results

We found four patterns of DO of technical skills: initial planned DO sessions; resident‐initiated ad hoc DO; supervisor‐initiated ad hoc DO, and continued planned DO sessions. Different patterns of DO related to varying meanings, such as checking or trusting, and effects, such as learning a new skill or experiencing emotional discomfort, all of them concerning the training relationship, patient safety or residents’ learning.

Conclusions

Direct observation, to supervisors, means much more than gathering information for purposes of feedback and assessment. Planned DO sessions are an important routine during the initiation phase of a training relationship. Continued planned bidirectional DO sessions, although infrequently practised, potentially combine most benefits with least side‐effects of DO. Ad hoc DO, although much relied upon, is often hampered by internal tensions in supervisors, residents or both.     

Aged care residents’ prioritization of care: A mixed‐methods study

BackgroundEliciting residents’ priorities for their care is fundamental to delivering person‐centred care in residential aged care facilities (RACFs). Prioritization involves ordering different aspects of care in relation to one another by level of importance. By understanding residents’ priorities, care can be tailored to residents’ needs while considering practical limitations of RACFs.ObjectivesTo investigate aged care residents’ prioritization of care.DesignA mixed‐methods study comprising Q methodology and qualitative methods.Setting and participantsThirty‐eight residents living in one of five Australian RACFs.MethodParticipants completed a card–sorting activity using Q methodology in which they ordered 34 aspects of care on a pre‐defined grid by level of importance. Data were analysed using inverted factor analysis to identify factors representing shared viewpoints. Participants also completed a think‐aloud task, demographic questionnaire, post‐sorting interview and semi‐structured interview. Inductive content analysis of qualitative data was conducted to interpret shared viewpoints and to identify influences on prioritization decision making.ResultsFour viewpoints on care prioritization were identified through Q methodology: Maintaining a sense of spirituality and self in residential care; information sharing and family involvement; self‐reliance; and timely access to staff member support. Across the participant sample, residents prioritized being treated with respect, the management of medical conditions, and their independence. Inductive content analysis revealed four influences on prioritization decisions: level of dependency; dynamic needs; indifference; and availability of staff.ConclusionsRecommendations for providing care that align with residents’ priorities include establishing open communication channels with residents, supporting residents’ independence and enforcing safer staffing ratios.     

Locating the lived body in client–nurse interactions: Embodiment,intersubjectivity and intercorporeality

The practice of nursing involves ongoing interactions between nurses' and clients' lived bodies. Despite this, several scholars have suggested that the “lived body” (Merleau‐Ponty, 1962) has not been given its due place in nursing practice, education or research (Draper, J Adv Nurs, 70, 2014, 2235). With the advent of electronic health records and increased use of technology, face‐to‐face assessment and embodied understanding of clients' lived bodies may be on the decline. Furthermore, staffing levels may not afford the time nurses need to be as “present” with their clients in embodied ways. The failure to attend to the lived body may contribute to missed opportunities for care and decreased quality of life for both clients and healthcare practitioners. In this paper, we undertake an analysis of selected aspects of the work of Maurice Merleau‐Ponty. The aim is to advance understanding of the affordances this work may offer to enhancing client–nurse interactions within the practice of nursing. Merleau‐Ponty's notions of embodiment, intersubjectivity and intercorporeality as articulated in his seminal texts The Phenomenology of Perception (New York, NY: Routledge, 2012) and The Visible and the Invisible (Evanston, IL: Northwestern University Press, 1968) are examined. These three constructs are discussed as they relate to the lived body in client–nurse interactions in nursing practice and education. Finally, implications of how attention to “the lived body” could shape interactions and have the potential to foster increased quality of life of clients and nurses are considered.     

Unravelling salutogenic mechanisms in the workplace: the role of learning

Objective

To explore the moderating and mediating role(s) of learning within the relationship between sense of coherence (SOC) and generalized resistance resources.

The health–promoting workplace: an integrative perspective

Abstract: The workplace is an important setting, affecting the physical, mental, economic and social wellbeing of workers, and, in turn, their families. Health of workers has many determinants, and a multidisciplinary, integrated approach is important. An overview of trends in workplace health promotion shows that current thinking has changed from a narrowly based risk–factors approach aimed at individual behaviour changes, to an integrative approach aimed at creating health–promoting workplaces. The health–promoting workplace has 'an all—encompassing approach that empowers workers and employers to improve all facets of their health'. There are gaps in knowledge, at the state and national levels, relevant to the planning and assessment of workplace health. A national information network is needed to facilitate better links between public health practitioners and researchers in advancing the health of working Australians.     

The effects of refurbishment on residents’ quality of life and wellbeing in two Swedish residential care facilities

This study was conducted to follow a refurbishment aimed at enhancing the supportiveness of the physical environment in two Swedish residential care facilities. Significant differences between intervention and equivalent reference groups were found for quality of life (p=0.007) and wellbeing (p=0.02, 0.01) indicating a deterioration for the intervention group. These results suggest that residential care facilities residents are more frail and sensitive to change than has been assumed. This needs to be considered when facilities accommodating the elderly need refurbishment. It also indicates that interior design features alone have little importance for the care climate in nursing homes.     

Beyond the workplace: an exploratory study of the impact of neurotoxic workplace exposure on marital relations

BACKGROUND: The impact on family life and social relations that may result from symptoms associated with exposure to neurotoxic substances has never been addressed. This exploratory study assessed the associations between exposure to neurotoxic agents in the workplace, mental health, and marital difficulties. METHODS: Fifty-five (55) male workers and their spouses completed standardized measures of mental health and marital difficulties. Workers' exposure to neurotoxic substances was evaluated by questionnaire and interview, using a semiquantitative classification system. RESULTS: A positive relation was observed between exposure level and measures of workers' psychological symptoms and marital stress; no relation was observed between workers' exposure level and wives' psychological symptoms. More severe exposure to neurotoxic substances was associated with wives' reports of more severe marital conflicts, and this association was mediated by husbands' psychological symptoms. As compared to low exposure husbands, high exposure husbands reported higher degrees of stress surrounding marital discussions, more consistent incidence of minor physical assaults by wives, and stronger associations between their levels of stress, the verbal aggressions of wives, and the number of marital conflicts. CONCLUSIONS: The results of this study confirm that neurotoxic exposure is a risk factor for mental health and suggest how this may influence marital relations. Because of the importance of these findings for the well-being of workers and their families, these associations should be further studied.     

Psychosocial factors and health: community and workplace study

The effects of psychosocial factors on health have drawn growing attention. An important prerequisite for epidemiologic studies is that instruments to measure psychosocial factors be reliable and valid based on psychometric properties. The introduction of occupational stress models has made breakthroughs in conceptualizing real-life complex phenomena in the workplace. This article describes some trials that explore the associations between psychosocial factors and health in the community and workplace. Scales for measuring social support and psychosocial job characteristics were developed, and their validation was pursued. Findings suggest that adverse social relationships and job characteristics measured by these instruments are associated with ill health. To strengthen the validities of the measurements and to provide strong causal evidence between psychosocial factors and health, more prospective studies and interventional approaches are needed.     

‘You’re judged all the time!’ Students’ views on professionalism: a multicentre study

Medical Education 2010: 44 : 814–825 Objectives This study describes how medical students perceive professionalism and the context in which it is relevant to them. An understanding of how Phase 1 students perceive professionalism will help us to teach this subject more effectively. Phase 1 medical students are those in the first 2 years of a 5‐year medical degree. Methods Seventy‐two undergraduate students from two UK medical schools participated in 13 semi‐structured focus groups. Focus groups, carried out until thematic saturation occurred, were recorded and transcribed verbatim. Data were analysed and coded using NVivo 8, using a grounded theory approach with constant comparison. Results From the analysis, seven themes regarding professionalism emerged: the context of professionalism; role‐modelling; scrutiny of behaviour; professional identity; ‘switching on’ professionalism; leniency (for students with regard to professional standards), and sacrifice (of freedom as an individual). Students regarded professionalism as being relevant in three contexts: the clinical, the university and the virtual. Students called for leniency during their undergraduate course, opposing the guidance from Good Medical Practice. Unique findings were the impact of clothing and the online social networking site Facebook on professional behaviour and identity. Changing clothing was described as a mechanism by which students ‘switch on’ their professional identity. Students perceived society to be struggling with the distinction between doctors as individuals and professionals. This extended to the students’ online identities on Facebook. Institutions’ expectations of high standards of professionalism were associated with a feeling of sacrifice by students caused by the perception of constantly ‘being watched’; this perception was coupled with resentment of this intrusion. Students described the significant impact that role‐modelling had on their professional attitudes. Conclusions This research offers valuable insight into how Phase 1 medical students construct their personal and professional identities in both the offline and online environments. Acknowledging these learning mechanisms will enhance the development of a genuinely student‐focused professionalism curriculum.     

‘Bourdieu’, medical elites and ‘social class’: a qualitative study of ‘desert island’ doctors

Sociologists of professions draw on Weberian theories of closure. However they have tended to ignore Bourdieu's work, which rejects Weberian notions of class and status groups as distinct ideal types and sees these concepts as inextricably linked. Bourdieu emphasises the importance of a class‐based habitus which generates orientations, inclinations and dispositions that organise practices and the perception of practice. For Bourdieu, because individuals perceive one another primarily through the status that attaches to their practices (through a symbolic veil of honour) they fail to perceive the real basis of these practices: the forms of capital that underlie the different habitus and enable their realisation. This article draws on interviews with 17 elite doctors appearing on a national (UK) radio show during which they choose eight discs to take to a desert island. According to Bourdieu, ‘nothing more clearly affirms one's “class”, nothing more infallibly classifies, than one's taste in music’. An analysis of the doctors' musical tastes and their mode of acquisition (largely, for these elites, via their family and education at independent schools), as well as other insights into their cultural capital reveals the importance of linking class and status when exploring professional status and prestige.     

Affective interactions with children in shelters: an ethnographic study

This study was conducted in order to observe interactions among twenty children living in a sheltered home and their care-givers. Using ethnographic methodology, these children (between ten months and five years old) were observed during half-hour meetings held twice a week for three and a half months. The findings indicate a lack of training among the care-givers, reflected in verbal hostility towards the children, with limited care, few words of encouragement and little physical contact. At the same time, it was noted that the children searched continuously for attention and care from other adults visiting the home. This underscores the need to prevent and restructure poor relationships between care-givers and children, shaping healthy environment for their development.     

Men’s work,women’s work and suicide: a retrospective mortality study in Australia

Objectives: This research sought to investigate the influence of being a in male‐dominated occupation on suicide. Methods: A population‐level retrospective mortality study was conducted over the period 2001 to 2015. Data from the Australian Census and the National Coronial Information System were combined. Negative binomial regression was used to assess the relationship between occupational gender ratio and suicide rates, controlling for age, socioeconomic status and year of death. Probabilistic sensitivity analysis accounted for unmeasured confounding due to common mental disorders. Results: Males in male‐dominated occupations had a rate ratio (RR) of 7.50 (95%CI 6.07 to 9.25) compared to males in female‐dominated occupations. Females in male‐dominated occupations had a RR of 0.13 (95%CI 0.07 to 0.26) compared to females in female‐dominated occupations. Results for males were maintained after adjusting for common mental disorders. There was evidence of interaction on both additive and multiplicative scales. Conclusions: The gendered context of an occupation influences suicide, with varying risks for women and men. More research is needed to understand the mechanisms of this relationship. Implications for public health: These results suggest the need for targeted suicide prevention activities in male‐dominated occupational groups.