Comparing an In-Person and Online Continuing Education Intervention to Improve Professional Decision-Making: A Mixed Methods Study.

Purpose: This paper compares two iterations (in-person and online) of a multi-stage continuing education program for improving high-risk decision-making among mental health workers. Methods: The mixed-methods study analyzed the following: (1) physiological and psychological arousal during simulated patient interviews; (2) physiological and psychological arousal recorded during real-time decision-making over four months; and (3) thoughts on the process and outcomes of the intervention raised in reflective interviews. Findings: Quantitatively, there were no statistical differences in stress measures between in-person and online simulated interviews or decision-making logs, suggesting they were effective in eliciting reactions commonly found in challenging clinical situations. Qualitatively, participants in both iterations indicated that the intervention caused them to reflect on practice, consider a wider range of factors related to the decisions, and enact approaches to improve decision-making. Conclusions: A carefully constructed online continuing education experience can result in outcomes for experienced social workers that are equivalent to an in-person iteration.

Assessing the equivalency of face-to-face and online simulated patient interviews in an educational intervention.

BACKGROUND: In adapting to COVID-19, many health professional training programs moved abruptly from in-person to online simulated patient interviews for teaching and evaluation without the benefit of evidence regarding the efficacy of this mode of delivery. This paper reports on a multi-methods research project comparing in-person and online simulated patient interviews conducted by allied health professionals as part of an educational intervention offered at a large university teaching hospital. METHODS: Twenty-three participants conducted two 15-min interviews with simulated patients using previously validated scenarios of patients presenting with suicide risk. In order to assess the equivalency of the two modalities, physiological and psychological stress were measured using heart rate variability parameters and the State-Trait Anxiety Inventory respectively, and then were compared across cohorts using t-tests. Reflective interviews elicited qualitative impressions of the simulations that were subject to thematic qualitative analysis. RESULTS: There were no statistical differences in measures of psychological stress or physiological arousal of participant health care professionals who engaged with in-person versus online simulated interviews, suggesting they were equally effective in eliciting reactions commonly found in challenging clinical situations. In reflective interviews, participants commented on the realism of both modalities of simulated patient encounters and that simulated interviews provoked emotional and physiological responses consistent with actual patient encounters. CONCLUSIONS: These findings provide developing evidence that carefully designed online clinical simulations can be a useful tool for the education and assessment of healthcare professionals.

"I think we did the best that we could in the space:" A qualitative study exploring individuals' experiences with three unconventional environments for patients with a delayed hospital discharge.

BACKGROUND: Given growing hospital capacity pressures, persistent delayed discharges, and ongoing efforts to improve patient flow, the use of unconventional environments (newly created or repurposed areas for patient care) is becoming increasingly common. Despite this, little is known about individuals' experiences in providing or receiving care in these environments. OBJECTIVES: The objectives of this study were to: (1) describe the characteristics of three unconventional environments used to care for patients experiencing a delayed discharge, and (2) explore individuals' experiences with the three unconventional environments. METHODS: This was a multi-method qualitative study of three unconventional environments in Ontario, Canada. Data were collected through semi-structured interviews and observations. Participants included patients, caregivers, healthcare providers, and clinical managers who had experience with delayed discharges. In-person observations of two environments were conducted. Interviews were transcribed and notes from the observations were recorded. Data were coded and analyzed thematically. RESULTS: Twenty-nine individuals participated. Three themes were identified for unconventional environments: (1) implications on the physical safety of patients; (2) implications on staffing models and continuity of care; and, (3) implications on team interactions and patient care. Participants discussed how the physical set-up of some unconventional spaces was not conducive to patient needs, especially those with cognitive impairment. Limited space made it difficult to maintain privacy and develop social relationships. However, the close proximity of team members allowed for more focused collaborations regarding patient care and contributed to staff fulfilment. A smaller, consistent care team and access to onsite physicians seemed to foster improved continuity of care. CONCLUSIONS: There is potential to learn from multi-stakeholder perspectives in unconventional environments to improve experiences and optimize patient care. Key considerations include keeping hallways and patient rooms clear, having communal spaces for activities and socialization, co-locating team members to improve interactions and access to resources, and ensuring a consistent care team.

Workplace Trauma in a Digital Age: The Impact of Video Evidence of Violent Crime on Criminal Justice Professionals.

High-quality video and audio recordings of violent crimes, captured using now ubiquitous digital technologies, play an increasingly important role in the administration of justice. However, the effects of exposure to gruesome material presented in this form on criminal justice professionals who analyze, evaluate, and use this potentially traumatic content in the context of their work, are largely unknown. Using long interviews and constructivist grounded theory, this qualitative study sought to explore experiences of exposure to video evidence of violent crime among Canadian criminal justice professionals. Sixteen individuals including police, lawyers, judges, psychiatrists, law clerks, and court reporters volunteered to participate in qualitative long interviews asking about workplace exposures to violent videos. Themes identified address the ubiquity of video evidence of violent crime; proximity to violence through video; being blindsided through lack of preparedness for violent content; repeated exposures through multiple and protracted viewings; insufficient customary methods for self-protection; and the enduring impact of exposure to videoed violence. We determine that criminal justice professionals are increasingly and repeatedly presented with deeply disturbing imagery that was once imperceptible or unknowable and thus previously held at a greater distance. Elements of what is newly visible and audible in video evidence of violent crime create a new emotional proximity to violence that potentially increases the risks of secondary trauma and underscores the need for improved safety measures.

Understanding Bullying and Cyberbullying Through an Ecological Systems Framework: the Value of Qualitative Interviewing in a Mixed Methods Approach.

Recognized as complex and relational, researchers endorse a systems/social-ecological framework in examining bullying and cyberbullying. According to this framework, bullying and cyberbullying are examined across the nested social contexts in which youth live-encompassing individual features; relationships including family, peers, and educators; and ecological conditions such as digital technology. Qualitative inquiry of bullying and cyberbullying provides a research methodology capable of bringing to the fore salient discourses such as dominant social norms and otherwise invisible nuances such as motivations and dilemmas, which might not be accessed through quantitative studies. Through use of a longitudinal and multi-perspective mixed methods study, the purpose of the current paper is to demonstrate the ways qualitative interviews contextualize quantitative findings and to present novel discussion of how qualitative interviews explain and enrich the quantitative findings. The following thematic areas emerged and are discussed: augmenting quantitative findings through qualitative interviews, contextualizing new or rapidly evolving areas of research, capturing nuances and complexity of perspectives, and providing moments for self-reflection and opportunities for learning.

Traumatic residue, mediated remembering and video evidence of sexual violence: A case study.

This qualitative case study examines the impact of video evidence of violent crime in the tragic Canadian case of serial killers Paul Bernardo and Karla Homolka. Through in-depth interviews with those centrally involved in the case, interviews with criminal justice professionals currently working with video evidence of violent crime, and review of official documents and media reports, we explore the complex role video evidence played in this case and the legacy it continues to have in society, the justice system, and in the individual lives of those involved twenty-five years later. Two primary sources of harm arose in our analysis: critogenic harm related to the use of video evidence in the justice process; and harm arising from the media publicity surrounding the video evidence. Both of these sources of harm intensified the trauma for victims and their families, and contributed to distress and trauma reactions of criminal justice professionals and members of the jury. Given the global increase in the use of video-evidence in criminal justice processes, it is imperative that continuing harms to those involved in the process are considered and mitigated.

Perceived organizational support and emotional labour among police communicators: what can organizational context tell us about posttraumatic stress?

OBJECTIVE: As central members of the emergency response system, communicators are regularly exposed to potentially traumatic events and experience some of the highest rates of posttraumatic stress. Given elevated rates of distress, they are regularly called upon to manage emotions-their own and others'-during high-risk and high-stress situations, within a highly controlled organizational context. Emotional labour (EL) theory suggests that many individuals faced with this challenge utilize a strategy in which emotions are suppressed or faked (surface acting-SA) in keeping with organizational expectations. METHODS: This study was designed to examine the relationships among reported EL, perceived organizational support, job stress, and severity of posttraumatic stress among a population of communicators. RESULTS: Job pressure and perceived lack of organizational support were positively associated with posttraumatic stress. Although the highest reported levels of SA occurred when interacting with members of the public, this SA was not associated with posttraumatic stress, unlike SA with co-workers and supervisors. SA with co-workers and supervisors was further related to perceptions of lack of organizational support. CONCLUSION: Thus, an organization perceived as unsupportive may create a culture in which individuals are dissuaded from expressing true emotions with colleagues and supervisors, potentially magnifying the traumatic effects of exposure to critical incidents.

How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis.

BACKGROUND: Despite substantial implications for healthcare provider practice and patient outcomes, gender has yet to be systematically explored with regard to interprofessional operating room (OR) teamwork. We aimed to explore and describe how gender and additional social identity factors shape experiences and perceptions of teamwork in the OR. METHODS: This study was a qualitative secondary analysis of semi-structured interviews with OR team members conducted between November 2018 and July 2019. Participants were recruited across hospitals in Ontario, Canada. We conducted both purposive and snowball sampling until data saturation was reached. Transcripts were analyzed thematically by two independent research team members, moving from open to axial coding. RESULTS: Sixty-six interviews of OR healthcare professionals were completed: anesthesia (n=17), nursing (n=19), perfusion (n=2), and surgery (n=26). Traditional gender roles, norms, and stereotypes were perceived and experienced by both women and men, but with different consequences. Both women and men participants described challenges that women face in the OR, such as being perceived negatively for displaying leadership behaviours. Participants also reported that interactions and behaviours vary depending on the team gender composition, and that other social identities, such as age and race, often interact with gender. Nevertheless, participants indicated a belief that the influence of gender in the OR may be modified. CONCLUSIONS: The highly gendered reality of the OR creates an environment conducive to breakdowns in communuication and patient safety risks in addition to diminishing team morale, psychological safety, and provider well-being. Consequently, until teamwork interventions adequately account for gender, they are unlikely to be optimally effective or sustainable.

Looking Beyond Assumptions to Understand Relationship Dynamics in Bullying.

To account for the complex relationships and processes that constitute the phenomenon of bullying, it is critical to understand how students and their parents and teachers conceptualize traditional and cyberbullying. Qualitative data were drawn from a mixed methods longitudinal study on cyberbullying. Semi-structured interviews were held with Canadian students in grades 4, 7, and 10 in a large urban school board, and their parents and teachers. To account for the complexity and interactions of different systems of relationships, the purpose of the current article is to examine how students and their matched parents and teachers understand traditional and cyberbullying. Central to participants' understanding of traditional and cyberbullying was whether they considered bullying to represent harmful relationship dynamics. Three main assumptions emerged as shaping participants' understanding of bullying and appeared to obscure the deep relationship processes in bullying: (a) assumptions of gender in bullying, (b) type of bullying-comparing traditional and cyberbullying, and (c) physical bullying as disconnected from relationship dynamics. It is essential that assessment, education, and prevention and intervention strategies in traditional and cyberbullying be informed by the inherent relationships in bullying and be implemented at multiple levels of relationships and broader social systems.

The "Managed" or Damaged Heart? Emotional Labor, Gender, and Posttraumatic Stressors Predict Workplace Event-Related Acute Changes in Cortisol, Oxytocin, and Heart Rate Variability.

Vital to the everyday operation of police services, police communicators (911 call-takers and dispatchers) are persistently subject to imminent challenges in the workplace; they must always be prepared to engage and deal with a wide variety of circumstances that provoke various intense emotions and physiological stress responses. Acute changes in cortisol, oxytocin, and heart rate variability are central to adaptive responses in stressful complex social interactions, but they might also be indicative of physiological dysregulation due to long-term psychosocial stress exposures. Thus, we examine acute stress-induced release of peripheral oxytocin and cortisol along with changes in heart rate variability, and how each relates to persistent workplace stressors and symptoms of posttraumatic stress. Findings indicate chronic forms of gendered workplace stress such as emotional labor, gender role stress and, posttraumatic stress each have differential associations with, and predict physiological responses to, acutely stressful events in the workplace. These associations suggest potential mechanisms through which communicators become more vulnerable to developing stress-related disorders such as posttraumatic stress injuries, especially after cumulative traumatic exposures in this context. The results also suggest potential pathways for the biological embedding of stressful gendered workplace experiences.

Prevalence, Motivations, and Social, Mental Health and Health Consequences of Cyberbullying Among School-Aged Children and Youth: Protocol of a Longitudinal and Multi-Perspective Mixed Method Study.

BACKGROUND: While the online environment may promote important developmental and social benefits, it also enables the serious and rapidly growing issue of cyberbullying. Cyberbullying constitutes an increasing public health problem - victimized children and youth experience a range of health and mental health concerns, including emotional and psychosomatic problems, maladaptive behaviors, and increased suicidality. Perpetrators demonstrate a lack of empathy, and may also struggle with health and mental health issues. OBJECTIVE: This paper describes the protocols applied in a longitudinal and multi-perspective mixed-methods study with five objectives: (1) to explore children/youth's experiences, and children/youth's, parents', and teachers' conceptions, definitions, and understanding of cyberbullying; (2) to explore how children/youth view the underlying motivations for cyberbullying; (3) to document the shifting prevalence rates of cyberbullying victimization, witnessing, and perpetration; (4) to identify risk and protective factors for cyberbullying involvement; and (5) to explore social, mental health, and health consequences of cyberbullying. METHODS: Quantitative survey data were collected over three years (2012-2014) from a stratified random baseline sample of fourth (n=160), seventh (n=243), and tenth (n=267) grade children/youth, their parents (n=246), and their teachers (n=103). Quantitative data were collected from students and teachers during in-person school visits, and from parents via mail-in surveys. Student, parent, and teacher surveys included questions regarding: student experiences with bullying/cyberbullying; student health, mental health, and social and behavioral issues; socio-demographics; and information and communication technology use. In-depth semi-structured qualitative interviews were conducted twice with a sub-sample of students (n=57), purposively selected based on socio-demographics and cyberbullying experience, twice with their parents (n=50), and once with their teachers (n=30). RESULTS: Data collection for this study is complete. Planned analyses include transition probabilities and repeated measures analyses to determine involvement in cyberbullying. Repeated measures analyses, including between-subject factors (eg, socio-demographics), will be utilized to determine factors that protect or increase risk of involvement in cyberbullying. Qualitative analysis utilizing grounded theory is planned, to permit rich understanding of participant experiences and perspectives. Results will be reported in 2016 and 2017. CONCLUSIONS: This study will offer insight into the contemporary phenomenon of cyberbullying while also informing interventions to curb cyberbullying and address its pervasive social, mental health, and health consequences. Knowledge mobilization strategies and implications for research and practice are discussed.

Suicide risk assessments: Examining influences on clinicians' professional judgment.

Professional judgment in complex clinical situations such as the assessment of suicide risk encompasses a multifaceted cognitive understanding of the substantive issues, technical expertise, and emotional awareness. This experimental design study investigated the degree to which the previous work-related experiences of clinicians and their preexisting emotional state influence professional judgment regarding acute risk in patients presenting with suicidal ideation. Experienced social workers and social work students conducted suicide risk assessments on 2 standardized patients performing in scenarios constructed to depict individuals presenting with suicidal ideation. This study revealed significant variations in clinical judgments of practitioners assessing suicide risk. While scores on standardized risk assessment measures were the strongest predictor of judgments regarding the need for hospitalization to ensure the safety of the patient, other influences included clinician age and levels of posttraumatic stress symptoms. Mental health clinicians and organizations that employ them should be aware of possible individual influences on professional judgments related to suicide risk.

A Culture in Transition: Paramedic Experiences with Community Referral Programs.

OBJECTIVES: As an aging population continues to place strain on the health care system, many older adults are living with unmet social and medical needs. In response, Emergency Medical Services (EMS) have initiated programs that encourage paramedics to refer patients in need to community based support services. This qualitative study explores frontline paramedic experiences with referral programs to identify opportunities and challenges in their practice. METHODS: This study used an intepretivist qualitative study design involving interviews of frontline paramedics employed in a region where referral programs were in place. Interviews were semi-structured and one-on-one. Data were transcribed verbatim and analyzed using inductive open coding throughout, then grouped to identify themes. Data collection and analysis were conducted simultaneously and flexibly until saturation. RESULTS: Twenty-three interviews were conducted representing 6 regions. When participating with referral programs the data revealed that frontline paramedics appear to experience (a) role confusion, (b) an inadequate knowledge base, (c) inadequate feedback, (d) undefined accountability, and (e) strong patient advocacy. CONCLUSIONS: In a strained health care system, EMS and paramedics have an opportunity to better serve patients by initiating referrals for patients they encounter with unmet social and medical needs. However, referral programs face a number of challenges that, if left poorly addressed, may threaten the success of such programs.