Surgical safety checklist compliance process as a moral hazard: An institutional ethnography.

BACKGROUND: Charting is an essential component of professional nursing practice and is arguably a key element of patient safety in surgery: without proper, objective, and timely documentation, both benign and tragical errors can occur. From surgery on wrong patients to wrong limbs, to the omission of antibiotics administration, many harms can happen in the operating room. Documentation has thus served as a safeguard for patient safety, professional responsibility, and professional accountability. In this context, we were puzzled by the practices we observed with respect to charting compliance with the surgical safety checklist (SSC) during a study of surgical teams in a large, urban teaching hospital in Canada (pseudonym 'C&C'). METHODS: This article leverages institutional ethnography and a subset of data from a larger study to describe and explain the social organisation of the system that monitored surgical safety compliance at C&C from the standpoint of operating room nurses. This data included fieldnotes from observations of 51 surgical cases, on-the-spot interviews with nurses, formal interviews with individuals who were involved in the design and implementation of the SSC, and open-ended questions from two rounds of survey of OR teams. FINDINGS: We found that the compliance form and not the SSC itself formed the basis for reporting. To meet hospital accuracy in charting goals and legislated compliance documentation reporting requirements nurses 'pre-charted' compliance with the surgical checklist. The adoption of this workaround technically violated nursing charting principles and put them in ethically untenable positions. CONCLUSIONS: Documenting compliance of the SSC constituted a moral hazard, constrained nurses' autonomy and moral agency, and obscured poor checklist adherence. The findings highlight how local and extra local texts, technologies and relations create ethical issues, raise questions about the effectiveness of resulting data for decision-making and contribute to ongoing conversations about nursing workarounds.

The ritualisation of the surgical safety checklist and its decoupling from patient safety goals.

Patient harm, patient safety and their governance have been ongoing concerns for policymakers, care providers and the public. In response to high rates of adverse events/medical errors, the World Health Organisation (WHO) advocated the use of surgical safety checklists (SSC) to improve safety in surgical care. Canadian health authorities subsequently made SSC use a mandatory organisational practice, with public reporting of safety indicators for compliance tied to pre-existing legislation and to reimbursements for surgical procedures. Perceived as the antidote for socio-technical issues in operating rooms (ORs), much of the SSC-related research has focused on assessing clinical and economic effectiveness, worker perceptions, attitudes and barriers to implementation. Suboptimal outcomes are attributed to implementations that ignored contexts. Using ethnographic data from a study of SSC at an urban teaching hospital (C&C), a critical lens and the concepts of ritual and ceremony, we examine how it is used, and theorise the nature and implications of that use. Two rituals, one improvised and one scripted, comprised C&C's SSC ceremony. Improvised performances produced dislocations that were ameliorated by scripted verification practices. This ceremony produced causally opaque links to patient safety goals and reproduced OR/medical culture. We discuss the theoretical contributions of the study and the implications for patient safety.

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.

"Some version, most of the time": The surgical safety checklist, patient safety, and the everyday experience of practice variation.

BACKGROUND: This study investigated checklist compliance to highlight where assumptions about the Surgical Safety Checklist might not be met in practice. METHODS: We used ethnographic methods to investigate the practice of the Surgical Safety Checklist in one hospital. Fifty-one observation days, eight semi-structured interviews, and two surveys of operating room staff over two years were conducted. Data were collected and analyzed iteratively. RESULTS: Despite the near 100% compliance rates reported to the Ministry of Health, practice of the Surgical Safety Checklist varied widely: 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings included some sort of team huddle. Gaps between policy and practice were identified at four different levels: compliance with the stages and items; responsibility for the checklist; documentation of adherence; and interprofessional teamwork. CONCLUSIONS: Checklist compliance data are insufficient to understand how complex interventions impact care delivery. Greater and continued attention to practice in healthcare is needed.

Relational professional identity: How do pharmacy students see themselves in relation to others?

BACKGROUND: As the pharmacy profession moves towards patient-centred care, pharmacy schools have updated their curricula to prepare students for a full scope of practice. A critical objective of the new curricula is the professional socialization of pharmacy students into relational aspects of the profession: how pharmacists should interact with patients and other health care professionals. Through an examination of how one cohort of pharmacy students perceives its relationship to patients and physicians, this study aims to determine how these relational aspects of professional identity evolve with time spent in the program. METHODS: At 3 time points over a 2-year period, pharmacy students were asked to detail in writing how they would communicate with a physician concerning a hypothetical drug allergy scenario. A directed content analysis of their responses was conducted based on 3 main analytic categories: patient-centredness, physician collaboration and physician deference. These categories were further divided into 6 subcategories that were used as the variables for analysis. Statistical analyses examined longitudinal group trends for these variables. RESULTS: Over the 2 years of observation, an examination of the proportion of messages demonstrating the subcategories of interest showed that the only measure of the pharmacy students' relational professional identity that changed significantly over time occurred for the perception of a sense of shared care for the patient. All other aspects of their relational identity were stagnant and did not change as they progressed through training (χ2; 12.772, df = 2, p < 0.002). CONCLUSION: Our results suggest that the relational professional identity of participants was poorly developed with regards to both patients and physicians. Pharmacy educators must reexamine the methods currently being employed to foster students' professional identity development to ensure that new graduates are prepared to meet the challenges of a changing scope of practice. Can Pharm J (Ott) 2021;154:xx-xx.

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.

Tackling the void: the importance of addressing absences in the field of health professions education research.

Many processes and practices in the field of health professions education have been based more on tradition and assumption than on evidence and theory. As the field matures, researchers are increasingly seeking evidence to support various teaching and assessment methods. However, there is a tendency to focus on a limited set of topics, leaving other areas under-examined and limiting our understanding of the field. By explicitly examining areas that are undescribed, i.e. absences in the literature, researchers and scholars have the potential to enrich our practice and our field's understanding of what counts as legitimate research. Using the theoretical framework of Bourdieu's concept of field, we conducted an instrumental case study of three published research projects that each had a finding of absence. We examined each case individually, and then analyzed across cases. Our dataset included published papers, peer-review feedback, and reflective notes. Each of the cases interrogated a different form of absence: absence of content, absence of research, and absence of evidence. While the typology suggests that each absence was different, there were similarities across cases in terms of challenges in 'proving' the reality of the absence and some disbelief or discomfort with accepting the findings as rigorous and/or legitimate. Absence research has potential to add to our theoretical and methodological approaches to the field. This type of research is potentially an exciting and productive new way for scholars to shed light on aspects of health professions education that have received limited attention to date.

Interprofessional education in the U.S. military: harnessing simulation for team readiness.

Research into military interprofessional healthcare teams (MIHTs) is rarely reported in the interprofessional literature. MIHTs must effectively collaborate in the low resource and chaotic contexts of humanitarian and combat deployments; however, we have yet to study how MIHTs learn to work in these contexts. To address this gap, we investigated military interprofessional education (MIPE). Using an ethnographic approach, we conducted non-participant observations (n = 30.5 hours) of a specific platoon (n = 32 participants) during an MIPE simulation called Operation Bushmaster - a large-scale immersive simulation of battlefield deployment. Findings indicated three aspects of MIPE: (1) a culture where flailing isn't failing; (2) the importance of followership; and (3) an interprofessional respect fostered by role adoption. Considering these findings through Dweck's fixed vs growth mind-set conceptualization, we suggest that - although unusual when compared with traditional IPE - MIPE's teaching and learning methods provide developmental opportunities for team members. We also suggest why Dweck's mind-set conceptualizations could be usefully extended from an individual-focus to also include a collaborative-team-focus. We contend that the findings developed from this research could be transferred to civilian contexts so that the lessons learned by those who serve on the war front could inform those who serve at home.

A Historical Discourse Analysis of Pharmacist Identity in Pharmacy Education.

Objective. To determine the discourses on professional identity in pharmacy education over the last century in North America and which one(s) currently dominate. Methods. A Foucauldian critical discourse analysis using archival resources from the American Journal of Pharmaceutical Education (AJPE) and commissioned education reports was used to expose the identity discourses in pharmacy education. Results. This study identified five prominent identity discourses in the pharmacy education literature: apothecary, dispenser, merchandiser, expert advisor, and health care provider. Each discourse constructs the pharmacist's professional identity in different ways and makes possible certain language, subjects, and objects. The health care provider discourse currently dominates the literature. However, an unexpected finding of this study was that the discourses identified did not shift clearly over time, but rather piled up, resulting in students being exposed to incompatible identities. Conclusion. This study illustrates that pharmacist identity constructs are not simple, self-evident, or progressive. In exposing students to incompatible identity discourses, pharmacy education may be unintentionally impacting the formation of a strong, unified healthcare provider identity, which may impact widespread practice change.

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.

Being Edgy in Health Professions Education: Concluding the Philosophy of Science Series.

The philosophy of science is concerned with what science is, its conceptual framing and underlying logic, and its ability to generate meaningful and useful knowledge. To that end, concepts such as ontology (what exists and in what way), epistemology (the knowledge we use or generate), and axiology (the value of things) are important if somewhat neglected topics in health professions education scholarship. In an attempt to address this gap, Academic Medicine has published a series of Invited Commentaries on topics in the philosophy of science germane to health professions educational science. This Invited Commentary concludes the Philosophy of Science series by providing a summary of the key concepts that were elucidated over the course of the series, highlighting the intent of the series and the principles of ontology, epistemology, axiology, and methodology. The authors conclude the series with a discussion of the benefits and challenges of cross-paradigmatic research.

Making it real: the institutionalization of collaboration through formal structure.

Collaboration has achieved widespread acceptance as an indispensable element of healthcare delivery in recent decades, despite modest evidence for its impact on healthcare outcomes. Attempts to understand this seeming paradox have been based mostly in functionalist or conflict-theoretical approaches. Currently lacking, however, is an articulation of how collaborative ideals are embedded in broadly shared beliefs about what healthcare is and how it operates. In this article, we examine how language used in the CanMEDS competency framework and in two guides for Family Health Teams construct idealized versions of rational, autonomous physicians and primary care organizations, respectively. Informed by phenomenological sociology and neo-institutional theory, we characterize these documents as elements of formal structure, the putative "blueprints" for healthcare planning and activity. Drawing on this analysis, we argue that these documents and "collaborative" formal structures in general, not only function as tools to make healthcare more collaborative, but also create an appearance of "real" collaboration, independently of the realities of practice. We argue that they thus instill confidence that the current healthcare system functions according to deep-seated societal values of justice and progress. We conclude by emphasizing the potentially distorting influence of this on efforts to understand and improve healthcare.

Ethnography in health professions education: Slowing down and thinking deeply.

CONTEXT: Ethnography has been gaining appreciation in the field of health professions education (HPE) research, yet it remains misunderstood. Our article contributes to this growing literature by describing some of the key tensions with which both aspiring and seasoned ethnographers should productively struggle. METHODS: We respond to the injunction made by Varpio et al (2017) that HPE researchers should ground their methodological ventures in their historical and philosophical tenets. To do so, we first review core ethnographic texts that provide a background for ethnographic research in HPE, then provide an orienting definition to bind the specificities of ethnographic research. Finally, we review core theoretical and practical considerations for ethnographic research. RESULTS: Ethnography is a slow and deep approach to knowledge production, and as such it requires careful engagement with theory and deliberate choice of methods. Core theoretical tensions include the ontological, epistemological and axiological dimensions of ethnography, and concerns with quality and rigour. Practical tensions include the scope and remit of ethnography, the importance of observing naturally occurring behaviour and the crafting of rich field notes. CONCLUSIONS: We encourage ethnographers to pursue scholarship that challenges the status quo. Ethnographers should favour deep encounters with research participants, dig deep into the cultural and structural aspects of HPE and be reflexive about knowledge outputs. At a time in HPE when the pressures to publish are high, using ethnography as a research methodology offers an opportunity to slow down and think deeply.

Critical Theory: Broadening Our Thinking to Explore the Structural Factors at Play in Health Professions Education.

As part of the Philosophy of Science series of Invited Commentaries, this article on critical theory describes the origins of this research paradigm and its key concepts and orientations (ontology, epistemology, axiology, methodology, and rigor). The authors frame critical theory as an umbrella term for different theories, including feminism, antiracism, and anticolonialism. They emphasize the structural analysis that critical scholars conduct to uncover and sometimes address the role that social, political, cultural, economic, ethnic, and gender factors play in health professions education. They note the importance of acknowledging one's social location when doing critical research and highlight the core values of democracy and egalitarianism that underpin critical research. Methodologically, the authors stress how critical scholars reject singular truths in favor of more nuanced portraits of concepts and events, mobilize inductive approaches over deductive ones, and use critical theory to develop their projects and analyze their data. Following upon this elucidation of critical theory, the authors apply this paradigm to analyze the sample case of Lee, a medical resident who was involved in a medication error. The authors conclude that research conducted in the critical tradition has the potential to transcend individualistic accounts by revealing underlying structural forces that constrain or support individual agency.

The Distinctions Between Theory, Theoretical Framework, and Conceptual Framework.

Health professions education (HPE) researchers are regularly asked to articulate their use of theory, theoretical frameworks, and conceptual frameworks in their research. However, all too often, these words are used interchangeably or without a clear understanding of the differences between these concepts. Further problematizing this situation is the fact that theory, theoretical framework, and conceptual framework are terms that are used in different ways in different research approaches. In this article, the authors set out to clarify the meaning of these terms and to describe how they are used in 2 approaches to research commonly used in HPE: the objectivist deductive approach (from theory to data) and the subjectivist inductive approach (from data to theory). In addition to this, given that within subjectivist inductive research theory, theoretical framework, and conceptual framework can be used in different ways, they describe 3 uses that HPE researchers frequently rely on: fully inductive theory development, fully theory-informed inductive, and theory-informing inductive data analysis.

One Size Does Not Fit All: Balancing Individual and System Needs in Primary Care and Beyond.

In this issue, Dewan and Norcini invite readers to reconsider the basic minimum standards for independent primary care practice. Their willingness to push boundaries, question turf wars, and suggest innovative ways forward is laudable. Although their piece is timely and provocative, it does not fully consider the interplay between individual and system factors that influence people to pursue different kinds of degrees and practice in this context. In this Invited Commentary, the authors discuss imperatives that are underacknowledged by Dewan and Norcini: the importance of diversity in health system planning; status, power, and privilege; the extension of their argument beyond primary care; the conflation of time in training with competence; and important issues of distribution of health care resources. Ultimately, the authors argue that there may be strength in diversity, one that should not be obscured by attempts to normalize training time.