Temporal structures that determine consistency and quality of care: a case study in hyperacute stroke services

BACKGROUND

Temporal structuring is determined by practices and social norms and affects the quality and timing of care. In this case study of hyperacute stroke wards which provide initial stroke investigation, treatment and care, we explored temporal structuring patterns to explain how these may affect quality of care.

METHODS

This paper presents a thematic analysis of qualitative interviews with hyperacute stroke staff (n=76), non-participant observations (n=41, ~102 hours) and documentary analysis of the relevant service standards guidance. We used an inductive coding process to generate thematic findings around the concept of temporal structuring, with graphically illustrated examples.

RESULTS

Five temporal structures influence what-happens-when: (1) clinical priorities and quality assurance metrics motivate rapid activity for the initial life-prolonging assessments and interventions; (2) static features of ward organisation such as rotas and ward rounds impact consistency of care, determining timing and quality of care for patients; (3) some services experimented with staff rotas to try to meet peaks in demand, sometimes unsuccessfully; (4) implicit social norms or heuristics about perceived necessity affected staff motivation to make changes or improvements to consistency of care, particularly around weekend work; and (5) after-effects such as bottlenecks or backlogs affect quality of care, which are hard to measure effectively to drive service improvement.

CONCLUSIONS

Patients need temporally consistent high quality of care. Temporal consistency stems from the design of services, including staffing, targets and patient pathway design as well as cultural attitudes to working patterns. Improvements to consistency of care will be limited without changes to structures such as rotas and ward rounds, but also social norms around weekend work for certain professional groups.

Creativity From Constraint Exploration and Exploitation

Using the frameworks of creativity as problem solving and Integrated Constraints in Creativity (IConIC), this article develops the proposal that creativity is best understood in terms of a cycle of constraint exploration and exploitation. This general thesis, which applies to varied domains and levels of creativity, is supported by three specific proposals about the role of constraints in creativity, each of which is developed and illustrated with examples. First, constraints provide the criteria for the evaluation of creative outcomes, which can vary as a function of the emphasis on novel usefulness or useful novelty. Second, constraints are critical in each step of the creative process: problem finding, problem construction, and problem solving. Third, constraints play a key role in both open-ended and closed-ended creative problems. These arguments are supported by specific predictions, concerning: (a) task differences in whether novelty or usefulness are emphasized more; (b) individual differences in the processing of constraints (some may favor flexible constraint exploration, while others may favor persistent constraint exploitation), which I hypothesize also correlate with (c) engagement in different types of creative problem-solving (more open-ended, of the sort encountered in art, vs. more closed-ended, of the sort encountered in science, business, and engineering).

Preference for depth versus breadth in social relationships: Childhood socioeconomic background matters

Although the need for social connection is fundamental, people approach this need through different strategies. Drawing from life history theory, the current research explored whether individuals' early-life experiences are associated with narrow/deep (depth), or broad/shallow (breadth) approach to social relationships. Three studies revealed that participants' childhood socioeconomic status (SES) interacts with perception of economic instability to create diverging preferences in social relationship pattern. Specifically, when economic instability was salient (chronic belief, Study 1; experimentally primed, Studies 2 and 3), individuals from lower-SES childhood preferred a narrower and deeper social network, whereas those from higher-SES childhood preferred a broader and shallower network. Taken together, the present research offers a novel understanding of depth- versus breadth-focused approach to social relationships from the perspective of life history theory.

The Role of Decision Authority and Stated Social Intent as Predictors of Trust in Autonomous Robots

Prior research has demonstrated that trust in robots and performance of robots are two important factors that influence human-autonomy teaming. However, other factors may influence users' perceptions and use of autonomous systems, such as perceived intent of robots and decision authority of the robots. The current study experimentally examined participants' trust in an autonomous security robot (ASR), perceived trustworthiness of the ASR, and desire to use an ASR that varied in levels of decision authority and benevolence. Participants (N = 340) were recruited from Amazon Mechanical Turk. Results revealed the participants had increased trust in the ASR when the robot was described as having benevolent intent compared to self-protective intent. There were several interactions between decision authority and intent when predicting the trust process, showing that intent may matter the most when the robot has discretion on executing that intent. Participants stated a desire to use the ASR in a military context compared to a public context. Implications for this research demonstrate that as robots become more prevalent in jobs paired with humans, factors such as transparency provided for the robot's intent and its decision authority will influence users' trust and trustworthiness.

Concepts and Reasoning: a Conceptual Review and Analysis of Logical Issues in Empirical Social Science Research

A substantial number of social science studies have shown a lack of conceptual clarity, inadequate understanding of the nature of the empirical research approaches, and undue preference for deduction, which have caused much confusion, created paradigmatic incommensurability, and impeded scientific advancement. This study, through conceptual review and analysis of canonical discussions of concepts and the reasoning approaches of deduction and induction and their applications in social science theorization by philosophers and social scientists, is purported to unveil the logical nature of empirical research and examine the legitimacy of the preference of deduction among social scientists. The findings note that conceptual clarity as the foundation of social science research, exchange, and replication can be achieved through interdisciplinary stress of conceptual analyses to establish universal measurements and that the primacy of deduction in social sciences needs to concede to or be balanced with induction for new knowledge, more discoveries, and scientific advancement. The study recommends that institutions and researchers of social sciences invest more in conceptual analysis and inductive research through collaboration and separate efforts.

Can a culture of team psychological safety and MDT proforma improve team performance and patient outcomes in spinal MDTs?

PURPOSE

Spinal multidisciplinary teams (MDTs) are now standard of care for complex patient management in tertiary spinal units. This study investigates whether a scheduling proforma, and cultural change to the team that promotes psychological safety, can improve spinal MDT effectiveness for team members and patients.

METHODS

Retrospective cohort study including 165 spinal MDT patients before and after intervention. The intervention was use of a scheduling proforma and team learning to promote a culture of psychological safety. Data on accident and emergency (A&E) attendances, unplanned emergency admissions and post-operative 30-day readmissions were collected. At the team level, data were collected from 16 MDT participants using the MDT Observational Assessment Rating Scale (MDT-OARS), which measures MDT effectiveness.

RESULTS

Pre-intervention MDT-OARS was 28. Analysis of 80 patients demonstrated there were six A&E attendances, three unplanned emergency admissions and four post-operative 30-day re-admissions. Post-intervention MDT-OARS was 38 (p < 0.05). Analysis of 85 patients demonstrated there were three A&E attendances, one unplanned emergency admission and one post-operative re-admission.

CONCLUSIONS

Team culture that promotes psychological safety, along with use of a scheduling proforma, can improve MDT effectiveness for participants in spinal MDTs.

Big Is Bad: Stereotypes About Organizational Size, Profit-Seeking, and Corporate Ethicality

Individuals tend to hold a dim view of for-profit corporations, believing that profit-seeking comes at the expense of ethicality. In the present research, we show that this belief is not universal; rather, people associate ethicality with an organization's size. Across nine experiments (N = 4,796), people stereotyped large companies as less ethical than small companies. This size-ethicality stereotype emerged spontaneously (Study 1), implicitly (Study 2), and across industries (Study 3). Moreover, we find this stereotype can be partly explained by perceptions of profit-seeking behavior (Supplementary Studies A and B), and that people construe profit-seeking and its relationship to ethicality differently when considering large and small companies (Study 4). People attribute greater profit-maximizing motives (relative to profit-satisficing motives) to large companies, and these attributions shape their subsequent judgments of ethicality (Study 5; Supplementary Studies C and D).

Can't Live With Them, Can't Live Without Them: The Ambivalent Effects of Existential Outgroup Threat on Helping Behavior

Social comparison theories suggest that ingroups are strengthened whenever important outgroups are weakened (e.g., by losing status or power). It follows that ingroups have little reason to help outgroups facing an existential threat. We challenge this notion by showing that ingroups can also be weakened when relevant comparison outgroups are weakened, which can motivate ingroups to strategically offer help to ensure the outgroups' survival as a highly relevant comparison target. In three preregistered studies, we showed that an existential threat to an outgroup with high (vs. low) identity relevance affected strategic outgroup helping via two opposing mechanisms. The potential demise of a highly relevant outgroup increased participants' perceptions of ingroup identity threat, which was positively related to helping. At the same time, the outgroup's misery evoked schadenfreude, which was negatively related to helping. Our research exemplifies a group's secret desire for strong outgroups by underlining their importance for identity formation.

Objective Communication Patterns Associated With Team Member Effectiveness in Real-World Virtual Teams

OBJECTIVE

We explore the relationships between objective communication patterns displayed during virtual team meetings and established, qualitative measures of team member effectiveness.

BACKGROUND

A key component of teamwork is communication. Automated measures of objective communication patterns are becoming more feasible and offer the ability to measure and monitor communication in a scalable, consistent and continuous manner. However, their validity in reflecting meaningful measures of teamwork processes are not well established, especially in real-world settings.

METHOD

We studied real-world virtual student teams working on semester-long projects. We captured virtual team meetings using the Zoom video conferencing platform throughout the semester and periodic surveys comprising peer ratings of team member effectiveness. Leveraging audio transcripts, we examined relationships between objective measures of speaking time, silence gap duration and vocal turn-taking and peer ratings of team member effectiveness.

RESULTS

Speaking time, speaking turn count, degree centrality and (marginally) speaking turn duration, but not silence gap duration, were positively related to individual-level team member effectiveness. Time in dyadic interactions and interaction count, but not interaction length, were positively related to dyad-level team member effectiveness.

CONCLUSION

Our study highlights the relevance of objective measures of speaking time and vocal turn-taking to team member effectiveness in virtual project-based teams, supporting the validity of these objective measures and their use in future research.

APPLICATION

Our approach offers a scalable, easy-to-use method for measuring communication patterns and team member effectiveness in virtual teams and opens the opportunity to study these patterns in a more continuous and dynamic manner.

Team Situation Awareness, Cohesion, and Autonomic Synchrony

OBJECTIVE

This study evaluated the causal relationships among situation awareness (SA), cohesion, and autonomic synchrony (SE) within teams. SA is often a team effort and should be more accurate in better-functioning teams.

BACKGROUND

Cohesive teams perform better overall, although the relationship appears reciprocal; the relationship to SA has not been considered previously. SE is a collective neurocognitive activity that has been connected to team coordination, communication, and performance in some circumstances.

METHOD

In this experiment, 71 undergraduates, organized into 16 teams, played two matches of a first-person shooter computer game and completed self-report measures of cohesion and SA. SE was determined through time series analysis of electrodermal responses using the driver-empath framework.

RESULTS

Empaths and those who came from more synchronized teams reported less cohesion in the team. Granger causality regression showed reciprocal relations among SA, SE, and cohesion that were both positive and negative after controlling for match difficulty.

CONCLUSION

The cohesion-SA relationship is similar to the reciprocal cohesion-performance relationship. SE plays an important and independent role in both the social and cognitive aspects of team behavior. It is possible, furthermore, that individuals who are more attuned to their co-workers reported a more accurate, and less obliging, social situation.

APPLICATION

Results are applicable to situations requiring teamwork in a dynamic environment.

Collective Information Seeking During a Health Crisis : Predictors of Google Trends During COVID-19

This article approaches collective health information seeking from computational method by investigating patterns of Google Trends data in the United States during the early stages of the COVID-19 pandemic. We analyzed factors that prompted a community's curiosity, and information that communities were most curious about. The results of our cross-sectional and time-series-based analyses reveal a few salient findings: (1) Republican leaning states searched less frequently, and while states with more cases searched more, partisan lean is a more significant predictor; (2) States with greater level of poverty searched less frequently; (3) Leadership on the national level significantly influenced people's searching behavior; (4) Communities were most interested in "local risk" information as well as quantifiable information. We show in this work that established individual information seeking theoretical predictors (risk) can predict online collective information demand and information seeking subcategories with important contributions from collective conditions (leadership). Health communication practitioners can design health messages and choose media channels more purposefully according to what people are most interested in searching.

The Influence of Robots' Fairness on Humans' Reward-Punishment Behaviors and Trust in Human-Robot Cooperative Teams

OBJECTIVE

Based on social exchange theory, this study investigates the effects of robots' fairness and social status on humans' reward-punishment behaviors and trust in human-robot interactions.

BACKGROUND

In human-robot teamwork, robots show fair behaviors, dedication (altruistic unfair behaviors), and selfishness (self-interested unfair behaviors), but few studies have discussed the effects of these robots' behaviors on teamwork.

METHOD

This study adopts a 3 (the independent variable is the robot's fairness: self-interested unfair behaviors, fair behaviors, and altruistic unfair behaviors) × 3 (the moderator variable is the robot's social status: superior, peer, and subordinate) experimental design. Each participant and a robot completed the experimental task together through a computer.

RESULTS

When robots have different social statuses, the more altruistic the fairness of the robot, the more reward behaviors, the fewer punishment behaviors, and the higher human-robot trust of humans. Robots' higher social status weakens the influence of their fairness on humans' punishment behaviors. Human-robot trust will increase humans' reward behaviors and decrease humans' punishment behaviors. Humans' reward-punishment behaviors will increase repaired human-robot trust.

CONCLUSION

Robots' fairness has a significant impact on humans' reward-punishment behaviors and trust. Robots' social status moderates the effect of their fair behavior on humans' punishment behavior. There is an interaction between humans' reward-punishment behaviors and trust.

APPLICATION

The study can help to better understand the interaction mechanism of the human-robot team and can better serve the management and cooperation of the human-robot team by appropriately adjusting the robots' fairness and social status.

The Emergence of Specialized Roles Within Groups

Humans routinely form groups to achieve goals that no individual can accomplish alone. Group coordination often brings to mind synchrony and alignment, where all individuals do the same thing (e.g., driving on the right side of the road, marching in lockstep, or playing musical instruments on a regular beat). Yet, effective coordination also typically involves differentiation, where specialized roles emerge for different members (e.g., prep stations in a kitchen or positions on an athletic team). Role specialization poses a challenge for computational models of group coordination, which have largely focused on achieving synchrony. Here, we present the CARMI framework, which characterizes role specialization processes in terms of five core features that we hope will help guide future model development: Communication, Adaptation to feedback, Repulsion, Multi-level planning, and Intention modeling. Although there are many paths to role formation, we suggest that roles emerge when each agent in a group dynamically allocates their behavior toward a shared goal to complement what they expect others to do. In other words, coordination concerns beliefs (who will do what) rather than simple actions. We describe three related experimental paradigms-"Group Binary Search," "Battles of the Exes," and "Find the Unicorn"-that we have used to study differentiation processes in the lab, each emphasizing different aspects of the CARMI framework.

A Cross-Country Analysis of the Combined Influence of Social Media Use and Perceived Social Media Networks on Pandemic Communicative Responses

This study examines how social media (SM) use is related to human responses to emerging infectious disease risks in the context of the COVID-19 pandemic via an online survey conducted in the United States and Taiwan. Results showed that SM use was related to different types of communicative responses (information seeking, interpersonal discussion, and rumor correction) directly and indirectly through cognitive and affective responses (risk perception, responsibility attribution, and negative and positive emotions). The indirect relationships between SM use and communicative responses through these cognitive and affective responses were moderated by perceived SM network structures. In particular, the mediating influence of negative emotions on communicative responses was associated with perceived SM network homogeneity, while that of positive emotions was related to perceived SM network centrality. Furthermore, responsibility attribution drove Taiwanese SM users' communicative responses, whereas the interrelated influence of positive emotions and perceived SM network centrality shaped American SM users' communicative responses.

Maintaining Transient Diversity Is a General Principle for Improving Collective Problem Solving

Humans regularly solve complex problems in cooperative teams. A wide range of mechanisms have been identified that improve the quality of solutions achieved by those teams on reaching consensus. We argue that many of these mechanisms work via increasing the transient diversity of solutions while the group attempts to reach a consensus. These mechanisms can operate at the level of individual psychology (e.g., behavioral inertia), interpersonal communication (e.g., transmission noise), or group structure (e.g., sparse social networks). Transient diversity can be increased by widening the search space of possible solutions or by slowing the diffusion of information and delaying consensus. All of these mechanisms increase the quality of the solution at the cost of increased time to reach it. We review specific mechanisms that facilitate transient diversity and synthesize evidence from both empirical studies and diverse formal models-including multiarmed bandits, NK landscapes, cumulative-innovation models, and evolutionary-transmission models. Apparent exceptions to this principle occur primarily when problems are sufficiently simple that they can be solved by mere trial and error or when the incentives of team members are insufficiently aligned. This work has implications for our understanding of collective intelligence, problem solving, innovation, and cumulative cultural evolution.

Usability of a Human Factors-based Clinical Decision Support in the Emergency Department: Lessons Learned for Design and Implementation

OBJECTIVE

To evaluate the usability and use of human factors (HF)-based clinical decision support (CDS) implemented in the emergency department (ED).

BACKGROUND

Clinical decision support can improve patient safety; however, the acceptance and use of CDS has faced challenges. Following a human-centered design process, we designed a CDS to support pulmonary embolism (PE) diagnosis in the ED. We demonstrated high usability of the CDS during scenario-based usability testing. We implemented the HF-based CDS in one ED in December 2018.

METHOD

We conducted a survey of ED physicians to evaluate the usability and use of the HF-based CDS. We distributed the survey via Qualtrics, a web-based survey platform. We compared the computer system usability questionnaire scores of the CDS between those collected in the usability testing to use of the CDS in the real environment. We asked physicians about their acceptance and use of the CDS, barriers to using the CDS, and areas for improvement.

RESULTS

Forty-seven physicians (56%) completed the survey. Physicians agreed that diagnosing PE is a major problem and risk scores can support the PE diagnostic process. Usability of the CDS was reported as high, both in the experimental setting and the real clinical setting. However, use of the CDS was low. We identified several barriers to the CDS use in the clinical environment, in particular a lack of workflow integration.

CONCLUSION

Design of CDS should be a continuous process and focus on the technology's usability in the context of the broad work system and clinician workflow.

Naturalistic observations of multiteam interaction networks: Implications for cognition in crisis management teams

Interaction has been recognised as an essential lens to understand how cognition is formed in a complex adaptive team such as a multidisciplinary crisis management team (CMT). However, little is known about how interactions within and across CMTs give rise to the multi-team system's overall cognitive functioning, which is essential to avoid breakdowns in coordination. To address this gap, we characterise and compare the component CMTs' role-as-intended (RAI) and role-as-observed (RAO) in adapting to the complexity of managing informational needs. To characterise RAI, we conducted semi-structured interviews with subject matter experts and then made a qualitative synthesis using a thematic analysis method. To characterise RAO, we observed multiteam interaction networks in real-time at a simulated training environment and then analysed the component CMTs' relative importance using node centrality measures. The resulting inconsistencies between RAI and RAO imply the need to investigate cognition in multiple CMTs through the lens of interaction.Practitioner summary: When a disaster occurs, multidisciplinary CMTs are expected to serve their roles as described in written or verbal guidelines. However, according to our naturalistic observations of multiteam interaction networks, such descriptions may be (necessary but) insufficient for designing, training, and evaluating CMTs in the complexity of managing informational needs together.

The "Ladder of Inference" as a Conflict Management Tool: Working with the "Difficult" Patient or Family in Healthcare Ethics Consultations

Conflict resolution is a core component of healthcare ethics consultation (HEC) and proficiency in this skill set is recognized by the national bioethics organization and its HEC certification process. Difficult interpersonal interactions between the clinical team and patients or their families are often inexorably connected to the normative disputes that are the catalyst for the consult. Ethics consultants are often required to navigate challenging dynamics that have become entrenched and work with patient-provider or family-provider relationships that have already broken down. The first step in conflict resolution is diagnosing the source of the conflict. Because so many interpersonal and normative conflicts rest on misunderstanding and mischaracterization, the diagnosis of the problem requires untangling the actual positions and perspectives of the conflicting parties from the fallacious assumptions made about the parties' respective positions and views. Developed in management science, the Ladder of Inference (LOI) is a diagnostic tool for assisting stakeholders in re-examining the process they used to form beliefs about others involved in the conflict. The LOI is a device that detects errors in reasoning, including implicit racial bias, that lead to false judgments and counterproductive responses to those judgments. The LOI is an instrument that can be used by ethics consultants to help resolve contentious bedside conflicts, but the LOI can also be employed as a teaching tool used by healthcare ethics consultants in training the clinical staff in how to avoid such conflicts in the first place.

Influencing factors of environmental efficiency of strategic emerging industries and their power cooperation mechanism design

We investigate the influencing factors of environmental efficiency of strategic emerging industries (SEIs) and cooperative game mechanism design amongst diversified actors by using China's provincial panel data from 2004 to 2019. Firstly, we find that the following factors improve the environmental efficiency of SEIs: rationalisation of the industrial structure, proportion of the tertiary industry, government's ability to intervene in the economy and fairness and integrity of environmental law enforcement. Conversely, factors, such as intensity of ecological construction and environmental regulation, hamper the environmental efficiency of SEIs. Secondly, evolutionary game analysis indicates that the behavioural strategies of game decision-making subjects depend on the behavioural decisions of the relative actors, social supervision and government regulation, which work together in influencing the environmental efficiency of SEIs. {innovation, supervision} is the optimal equilibrium state of the game. Thirdly, simulation results show that in the absence of government regulation, foreign direct investment (FDI) slows down the speed of firms tending to the equilibrium state of green innovation. The potential gain and loss of social supervision on corporate behaviour is an important factor affecting government behaviour decision making. Governments prefer punishment tools in environmental regulation, therefore influencing noninnovative firms in SEIs. We contribute to prior works by unifying various policy tools into the same econometric model framework based on an evolutionary game model.

Collectivism Impairs Team Performance When Relational Goals Conflict With Group Goals

This research challenges the idea that teams from more collectivistic cultures tend to perform better. We propose that in contexts in which there are tradeoffs between group goals (i.e., what is best for the group) and relational goals (i.e., what is best for one's relationships with specific group members), people in less collectivistic cultures primarily focus on group goals but those in more collectivistic cultures focus on both group and relational goals, which can lead to suboptimal decisions. An archival analysis of 100 years of data across three major competitive team sports found that teams from more collectivistic nations consistently underperformed, even after controlling for a number of nation and team characteristics. Three follow-up studies with 108 Chinese soccer players, 109 Singapore students, and 119 Chinese and the U.S. adults provided evidence for the underlying mechanism (i.e., prioritizing relational goals over group goals). Overall, this research suggests a more balanced view of collectivism, highlighting an important context in which collectivism can impair team performance.

Remembering to Resume: A Randomized Trial Comparing Combined Interruption Management Training and Simulation-Based Education to Simulation-Based Education Alone

AIM

This study aimed to determine if purposeful presimulation interruption management training impacts cognitive load and successful completion of simulation objectives more than the experience alone.

BACKGROUND

Practicing nurses are frequently interrupted, increasing the risk for error and task time. Novices are particularly vulnerable to interruption consequences.

METHOD

A between-subjects design and block randomization of prelicensure baccalaureate nursing students ( n = 146) was used to compare group differences in cognitive load, use of interruption management strategies, and completion of simulation required elements. Potential relationships between outcomes and age, mindfulness, and experience were explored.

RESULTS

An analysis of covariance demonstrated significantly lower perceived mental demand for those receiving training. Older learners and those receiving training implemented more interruption management strategies.

CONCLUSION

Combining simulation-based education (SBE) with purposeful training enhances interruption management more than SBE alone. Frequent interruption training and SBE are recommended to enhance risk awareness.

Team Cognition in Handoffs: Relating System Factors, Team Cognition Functions and Outcomes in Two Handoff Processes

OBJECTIVE

This study investigates how team cognition occurs in care transitions from operating room (OR) to intensive care unit (ICU). We then seek to understand how the sociotechnical system and team cognition are related.

BACKGROUND

Effective handoffs are critical to ensuring patient safety and have been the subject of many improvement efforts. However, the types of team-level cognitive processing during handoffs have not been explored, nor is it clear how the sociotechnical system shapes team cognition.

METHOD

We conducted this study in an academic, Level 1 trauma center in the Midwestern United States. Twenty-eight physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) participated in semi-structured interviews. We performed qualitative content analysis and epistemic network analysis to understand the relationships between system factors, team cognition in handoffs and outcomes.

RESULTS

Participants described three team cognition functions in handoffs-(1) information exchange, (2) assessment, and (3) planning and decision making; information exchange was mentioned most. Work system factors influenced team cognition. Inter-professional handoffs facilitated information exchange but included large teams with diverse backgrounds communicating, which can be inefficient. Intra-professional handoffs decreased team size and role diversity, which may simplify communication but increase information loss. Participants in inter-professional handoffs reflected on outcomes significantly more in relation to system factors and team cognition (p < 0.001), while participants in intra-professional handoffs discussed handoffs as a task.

CONCLUSION

Handoffs include team cognition, which was influenced by work system design. Opportunities for handoff improvement include a flexibly standardized process and supportive tools/technologies. We recommend incorporating perspectives of the patient and family in future work.

The validity of a therapeutic invigoration task in avolitional schizophrenia outpatients

BACKGROUND AND OBJECTIVES

Avolition is associated with much morbidity and functional impairment in schizophrenia patients. Vigor may be taken as, in part, the inverse of avolition, but it has not been investigated as a therapeutic pursuit before. To this end, a therapeutic invigoration task was developed drawing on cognitive-behavioral and guided imagery therapies. This study investigated the validity and reliability of a therapeutic invigoration task in avolitional residual phase schizophrenia outpatients.

METHODS

In a proof-of-concept quasi-experimental one-group sequentially repeated pretest/posttest study design, patients (n = 76) participated in a structured invigoration task that was repeated after 1 month (n = 70).

RESULTS

Patients' vigor during the preceding 7 days measured on the Vigor Assessment Scale increased highly significantly in anticipation of the subsequent 7 days on both occasions with respectively very large (Cohen's δ with Hedges' correction [δ] = 1.46) and large (δ = 1.04) effect sizes. The anticipated vigor after the first occasion was partially consummated during the subsequent month in that vigor during the 7 days preceding the second occasion was lower than participants had anticipated but still significantly higher than at baseline (p < 0.001; δ = 0.70). Repeating the task a month later, together with homework, had a cumulative effect as indicated by a very large effect size (δ = 1.61).

CONCLUSION

Results suggest that the invigoration task did what it was supposed do, and did so consistently, in patients with avolitional residual schizophrenia. These results warrant a subsequent randomized controlled trial to establish the efficacy of the invigoration task.

Risk communication in multistakeholder engagement: A novel spatial econometric model

Existing studies on the environmental Kuznets curve (EKC) neglect the inverse effect of pollution transfer from environmental regulation interactions on pollution reduction from a risk analysis perspective. Based on the regional differentiated attitudes on the environmental regulation reached in risk communication by the risk awareness biases of multiple interest groups, this article clarifies the causality between risk communication and risk transfer based on multistakeholder engagement processes; furthermore, the article incorporates the simultaneous action of the technological innovation effect and pollution risk transfer effect to construct a spatial environmental hyperbolic model with a bidirectional correlation between pollution emissions and economic growth in different regions. To verify our model, we select the pollution from agricultural watersheds in China as a sample to examine the two inverse effects. The results demonstrate that (1) agricultural watershed pollution and economic growth show an inverted U-shaped relation and a U-shaped relation in the local region and adjacent regions, respectively; (2) the pollution reduction assessment of the classical EKC model can be largely attributed to pollution risk transfer behavior; and (3) the turning point of the U-shaped curve appears earlier than that of the inverted U-shaped curve in the spatial hyperbola model. The findings suggest that stakeholders should consider the risk awareness bias caused by the imbalance of regional economic development and the scenarios that provide a "haven" for pollution risk transfer. Moreover, our study expands the theoretical connotation of the classical EKC hypothesis and is more suitable for pollution reduction scenarios in developing countries.

Autism Comes to the Pediatric Hospital: Perspectives of Child Life Specialists

The hospital setting may be especially difficult for pediatric patients on the autism spectrum and their families compared to those not on the spectrum. Child life specialists are healthcare professionals specifically trained to support parents and their children and help prepare them for hospital procedures. Because of this specialized skill set, these professionals likely have a wealth of expertise to share relevant to caring for autistic patients. This study aimed to understand 21 child life specialists' experiences working with patients on the spectrum. Our findings highlighted the following themes: Parents are the Experts, Proactive and Individualized Care, Disclosure, and Hospital-Wide Suggestions to Improve Patient Care. We discuss the practice implications of these findings on the healthcare experiences of pediatric patients on the spectrum.

King of the castle: organisational influences on authority gradients between network controllers and other team members

The rail system relies on the effective coordination of multiple disciplines and teams situated within an operational hierarchy to meet a single operational objective-the safe and timely movement of rail traffic. Power and status dispersals across these teams and the various roles within them impact interaction and communication. This study drew on the perceptions of network controllers, to identify organisational factors influencing power imbalances that generate authority gradients between network controllers and other team members. Network controllers (N = 55) across eight Australasian organisations engaged in interviews using the Scenario Invention Task Technique to explore perceptions of risk. Thematic analysis revealed relationships between teams were affected by: (1) the accountability mechanisms adopted by organisations; (2) the way power was vested in roles; and (3) the status attached to roles. This insight into organisational power hierarchies and the generation of authority gradients provides opportunities for understanding teamwork error.Practitioner summary: Communication is impaired by authority gradients across teams in rail and is a contributing factor in incidents occurring on the network. This paper explores the organisational influences on power hierarchies across teams from the perspective of the network controller, pointing to an adversarial culture, resulting in tribalism impeding team interactions.

Distributed cognition: Theoretical insights and practical applications to health professions education: AMEE Guide No. 159

Distributed cognition (DCog) is a member of the family of situativity theories that widens the lens of cognition from occurring solely inside the head to being socially, materially and temporally distributed within a dynamic system. The concept of extending the view of cognition to outside the head of a single health professional is relatively new in the healthcare system. DCog has been increasingly used by researchers to describe many ways in which health professionals perform in teams within structured clinical environments to deliver healthcare for patients. In this Guide, we expound ten central tenets of the macro (grand) theory of DCog (1. Cognition is decentralized in a system; 2. The unit of analysis is the system; 3. Cognitive processes are distributed; 4. Cognitive processes emerge from interactions; 5. Cognitive processes are interdependent; 6. Social organization is a cognitive architecture; 7. Division of labour; 8. Social organization is a system of communication; 9. Buffering and filtering; 10. Cognitive processes are encultured) to provide theoretical insights as well as practical applications to the field of health professions education.

Jumping with a parachute - is promoting research integrity meaningful?

Considering world-wide interest in prevalent research malpractice at higher education institutions, we focus on the role of European national research integrity promoters (ombudspersons, research funding organizations, research integrity networks) who play a role at the forefront of bringing systemic change. Given the constraints of the role of research integrity promoters, we strive to grasp the meaningfulness of their work. To accomplish that, we employ a qualitative research approach and use individual semi-structured interviews with 10 national research integrity promoters. Employing reflexive applied thematic analysis, we discuss our findings in light of the structural symbolic interactionist approach and sensemaking theory. We conclude that encapsulated in challenging prerequisites of the national research integrity promotion work, the meaningfulness of such work emerges through integrating research integrity in all aspects of academic life to entail indispensable systemic changes in academia.

Exploring the Connectivity Paradox: How the Sociophysical Environment of Telehealth Shapes Adolescent Patients' and Parents' Perceptions of the Patient-Clinician Relationship

Even before the widespread transition to telehealth as a result of COVID-19, there was a considerable amount of research exploring its value and impact. However, telehealth research with adolescent patients is somewhat limited, with most work focusing on access, feasibility, and acceptability but reporting far less frequently on relationship building and rapport. This study examines qualitative interviews with adolescent patients (n = 14) and parents (n = 20) from a larger convergent parallel mixed methods study to explore how they understand telehealth to have altered the sociophysical environment of primary care clinic encounters and whether they perceive these changes to influence adolescents' relationships with clinicians. We show that participants perceived the sociophysical environment of telehealth to be both less institutional (e.g. more relaxed and less rushed) and more instrumental (e.g. more focused on the chief complaint), which shaped interactions with clinicians in ways that were experienced as paradoxically less personal (e.g. lacking social connection) and more person-centered (e.g. more attentive to the individual patient). We discuss theoretical and practical implications of these findings and what they mean for defining person-centered communication for adolescent care.

I Am Not a 'Hero': U.S. Nurses' Identity Overlaps and Conflict During COVID-19

The current COVID-19 pandemic exemplifies a crisis that is redefining the meaning of communication for many. Metaphors like the "hero" trope are being used to represent our frontline employees, such as nurses who work directly with COVID-19 patients. However, we know very little about how these tropes influence the identities of these nurses and how it impacts their work. This article draws on social identity theory and key works related to role and identity conflict to look at nurses' perceptions of the hero trope being used to define them during this crisis. The study involved 23 semi-structured interviews with nurses from the United States who were working with COVID-19 patients. Nurses described how, due to COVID-19-especially in light of the hero trope - multiple identities became salient during the pandemic. Many of the identity overlaps were minimized during this time as the trope modified the meaning of how some norms around these different sub-identities were understood. This also highlights the role of communication in shaping and modifying group identity norms during crises, thus suggesting an integration of SIT with the constructivist or even some level of poststructural perspective. As a consequence of the pandemic and the minimized overlaps between the identities, nurses felt more self-doubt or failure, which impacted their overall psychological well-being as well as their efficacy at work. Nurses used communication strategies such as providing reminders, separating myth from reality, and directly approaching their managers, to cope with the identity conflicts.

A social network perspective on peer relationship formation of medical undergraduates within large-scale learning communities

INTRODUCTION

Students' formal networks, which are formed by a formal curriculum design, such as formally organized study groups within learning communities (LCs), may benefit students' interactions and learning. It is unclear how large-scale LCs contribute to the formation of different informal peer relationships, which refers to student self-organized out-of-class relationships. Two mechanisms can explain relationship formation in LCs. Propinquity within formal networks and homophily of students' characteristics (nationality, sex, academic performance) may promote students' peer relationships. This study explores to what extent the formation of students' informal networks was determined by their formal networks (LCs) while controlling for students' characteristics and which mechanisms play an important role.

METHODS

With online surveys, data were collected about five informal networks (help-seeking, collaboration, information sharing, friendship, and learn-from) from 69 first- and 51 second- bachelor year medical students (2890 relationships). Students were divided into four LCs in the formal curriculum. We compared students' five informal network structures between first- and second-year students, domestic and international students, within and between formal networks. Besides, we used Quadratic Assignment Procedure (QAP) Regression Analysis in Ucinet to investigate the associations between students' informal and formal networks (LCs) and students' characteristics.

RESULTS

Propinquity (in the same LC) plays a role since students have more informal connections within LCs than between LCs. Furthermore, it seems to play a greater role for second-year students than for first-year students. Homophily of nationality is important in informal networking since students are more likely to connect with others of similar nationalities.

CONCLUSION

Students become more connected within the LC when they remain in the same LC for a longer period. Formal networks enhance the students' informal interactions within LCs but seem to restrict the interactions among students from other LCs. International students need support in order to integrate with domestic students in LCs.

Now What? Collective Sensemaking and Sensegiving in the Cystic Fibrosis Community in Sweden During the Initial Phase of the COVID-19 Pandemic

The COVID-19 pandemic's effects on people's lives and society induced a need for rapid individual and collective sensemaking, including communication forums enabling stakeholders in the health ecosystem to share information, solve problems, and learn. This study specifically focused on the needs of the patients and family caregivers living with cystic fibrosis (CF) or primary ciliary dyskinesia (PCD), conditions that lead to chronic infections and inflammation in the airways. We explored how CF and PCD patients, family caregivers, and clinicians collectively received, processed, and used information about COVID-19 to facilitate self-care and health care decisions at the beginning of the pandemic. We applied macrocognitive theory to analyze qualitatively the questions and answers exchanged in a series of six webinars facilitated by a CF learning network at the beginning of the pandemic (March - April 2020). We identified three macrocognitive functions: sensemaking, decision-making, and replanning. We further generated nine themes: (a) understanding the nature of COVID-19, (b) exploring self-care needs and possibilities, (c) understanding health care possibilities, (d) making decisions about prevention and testing, (e) managing COVID-19 within families, (f) adjusting planned care, (g) replanning chronic care management, (h) defining COVID-19 health care strategies, and (i) refining health care policies. The exchange of questions and answers played a central role in facilitating important cognitive processes, which enabled a rapid anticipation of needs and adaptation of services to support patients, family caregivers, and clinicians during the COVID-19 pandemic.

Threats to the emotional wellbeing of mainland Chinese students studying in Australia: an interpretivist study

PURPOSE

In 2017, international students contributed almost $32 billion to Australia's economy, more than half of which was attributable to students from China. Despite its historical popularity as a study destination, research suggests that these students confront numerous obstacles in pursuing their studies within Australia. In this study, the perspectives of these students were explored. The dominant issues raised by these students related to mental health and emotional wellbeing.

METHODS

Nineteen students in one Australian university participated in one-on-one in-depth semi-structured interviews. Data were analysed using grounded theory approaches. Three broad themes were generated in the study: psychological stress (which was linked to language barriers, shifts in pedagogy, and changes in lifestyle); perceived safety (which was linked to lack of security, safety and perceived racial discrimination); and social isolation (linked to reduced sense of belonging; lacking close personal connections; and feelings of loneliness and homesickness).

CONCLUSIONS

Results suggested that a tripartite model of interactive risk factors may be appropriate for exploring how international students fare emotionally with their new environments.

Employee Engagement as Human Motivation: Implications for Theory, Methods, and Practice

The central theoretical construct in human resource management today is employee engagement. Despite its centrality, clear theoretical and operational definitions are few and far between, with most treatments failing to separate causes from effects, psychological variables from organizational variables, and internal from external mechanisms. This paper argues for a more sophisticated approach to the engagement concept, grounding it in the vast psychological literature on human motivation. Herein lies the contribution of our paper; we argue that the apparent diversity of operational definitions employed by academics and practitioners can be understood as tentative attempts to draw ever nearer to key motivational concepts, but never quite get there. We review the leading definitions of employee engagement in the literature and find that they are reducible to a core set of human motives, each backed by full literatures of their own, which populate a comprehensive model of twelve human motivations. We propose that there is substantial value in adopting a comprehensive motivational taxonomy over current approaches, which have the effect of "snowballing" ever more constructs adopted from a variety of fields and theoretical traditions. We consider the impact of rooting engagement concepts in existing motivational constructs for each of the following: (a) theory, especially the development of engagement systems; (b) methods, including the value of applying a comprehensive, structural approach; and (c) practice, where we emphasize the practical advantages of clear operational definitions.

The power of rotation schedules on the career selection decisions of medical students

Choosing a career pathway in medicine is a high stakes decision for both medical students and the field of medicine as a whole. While past research has examined how characteristics of the medical student or specialties influence this decision, we introduce temporal elements as novel variables influencing career selection decisions in medicine. Specifically, we investigate how timing and duration of residency options, based on a rotation schedule that medical students have limited control over, influence their career selection decisions. An archival study investigating 5 years of medical student rotation schedules (N = 115) reveals that clinical rotation options appearing earlier and more often in the schedule were more likely to be selected. Moreover, timing and duration of exposure interacted such that residency options appearing later in the schedules were more likely to be selected if they also appeared more often. Conditional logistic regressions using student fixed-effects to control for idiosyncratic medical student differences (i.e., gender, & debt, etc.), and residency fixed-effects to control for idiosyncratic residency differences (income, and lifestyle, etc.), revealed the rotation schedule had a significant impact on residency selection decisions even when controlling for factors typically influencing this decision. Medical students' career decisions are influenced by when and how long different choice options appear in their rotation schedule, especially when they have limited influence over this schedule. The results have implications for healthcare policy by highlighting a tool for adjusting physician workforce composition by broadening exposure to a greater array of career options.

The role of values in coping with health and economic threats of COVID-19

The current research examined the role of values in guiding people's responses to COVID-19. Results from an international study involving 115 countries (N = 61,490) suggest that health and economic threats of COVID-19 evoke different values, with implications for controlling and coping with the pandemic. Specifically, health threats predicted prioritization of communal values related to caring for others and belonging, whereas economic threats predicted prioritization of agentic values focused on competition and achievement. Concurrently and over time, prioritizing communal values over agentic values was associated with enactment of prevention behaviors that reduce virus transmission, motivations to help others suffering from the pandemic, and positive attitudes toward outgroup members. These results, which were generally consistent across individual and national levels of analysis, suggest that COVID-19 threats may indirectly shape important responses to the pandemic through their influence on people's prioritization of communion and agency. Theoretical and practical implications are discussed.

Shared understanding and task-interdependence in nursing interns' collaborative relations: A social network study of vocational health care internships in the Netherlands

Shared understanding among collaborators is a key element of delivering successful interprofessional care and a main challenge for professional education concerns nurturing such understanding among students. We assessed how nursing students perceived different levels of shared understanding in their collaborations with others in clinical internships. We analyse the collaborative networks of interns to examine whether individual factors (attitudes, perceptions of collaborative cultures, and motivation) or relational factors among collaborators (task-interdependence, cooperation frequency, and interprofessional and hierarchical roles) affect shared understanding among 150 Dutch nursing interns and their collaborators (n = 865). Theoretically, we stress the importance of focusing on collaborative relations in interprofessional care settings. Multilevel models distinguish two levels in explaining the variation in shared understanding, nesting collaborative relationships within individuals. Results indicate merely 37.4% of found variation of shared understanding could be attributed to individual-level factors (variation between interns), while 62.6% of variation is found within interns, showing that shared understanding differs substantially between the collaborations one intern engages in. Multilevel models reveal that task-interdependence strongly predicts shared understanding in inter- and intraprofessional collaborations. We conclude that focusing on collaborative relations is essential to foster shared understanding in vocational internship programmes, and that health care organisations should pay explicit attention to task-interdependence in interns' collaborations.

'Change talk' among physicians in small group learning communities: An ethnographic study

INTRODUCTION

Physicians face uncertainties in complex clinical environments. Small group learning initiatives allow physicians to decipher new evidence and address challenges. This study aimed to understand how physicians in small learning groups discuss, interpret and assess new evidence-based information to make decisions for practice.

METHODS

An ethnographic approach was used to collect data from observed discussions between practising family physicians (n = 15) that meet in small learning groups (n = 2). Physicians were members of a continuing professional development (CPD) programme that provides educational modules with clinical cases and evidence-based recommendations for best practice. Nine learning sessions were observed over 1 year. Field notes documenting the conversations were analysed using ethnographic observational dimensions and thematic content analysis. Observational data were supplemented with interviews (n = 9) and practice reflection documents (n = 7). A conceptual framework for 'change talk' was created.

RESULTS

Observations elucidated the following: Facilitators played a significant role in leading the discussion by focusing on practice gaps. As group members shared approaches to clinical cases, baseline knowledge and practice experiences were revealed. Members made sense of new information by asking questions and sharing knowledge. They determined what information was useful and whether it applied to their practice. They reviewed evidence, tested algorithms, benchmarked themselves to best practice and consolidated knowledge before committing to practice change(s). Themes from interviews emphasised that sharing of practice experiences played an integral part in decisions to implement new knowledge, helped validate guideline recommendations and provided strategies for feasible practice changes. Documented practice reflections regarding decisions for practice change(s) overlapped with field notes.

CONCLUSION

This study provides empirical data on how small groups of family physicians discuss evidence-based information and make decisions for clinical practice. A 'change talk' framework was created to illustrate the processes that occur when physicians interpret and assess new information to bridge gaps between current and best practices.