Fragilising clients: A positioning analysis of identity construction during clinical psychology trainees' supervision.

CONTEXT: Western mental healthcare system reforms prioritise person-centred care and require clinicians to adjust their professional positions. Realising these reforms will necessitate clinicians-including clinical psychologists-acquiring professional identities that align with them. Learners develop professional identities through socialisation activities: within interactional spaces such as supervision learners come to understand the self (clinician) and, by extension, the other (client). A clinician's understanding of who I am is intertwined with an understanding of who they are. Our study offers a moment-by-moment examination of supervision interactions of clinical psychology trainees to illuminate processes through which the identities of therapists and clients are constructed. AIM: We examined how clinical psychology trainees and supervisors construct identities for themselves and clients in supervision. METHODS: We used positioning analysis to explore identity construction during interactions between supervisors (n = 4) and trainees (n = 12) in a clinical psychology training clinic. Positioning analysis focuses on the linguistic choices participants make as they position themselves (and others) in certain social spaces during everyday interactions. Twelve supervision sessions were audio recorded and transcribed. We found that clients were frequently positioned as fragile and subsequently analysed these sequences (n = 12). RESULTS: Clients' identities were constructed as fragile, which co-occurred with clinical psychologists' claiming positions as responsible for managing their distress. Supervisors played an active role in linguistically positioning clients and trainees in this way. Trainees rarely contested the identities made available to them by supervisors. DISCUSSION AND CONCLUSION: We suggest that linguistically positioning clients as fragile perpetuates paternalistic clinical discourses that do not align with mental healthcare reform priorities. We make visible how this is achieved interactionally through language and influenced by organisational power relations. Intentional efforts are required to support the professional identity construction of clinical psychologists in ways that do not perpetuate paternalism. We offer recommendations for education and clinical practice to support these efforts.

Striving to thrive or striving to survive: Professional identity constructions of medical trainees in clinical assessment activities.

CONTEXT: Assessment plays a key role in competence development and the shaping of future professionals. Despite its presumed positive impacts on learning, unintended consequences of assessment have drawn increasing attention in the literature. Considering professional identities and how these can be dynamically constructed through social interactions, as in assessment contexts, our study sought to understand how assessment influences the construction of professional identities in medical trainees. METHODS: Within social constructionism, we adopted a discursive, narrative approach to investigate the different positions trainees narrate for themselves and their assessors in clinical assessment contexts and the impact of these positions on their constructed identities. We purposively recruited 28 medical trainees (23 students and five postgraduate trainees), who took part in entry, follow-up and exit interviews of this study and submitted longitudinal audio/written diaries across nine-months of their training programs. Thematic framework and positioning analyses (focusing on how characters are linguistically positioned in narratives) were applied using an interdisciplinary teamwork approach. RESULTS: We identified two key narrative plotlines, striving to thrive and striving to survive, across trainees' assessment narratives from 60 interviews and 133 diaries. Elements of growth, development, and improvement were identified as trainees narrated striving to thrive in assessment. Neglect, oppression and perfunctory narratives were elaborated as trainees narrated striving to survive from assessment. Nine main character tropes adopted by trainees with six key assessor character tropes were identified. Bringing these together we present our analysis of two exemplary narratives with elaboration of their wider social implications. CONCLUSION: Adopting a discursive approach enabled us to better understand not only what identities are constructed by trainees in assessment contexts but also how they are constructed in relation to broader medical education discourses. The findings are informative for educators to reflect on, rectify and reconstruct assessment practices for better facilitating trainee identity construction.

The graduate dietitian experience of employment and employability: A longitudinal qualitative research study from one Australian university.

AIMS: Diet-related chronic disease contributes significantly to the global burden of disease. Dietitians are best placed to address this disease burden, yet graduate dietitians may struggle to find employment. This study aimed to explore dietetics graduates' experiences of employment and employability, up to 6-month post-degree completion. METHODS: Secondary data analysis of in-depth qualitative interview data and longitudinal audio-diaries was undertaken. An interpretivist approach was employed whereby knowledge was viewed as subjective and multiple realities exist. A total of five entrance interviews, 31 audio-diaries and three exit interviews, from nine graduates were included in the analysis. This comprised 12 h of longitudinal audio data. Thematic analysis was undertaken using a framework analysis method. RESULTS: Four key themes were identified: (1) The tumultuous process of applying for jobs demonstrated that graduates struggled with repeated rejections. (2) The uncertain journey to employment indicated that job-seeking was a limbo stage marked by uncertainty. (3) Feeling the pressure showed that graduates experienced pressure from multiple sources. (4) Enhancing employability explained that graduates were not prepared for available employment opportunities, but utilised resources to increase their employability. CONCLUSION: Diverse placement experiences may better prepare graduates for available employment opportunities. To enhance employability, it may be beneficial to assist students to develop job-seeking skills, and to engage in networking and volunteering experiences during their education.

The development of professional identity in clinical psychologists: A scoping review.

INTRODUCTION: Our professional identity refers to our sense of who we are and how we should behave as professionals. Professional identities are developed through socialisation processes: Established ways of knowing and doing are acquired and reproduced. The professional identities of health care professionals have implications for the realisation of health care reforms that require new ways of being and doing from clinicians. Tension and frustration can arise when professional identities are incongruent with reform directions. More knowledge is required about the professional identities of mental health care professionals-including clinical psychologists-so that they can be supported to develop professional identities that align with health care system reforms. METHOD: We undertook a scoping review of existing literature aiming to (i) identify the relevant literature; (ii) review the literature quality; (iii) thematically summarise the literature findings; (iv) consult with clinical psychologists; and (v) identify recommendations for research, training and practice. RESULTS: A systematic database search (PsycINFO, CINAHL, Scopus and Web of Science) identified 24 relevant published articles and dissertations. Quantitative studies were excluded due to their markedly different research focus. Included studies were independently reviewed and findings summarised. Findings were organised around three themes: 'integration of personal and professional identities', 'intersectionality' and 'changes in professional identity over time'. Research quality issues were identified. The trustworthiness of the findings was corroborated in consultation with clinical psychologists. DISCUSSION: Clinical psychologists recognise their professional identities as being interrelated with their personal identities and changing over time. They recognised professional identity as important yet inadequately considered in the profession. The research area is emerging yet remains undertheorised and requires improved research methodologies. Future theoretically informed research is required to build up a credible research base to better understand the development of clinical psychologists' professional identities so that this process can be facilitated to enable the realisation of health care reforms.

Beyond mere respect: new perspectives on dignity for healthcare workplace learning.

Introduction: Although dignity in workplace learning in healthcare is gathering interest, we know little about stakeholders' conceptualizations in this area across professional groups. Dignity breaches in workplace learning are common, often with serious and long-lasting consequences for the affected. Conceptualizations shape behaviours and experiences. To prevent dignity violations in students' learning, it is thus important to understand stakeholders' understandings of the topic. This study therefore explores the dignity conceptualizations around workplace learning that students, placement educators and university staff hold across seven allied health professional groups. Methods: Using a social constructionist perspective, we conducted individual and group narrative interviews (n = 51) with students, placement educators and university workplace learning staff from seven allied health professional groups. We used the 5-step Framework Analysis to explore and develop themes, identifying differences and similarities across stakeholder groups. Results: We identified eight distinct, yet interrelated, dimensions of dignity from participants' narratives: dignity as respect, dignity as self-x (the various relationships we have with ourselves), dignity as feeling safe, dignity as understanding otherness, dignity as supporting others, dignity as equality, dignity as professionalism, and dignity as belonging. Dignity as respect was identified across all participants, although mutual respect and a culture of respect were only present in academic participants' talk. The remaining seven dimensions all present important factors extending our understanding of the construct of dignity. Discussion: In line with existing research, our study identifies the absence of an unambiguous, positive conceptualization of dignity in workplace learning among stakeholders. It adds novelty in two ways: by identifying dignity dimensions that require informed action beyond respecting others, and by revealing a tension between dignity as professionalism and dignity as equality. We suggest revising existing dignity concepts in workplace learning to address this tension and to reinforce that active care, team integration and skilled support are all non-negotiable elements of dignified behaviour within workplace learning.

Evaluating Clinical Educators' Competence in an East Asian Context: Who Values What?

Background: How to evaluate clinical educators is an important question in faculty development. The issue of who are best placed to evaluate their performance is also critical. However, the whos and the hows of clinical educator evaluation may differ culturally. This study aims to understand what comprises suitable evaluation criteria, alongside who is best placed to undertake the evaluation of clinical educators in medicine within an East Asian culture: specifically Taiwan. Methods: An 84-item web-based questionnaire was created based on a literature review and medical educational experts' opinions focusing on potential raters (i.e., who) and domains (i.e., what) for evaluating clinical educators. Using purposive sampling, we sent 500 questionnaires to clinical educators, residents, Post-Graduate Year Trainees (PGYs), Year-4~6/Year-7 medical students (M4~6/M7) and nurses. Results: We received 258 respondents with 52% response rate. All groups, except nurses, chose "teaching ability" as the most important domain. This contrasts with research from Western contexts that highlights role modeling, leadership and enthusiasm. The clinical educators and nurses have the same choices of the top five items in the "personal qualities" domain, but different choices in "assessment ability" and "curriculum planning" domains. The best fit rater groups for evaluating clinical educators were educators themselves and PGYs. Conclusions: There may well be specific suitable domains and populations for evaluating clinical educators' competence in East Asian culture contexts. Further research in these contexts is required to examine the reach of these findings.

Understanding Health Care Graduates' Conceptualizations of Transitions: A Longitudinal Qualitative Research Study.

PURPOSE: Although transitions have been defined in various ways in the higher education literature (e.g., inculcation, development, becoming), little research exists exploring health care learners' conceptualizations of transitions across their transition from final year to new graduate. How they understand transitions is important because such conceptualizations will shape how they navigate their transitions and vice versa. METHOD: The authors conducted a 3-month longitudinal qualitative research study with 35 health care learners from 4 disciplines (medicine, dietetics, nursing, and pharmacy) across their final year to new graduate transition to explore how they conceptualized transitions. Data collection occurred between July 2019 and April 2020 at Monash University in Victoria, Australia. The authors employed framework analysis to interrogate the interview and longitudinal audio diary data cross-sectionally and longitudinally. RESULTS: The authors found 10 different conceptualizations of transitions broadly categorized as time bound and linear (one-off events, systems, linear, adaptation, linked to identities), ongoing and complex (ongoing processes, multifaceted, complex), or related to transition shock (labor, linked to emotions). The adaptation conceptualization increased in dominance over time, the linear conceptualization was more apparent in the interviews (time points 1 and 3), and the multifaceted and emotion-linked conceptualizations were more dominant in the longitudinal audio diaries (time point 2). CONCLUSIONS: This novel study illustrates conceptualizations of transitions as broadly consistent with existing higher education literature but extends this research considerably by identifying differences in conceptualizations across time. The authors encourage health care learners, educators, and policy makers to develop expanded and more sophisticated understandings of transitions to ensure that health care learners can better navigate often challenging graduate transitions. Further research should explore stakeholders' transition conceptualizations over lengthier durations beyond the new graduate transition.

Safety net, gateway, market, sport, and war: Exploring how emergency physicians conceptualize and ascribe meaning to emergency care.

BACKGROUND: Metaphorical expressions and conceptualisations are widely used in medical discourse to convey complex and abstract concepts. Our study uses a novel way to examine the spontaneous use of metaphors by emergency physicians as they articulate their experiences of practicing emergency care. These co-constructions shed light on the values and beliefs that shape their emergency care practice. METHODS: We invited 25 Taiwanese emergency physicians to participate in one-to-one semi-structured interviews. RESULTS: Drawing on social constructionism theory, systematic metaphor analysis method and Metaphor Identification Procedure (MIP) we identified metaphorical linguistic expressions in their talk, grouping them into five-overarching conceptual metaphors. We argue that these metaphors underpin emergency physicians' experiences of practicing emergency medical care: Safety Net, Gateway, Market, War, and Sport. DISCUSSION: The Safety Net, Gateway, and Market conceptualisations highlight physician-patient relationships and the social mission, resource allocation, and consumerism aspects of emergency care practice. The Sport and War conceptualisations highlight the physician-physician relationship and the demanding, team-based nature of emergency care practice. CONCLUSION: We propose that the choice of metaphorical conceptualisation deployed by emergency physicians has implications on their embodiment of professional identities. This discussion of using metaphors to study professional identities contributes to the literature concerned with finding creative and innovative ways to research identities. Future studies may utilize metaphors to gain a comprehensive understanding of physicians' professional identities in other specialties.

Senior medical students as assistants in medicine in COVID-19 crisis: a realist evaluation protocol.

INTRODUCTION: The assistant in medicine is a new and paid role for final-year medical students that has been established in New South Wales, Australia, as part of the surge workforce management response to the COVID-19 pandemic. Eligibility requires the applicant to be a final-year medical student in an Australian Medical Council-accredited university and registered with the Australian Health Practitioner Regulation Agency. While there are roles with some similarities to the assistant in medicine role, such as assistantships (the UK) and physician assistants adopted internationally, this is completely new in Australia. Little is known about the functionality and success factors of this role within the health practitioner landscape, particularly within the context of the COVID-19 pandemic. Given the complexity of this role, a realist approach to evaluation has been undertaken as described in this protocol, which sets out a study design spanning from August 2020 to June 2021. METHODS AND ANALYSIS: The intention of conducting a realist review is to identify the circumstances and mechanisms that determine the outcomes of the assistant in medicine intervention. We will start by developing an initial programme theory to explore the potential function of the assistant in medicine role through realist syntheses of critically appraised summaries of existing literature using relevant databases and journals. Other data sources such as interviews and surveys with key stakeholders will contribute to the refinements of the programme theory. Using this method, we will develop a set of hypotheses on how and why the Australian assistants in medicine intervention might 'work' to achieve a variety of outcomes based on examples of related international interventions. These hypotheses will be tested against the qualitative and quantitative evidence gathered from all relevant stakeholders. ETHICS AND DISSEMINATION: Ethics approval for the larger study was obtained from the Western Sydney Local Health District (2020/ETH01745). The findings of this review will provide useful information for hospital managers, academics and policymakers, who can apply the findings in their context when deciding how to implement and support the introduction of assistants in medicine into the health system. We will publish our findings in reports to policymakers, peer-reviewed journals and international conferences.

'Nurses whisper.' Identities in nurses' patient safety narratives of nurse-trainee doctors' interactions.

CONTEXT: Nurses are integral to patient safety, but little is known about their narrative constructions of identity in relation to their dyadic interactions with trainee doctors about patient safety and competence during the trajectory of a medical career. AIM: We sought to examine how identities are constructed by experienced nurses in their narratives of patient safety encounters with trainee doctors. METHODS: Our qualitative study gathered narrative data through semi-structured interviews with nurses of different professional standing (n = 20). Purposive sampling was used to recruit the first eight participants, with the remainder recruited through theoretical sampling. Audio recordings were transcribed verbatim and analysed inductively through a social constructionist framework and deductively using a competence framework. RESULTS: We classified seven identities that participants constructed in their narratives of dyadic interactions with trainee doctors in relation to patient safety: nurses as teacher, guardian of patient wellbeing, provider of emotional support, provider of general support, expert advisor, navigator and team player. These identities related to the two key roles of nurses as educators and as practitioners. As they narrated these dyadic interactions, participants constructed identities that positioned trainee doctors in character tropes, suggesting gaps in professional competence: nurses as provider of general support was commonly narrated in the context of perceived deficits of personal or functional capabilities and nurses as team player was mainly associated with concerns (or reassurances) around ethical capabilities. DISCUSSION AND CONCLUSION: Our findings are consistent with, and extend the wider literature on the development of professional competence, interprofessional collaboration in health care, and the nature and organisation of nursing work. Nurses' work in ensuring patient safety and support trainee doctors' professional development merits greater formal recognition and legitimation.

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.

Differing viewpoints around healthcare professions' education research priorities: A Q-methodology approach.

Recently, due to scarce resources and the need to provide an evidence-base for healthcare professions' education (HPE), HPE research centres internationally have turned to identifying priorities for their research efforts. Engaging a range of stakeholders in research priority setting exercises has been posited as one way to address the issues around reducing researcher bias and increasing social accountability. However, assigning individuals to single a priori stakeholder groups is complex, with previous research overlooking cross-category membership and agreement between individuals across groups. Further, analyses have pitched stakeholder groups against one another in an attempt to understand who prioritises what, and often fails to grasp rationales underlying priorities. A deeper understanding of who prioritises what research areas and why is required to consider applicability of results across contexts and deepen social accountability and transferability. A web-based Q-methodological approach with n=91 participants (who) from ten pre-classified stakeholder groups was employed with post-sort interviews (why). Sixty-seven Q-set items (Chinese/English languages) were developed from previous research (what). Participants were mainly from Taiwan, although international researchers were included. Q-sorting was undertaken in groups or individually, followed by post-sort interviews. Eighty-six participants' Q-sorts were included in the final analysis. Intercorrelations among Q-sorts were factor-analysed (Centroid method) and rotated analytically (Varimax method). Interviews were thematically analysed. Six Viewpoints with eigenvalues exceeding 1 were identified (range = 3.55-10.34; 42% total variance; 35/67 topics), mapping high/low priorities for research foci: Workplace teaching and learning; Patient dignity and healthcare safety; Professionalism and healthcare professionals' development; Medical ethics and moral development; Healthcare professionals' retention and success; Preparing for clinical practice. Eighteen rationales for prioritisation were identified: impact, organisational culture and deficit of educators/practitioners were most highly cited. Each Viewpoint, held by multiple stakeholders, comprised a unique set of topic-groupings, target study participants, beneficiaries and rationales. The two most prolific Viewpoints represent how different stakeholder groups highlight key complementary perspectives of healthcare professions' education in the workplace (efficacy of teaching/learning practices, application of knowledge/values). By illuminating the detail around each Viewpoint, and presenting an holistic description of the who-what-why in research priority setting, others wishing to undertake such an exercise can more easily identify how stakeholder Viewpoints and their epistemic beliefs can help shape healthcare professions' research agendas more generally.

Exploring emergency physicians' professional identities: a Q-method study.

Professional identities research in medical education has made significant contributions to the field. However, what comprises professional identities is rarely interrogated. This research tackles this relatively understudied component of professional identities research by understanding emergency medicine physicians' perspectives on the important elements that comprise their professional identities. Q-methodology was used to identify different clusters of viewpoints on professional identities; by extension, the core components that comprise emergency medicine physicians' professional identities are disclosed. Thirty-three emergency medicine physicians were recruited, through purposive sampling, from five hospitals across Taiwan. R software was used to analyse the Q-sorts, determine loadings on each viewpoint and formulate the viewpoint array. Analysis of interview data enhanced our understanding of these viewpoints. In total, twenty-five emergency medicine physicians loaded onto four distinct viewpoints, reflecting dominant perspectives of emergency medicine physicians' understanding of their professional identities. These distinct viewpoints demonstrated what emergency medicine physicians deemed significant in how they understood themselves. The viewpoints comprised: skills acquisition, capabilities and practical wisdom; coping ability and resilience; professional recognition and self-esteem; and wellbeing and quality of life. All viewpoints stressed the importance of trust between colleagues. These findings demonstrate the multitude of ways in which seemingly unified professional identities diverge across groups of individuals. An enhanced understanding of speciality work culture is gained. By understanding facets of professional identities, the development of future educational interventions and departmental initiatives, which might support key components of professional identities, can be explored.

Medical Students' and Trainees' Country-By-Gender Profiles: Hofstede's Cultural Dimensions Across Sixteen Diverse Countries.

PURPOSE: The global mobility of medical student and trainee populations has drawn researchers' attention to consider internationalization in medical education. Recently, researchers have focused on cultural diversity, predominately drawing on Hofstede's cross-cultural analysis of cultural dimensions from general population data to explain their findings. However, to date no research has been specifically undertaken to examine cultural dimensions within a medical student or trainee population. This is problematic as within-country differences between gender and professional groups have been identified within these dimensions. We address this gap by drawing on the theoretical concept of national context effects: specifically Hofstede's six-dimensional perspective. In doing so we examine medical students' and trainees' country profiles across dimensions, country-by-gender clustering, and differences between our data and Hofstede's general population data. METHODS: We undertook a cross-cultural online questionnaire study (eight languages) containing Hofstede's 2013 Values Survey. Our questionnaire was live between 1st March to 19th Aug 2018, and December 2018 to mitigate country holiday periods. We recruited undergraduate medical students and trainees with at least 6-months' clinical training using school-specific methods including emails, announcements, and snowballing. RESULTS: We received 2,529 responses. Sixteen countries were retained for analyses (n = 2,307, 91%): Australia, Chile, China, Hong Kong, India, Indonesia, Ireland, Israel, Japan, Malaysia, New Zealand, Pakistan, South Africa, South Korea, Sri-Lanka, Taiwan. Power distance and masculinity are homogenous across countries. Uncertainty avoidance shows the greatest diversity. We identified four country clusters. Masculinity and uncertainty are uncorrelated with Hofstede's general population data. CONCLUSIONS: Our medical student and trainee data provides medical education researchers with more appropriate cultural dimension profiles than those from general population data. Country cluster profiles stimulate useful hypotheses for further research, especially as patterning between clusters cuts across traditional Eastern-Western divides with national culture being stronger than gendered influences. The Uncertainty dimension with its complex pattern across clusters is a particularly fruitful avenue for further investigation.

A scoping review examining funding trends in health care professions education research from Taiwan (2006-2017).

BACKGROUND: Traditionally health care professions education research (HCPER) is poorly funded, despite it being key to success. PURPOSE: This unique study maps HCPER evolution within a single country during a period when significant national governmental HCPER funding is introduced. METHODS: A scoping review method examined Taiwan's HCPER landscape across 12-years. Literature searches across four databases (OVID Medline; Scopus; Web of Science; the Airiti Library), a manual scan of HCPE journals and hand searches. Endnote and ATLAS.ti managed the data. Demographic and content codes were developed. PRISMA guidelines are used. DISCUSSION: One thousand four hundred and ten articles across 310 journals, with a steady rise in funded studies. Science/Social Science Citation Index and English language publications increased. Nursing Students/Nurses and Medical Students/Physicians are the most common populations. Significant associations with funding was found for indexed and English language publications. National funding influenced quality and local funding positively. CONCLUSION: Caution around local vs. global needs is highlighted and national funding policies for HCPER are advocated.