Ten tips for conducting focused ethnography in medical education research

International medical students' experiences of psychological safety in feedback episodes: a focused ethnographic study

BACKGROUND

Feedback and psychological safety are well-established concepts within medical education, vital for student learning and progress. However, the concepts remain unexplored in the context of international students. This area deserves attention given the unique challenges faced by the overseas medical students due to cultural differences. The present study examines international students' experiences of psychological safety in feedback interactions in a Scottish undergraduate medical programme.

METHODS

A focused ethnographic approach was adopted to explore international students' experiences and perceptions of psychological safety in their feedback experiences. Data were collected in the form of field observations and semi-structured interviews, involving both student and faculty participants. Approximately 13hrs of fieldwork and a total of 11 interviews were conducted. These were analysed using a combination of inductive and deductive thematic analysis.

RESULTS

Data analysis identified four key themes: feedback delivery, educator attributes, cultural factors and longitudinal educational relationships. Both staff and student participants highlighted how environmental factors such as room design and group size functioned as enablers or barriers to psychological safety in feedback episodes. Additionally, students appreciated tutors who expressed vulnerability and demonstrated awareness of their cultural backgrounds. Students described significant differences between the feedback approaches in the host (UK) institute and that in their home country. Longitudinal associations fostered trust and familiarity with peers and tutors, enhancing students' receptivity to learning and feedback.

CONCLUSION

This present study highlights cultural differences in feedback practices across countries and their impact on psychological safety among international students. It stresses the importance of integrating overseas students by considering group dynamics, environment and diverse student needs. Staff awareness of cultural variability, openness to tutor vulnerability and fostering long-term educational relationships can greatly enhance psychological safety in learning and teaching activities. These insights are relevant amidst the growing globalisation of medical education and the mobility of students across borders, advocating for tailored integration to optimise their learning experience and achievement.

Inequity in clinical research access for service users presenting comorbidity within alcohol treatment settings: findings from a focused ethnographic study

BACKGROUND

While healthcare policy has fostered implementation strategies to improve inclusion and access of under-served groups to clinical care, systemic and structural elements still disproportionately prevent service users from accessing research opportunities embedded within clinical settings. This contributes to the widening of health inequalities, as the absence of representativeness prevents the applicability and effectiveness of evidence-based interventions in under-served clinical populations. The present study aims to identify the individual (micro), organisational (meso) and structural (macro) barriers to clinical research access in patients with comorbid alcohol use disorder and alcohol-related liver disease.

METHODS

A focused ethnography approach was employed to explore the challenges experienced by patients in the access to and implementation of research processes within clinical settings. Data were collected through an iterative-inductive approach, using field notes and patient interview transcripts. The framework method was utilised for data analysis, and themes were identified at the micro, meso and macro levels.

RESULTS

At the micro-level, alcohol-related barriers included encephalopathy and acute withdrawal symptoms. Alcohol-unrelated barriers also shaped the engagement of service users in research. At the meso-level, staff and resource pressures, as well as familiarity with clinical and research facilities were noted as influencing intervention delivery and study retention. At the wider, macro-level, circumstances including the 'cost of living crisis' and national industrial action within healthcare settings had an impact on research processes. The findings emphasise a 'domino effect' across all levels, demonstrating an interplay between individual, organisational and structural elements influencing access to clinical research.

CONCLUSIONS

A combination of individual, organisational and structural barriers, exacerbated by the COVID-19 pandemic, and the socioeconomic landscape in which the study was conducted further contributed to the unequal access of under-served groups to clinical research participation. For patients with comorbid alcohol use disorder and alcohol-related liver disease, limited access to research further contributes towards a gap in effective evidence-based treatment, exacerbating health inequalities in this clinical population.

Decision-making about changing medications across transitions of care: Opportunities for enhanced patient and family engagement

BACKGROUND

Older patients often have complex medication regimens, which change as they move across transitions of care. Engagement of older patients and families in making medication decisions across transitions of care is important for safe and high-quality medication management.

AIMS

To explore decision-making between health professionals, older patients and families about medication changes across transitions of care, and to examine how patient and family engagement is enacted in the process of decision-making in relation to these medication changes.

METHODS

A focused ethnographic design was undertaken with semi-structured interviews, observations, and reflective focus groups or interviews. Reflexive thematic analysis was conducted on transcribed data. The study was undertaken at a public teaching acute care hospital and a public teaching community hospital in Australia.

RESULTS

In all, 182 older patients, 44 family members and 94 health professionals participated. Four themes were conceptualised from the data: different customs and routines, medication challenges, health professional interactions, and patient and family involvement. Environments had differences in their customs and routines, which increased the potential for medication delays or the substitution of unintended medications. Medication challenges included health professionals assuming that patients and families did not need information about regularly prescribed medications. Patients and families were informed about new medications after health professionals had already made decisions to prescribe these medications. Health professionals tended to work in disciplinary silos, and they had views about their role in interacting with patients and families. Patients and families were expected to take the initiative to participate in decision-making about medication changes.

CONCLUSIONS

Patient movements across transitions of care can create complex and chaotic medication management situations, which lacks transparency, especially for older patients and their families. A greater focus on pre-emptive and planned discussions about medication changes will contribute to improving patient and family involvement in medication decision-making.

Culture of patient care among international nursing students: a focused ethnographic study

BACKGROUND

This study was conducted to describe and explain the culture of patient care in international nursing students.

METHODS

This qualitative study was conducted using focused ethnography. Participants (n = 21) were purposefully selected from non-Iranian international students and their nursing instructors. Data collection included semi-structured interviews, and field-note taking. Data were analyzed with the Roper and Shapira inductive approach of ethnographic content analysis.

RESULTS

The cultural model of the study included the acquisition of cultural competence through acceptance of differences and finding commonalities. Subcategories were: "avoiding cultural bias", "trying to be on the path of adaptation", "appealing to the support and companionship of colleagues", "coping with culture shock", "acculturation", "getting help from cultural intelligence", "cultural empathy", and "language and communication enhancement".

CONCLUSION

Cultural competence is teachable. The pattern of formation is through accepting differences and searching for commonalities. Suggestions for promoting the culture of care among international students include effective use of peer groups and teaching different national ethnicities and cultures.

A Critical Comparison of Focused Ethnography and Interpretive Phenomenology in Nursing Research

Choosing an appropriate qualitative methodology in nursing research is a researcher's first step before beginning a study. Such a step is critical as the selected qualitative methodology should be congruent with the research questions, study assumptions, data gathering and analysis to promote the utility of such research in enhancing nursing knowledge. In this paper, we compare focused ethnography by Roper and Shapira and interpretive phenomenology by Benner. Though these methodologies are naturalistic and appear similar, both have different methodological underpinnings. The historical, ontological, epistemological, and axiological philosophy guiding each methodology are described. In addition, the methodological underpinnings of both methodologies and a justification for use in nursing research are provided. This paper will assist future researchers who aim to employ these methodologies in nursing research.

Undignified Maternity Care During Childbirth: An Ethnographic Study on Midwives' Perspectives in a Community Healthcare Centre in South Africa

Undignified care of women during labor has been associated with increased preventable maternal morbidity and mortality. The purpose of this study was to explore midwives' perspectives on undignified care of women in a midwife's obstetric unit within a rural community healthcare center in South Africa. Using ethnographic methods, seven midwives were recruited to participate in individual interviews and participant observations were conducted in the unit. Three main themes describing undignified care were identified based on an inductive analysis of observations and interview data. These included a lack of respect for women's bodily autonomy during labor, structural challenges in the provision of quality maternity care, and the lack of confidential care for women in labor and delivery. The study findings show that obstetric violence remains a serious crisis in the well-being of women during childbirth. Policy development by stakeholders in maternity care, including operational healthcare practitioners, should prioritize training, monitoring, and peer support on dignified care and curbing disrespect and abuse of women during childbirth, which seemed to be deeply rooted in the routine unorthodox treatment of childbirth.

What is simulation-based medical education (SBME) debriefing in prehospital medicine? A qualitative, ethnographic study exploring SBME debriefing in prehospital medical education

INTRODUCTION

Simulation-based medical education (SBME) debriefing - a construct distinct from clinical debriefing - is used following simulated scenarios and is central to learning and development in fields ranging from aviation to emergency medicine. However, little research into SBME debriefing in prehospital medicine exists. This qualitative study explored the facilitation and effects of prehospital SBME debriefing, and identified obstacles to debriefing, using the London's Air Ambulance Pre-Hospital Care Course (PHCC) as a model.

METHOD

Ethnographic observations of moulages and debriefs were conducted over two consecutive days of the PHCC in October 2019. Detailed contemporaneous field notes were made and analysed thematically. Subsequently, seven one-to-one, semi-structured interviews were conducted with four PHCC debrief facilitators and three course participants to explore their experiences of prehospital SBME debriefing. Interview data were transcribed and analysed thematically.

RESULTS

Four overarching themes were identified: approach to facilitation of debriefs, effects of debriefing, facilitator development, and obstacles to debriefing. The unpredictable debriefing environment was seen as both hindering and, paradoxically, benefitting SBME debriefing. Despite using varied debriefing structures, facilitators emphasised similar key debriefing components including exploring participants' reasoning and sharing experiences to improve learning and prevent future errors. Debriefing was associated with three effects: releasing emotion; learning and improving, particularly compound learning as participants progressed through sequential scenarios; and the application of learning to clinical practice. Facilitator training and feedback were central to facilitator learning and development. Several obstacles to debriefing were identified, including mismatch of participant and facilitator agendas, pressure and time.

CONCLUSIONS

SBME debriefing in prehospital medicine is complex, requiring an understanding of participant agendas and facilitator experience to maximise participant learning. Aspects unique to prehospital SBME debriefing were identified, notably, the unpredictable debriefing environment, and the paradoxical benefit of educational obstacles for learning. Aspects of SBME debriefing not extensively detailed in the literature were also highlighted, such as compound participant learning, facilitator candour, and facilitator learning, which require further exploration.

Defining focused ethnography: Disciplinary boundary-work and the imagined divisions between 'focused' and 'traditional' ethnography in health research - A critical review

This article offers the first critical review of focused ethnography, an increasingly popular research method across health disciplines. Focused ethnographers, we argue, exemplify the practice of methodological boundary work, defining their method in contrast to the 'traditional' ethnographic approach of anthropology and sociology. To examine this boundary work, we collected two samples of health research articles published over the last decade and compared how focused ethnographers and medical anthropologists described, justified, and practised ethnography. We found that the core characteristics most often asserted to differentiate focused ethnography from conventional ethnography were: a more limited study timeframe and scope; a limited subpopulation sample; more concentrated research questions; the inclusion of insider researchers; and more orientation towards applied results. We show, however, that these are imagined binaries that fail to map onto actual differences of practice in the two samples and which obscure many similarities between them. By contrast, we identified four alternative differences between the two methods of ethnography. These centre on understandings of 'research time'; the very meaning of ethnography; the relationship of researchers to 'data'; and the presumed best method of social intervention. We therefore define focused ethnography as a versatile method of ethnography that attends to specific epistemological expectations within the health sciences regarding valid proof and empirical description, the boundaries of research, the nature of research relationships, and the duty to improve biomedicine. Ultimately, our study highlights that methodological boundary-work matters, because assumed differences and unexpressed misunderstandings can prevent productive dialogue and fruitful collaboration between disciplines to address pressing health problems.

Culture and pandemic control at cross-roads: navigating the burial guidelines for COVID-19-related deaths in a Ghanaian setting

BACKGROUND

Despite the large volume of scientific evidence on the rapid spread of the COVID-19 pandemic and associated high morbidity and mortality, little is known about the sociocultural disruptions which ensued. The current study explored the nuanced navigation of the COVID-19-related death and burial protocols and its impact on traditional burial and funeral rites in Ghana.

METHODS

This qualitative study was based on the 'focused' ethnographic design. Data were collected using key informant interviews from nineteen COVID-19-related bereaved family members and public health officials involved in enforcing adherence to COVID-19-related death and burial protocols in the Cape Coast Metropolis of Central region of Ghana. Recursive analysis was conducted to generate the themes and sub-themes from the data.

RESULTS

The overarching theme was "Uncultural" connotations ascribed to the COVID-19-related death and burial protocols. The COVID-19-related death and burial protocols were ubiquitously deemed by participants to be 'uncultural' as they inhibited deep-rooted indigenous and eschatological rites of separation between the living and the dead. This was fueled by limited awareness and knowledge about the COVID-19 burial protocols, resulting in fierce resistance by bereaved family members who demanded that public health officials release the bodies of their deceased relatives. Such resistance in the midst of resource limitation led to negotiated compromises of the COVID-19-related death and burial protocols between family members and public health officials.

CONCLUSIONS

Insensitivity to socio-cultural practices compromised the implementation of the COVID-19 pandemic control interventions, particularly, the COVID-19-related death and burial protocols. Some compromises that were not sanctioned by the protocols were reached to allow health officials and families respectfully bury their dead. These findings call for the need to prioritize the incorporation of sociocultural practices in future pandemic prevention and management strategies.

Developing a best practice framework for musculoskeletal outpatient physiotherapy delegation: the MOPeD mixed-methods research study protocol

INTRODUCTION

Physiotherapy assistants/support workers are an important part of the physiotherapy workforce in the UK. Many of them work in National Health Service (NHS) physiotherapy outpatient services treating patients with musculoskeletal (MSK) conditions. In many services, they take responsibility, under professional supervision, for types of clinical work traditionally undertaken by physiotherapists such as leading exercise classes and treating individual patients. Nevertheless, their role(s) are relatively undefined and as such, there is considerable variation in the duties and tasks they undertake. This study aims to design a framework of 'best practice' in delegation to guide the work of clinicians in NHS physiotherapy MSK services and facilitate standardisation of practice to ensure that patients receive safe and effective treatment by the most appropriate person.

METHODS AND ANALYSIS

This mixed-methods study will be conducted in four stages. In stage 1, a focused ethnography in two MSK outpatient physiotherapy services will explore how the current use of delegation is informed by the culture within the clinical setting as well as views, attitudes about, and experiences of, delegation among clinicians, managers and patients. In stage 2a, nominal group technique will be used with three separate groups (physiotherapists/physiotherapy assistants/support workers, managers) to reach a consensus about what components should be included in a best practice framework of delegation. In stage 2b, a discrete choice experiment will elicit patients' preferences between care from physiotherapists and physiotherapy assistants/support workers within MSK physiotherapy services. In the final stage, the results of all previous stages will be triangulated to inform the development of a best practice delegation framework for future testing and use within NHS MSK outpatient physiotherapy services.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the South West-Frenchay Research Ethics Committee. The findings will be disseminated in peer-reviewed journals, conference presentations, the lay press and social media.

The interactional communication of feedback in clinical education: A focused ethnographic study in a hierarchical and collectivist culture

Background

The definition of feedback in clinical education has shifted from information delivery to student-teacher dialogue. However, based on Hofstede's theory, countries with large power distance or a robust social hierarchy and collectivistic cultural dimensions can reduce the feedback dialogue to a minimum. Indonesia is classified in this group, with some Asian, African, Mediterranean, and Latin American countries. This study explores the interactional communication of feedback during clinical education in a hierarchical and collectivistic context.

Methods

The focused ethnographic approach was applied to the clinical rotation program in an Indonesian teaching hospital. Data sources included observations of feedback episodes during workplace-based assessments followed by interviews with clinical supervisors and students. The data were compiled within 16 weeks of observation in 7 groups of clinical departments, consisting of 28 field notes, audiotaped interviews including nine focus group discussions of students (N = 42), and seven in-depth interviews with clinical supervisors. Data were analyzed through transcription, coding, categorization, and thematic analysis using the symbolic interactionist perspective.

Results

We identified four themes representing actual interactional communication and its 'meaning' or interpretation. The interactional communication in feedback is described in the first and second themes, such as 1) Students play the subordinate roles in a feedback dialogue; 2) The feedback content is focused on explanation and students' limitations. The third and fourth themes represent the clinical supervisors' and students' interpretation of their feedback experience, such as 3) Clinical supervisors' perspectives are mostly on dissatisfaction and teaching authority; 4) Students' acceptance of reality and negative affection.

Conclusions

This study shows that the social gap between students and clinical supervisors in Indonesia, and other countries in the same cultural classification, potentially causes communication barriers in the feedback dialogue. The adaptation of 'feedback as a dialogue' requires further effort and research to develop communication strategies in feedback that consider the national culture and context.

The Conflict between the Beliefs of the Health Care Providers and Family Caregivers in the Use of Traditional Medicine in Pediatric Oncology: An Ethnographic Study

Introduction: Traditional medicine are popular treatments among families of children with cancer. This study was designed to identify the behaviors, beliefs, and values of families and health care providers for the use of traditional medicine in pediatric oncology. Methods: This study was conducted with a focus on ethnography approach in the oncology department of a pediatric subspecialty hospital in northeastern of Iran from September 2021 to June 2022. A total of 20 key informants were observed and interviewed formally and informally. The Miles and Huberman (1994) approach was used for data analysis. Results: Finally, two main cultural themes were emerged, including the blame of traditional herbal medicine and the synergy of rituals with modern therapies. Families use traditional medicine based on values passed down from generation to generation, while health care providers make evidence-based decisions. Conclusion: The results of the present study represent the conflict between health care providers and families in the use of medicinal herbs. The findings allow care providers to be aware of the beliefs and values of children caregivers to make the right decision about traditional medicine use.

Why health system diagnosis delay among tuberculosis patients in Illubabor, Oromia region, South West Ethiopia? A qualitative study

BACKGROUND

The main target of tuberculosis control and prevention is to detect incident cases as quickly as possible and also to prevent the occurrence of disease. It is also the responsibility of the health facility to screen the contacts, identifying children for prophylactic therapy. However, the target is difficult to meet due to issues within health facilities that cause health system diagnostic delays. Despite this, there is no information explored why health system diagnostic delays among tuberculosis patients.

METHOD

A qualitative study was conducted by using different data collection methods and sources. Seventeen DOT providers, five laboratory professionals, six program managers, and seven Tuberculosis patients were interviewed. In addition, 22 governmental health facilities were observed for the availability of resources. Data obtained from the in-depth interviews was transcribed, coded, categorized, and thematized manually.

RESULT

Health system Diagnosis delays reasons were related with sample collection procedures, poor competency of health professionals, in addition to absences or scarcity of health professionals, medical products, and basic infrastructure. We found 18 health facilities without skilled personnel in the OPD, 7 health facilities with a broken microscope, and almost all health facilities without a separate room for sputum examination. Furthermore, 12 (54.5%) and 14 (63.6%) health facilities lacked access to water and electric power, respectively.

CONCLUSION

Many reasons for TB diagnosis delays have been identified in the study area. Poor competence of health workers and scarcity of resources were identified. Depending on the finding, we suggest strengthening the health workers' training. Concrete strategies need to be designed to retain professionals. Training on human resource planning and budget preparation is needed for front-line managers. Managers have to work on the maintenance of diagnostic tools and facilitate transportation. The rural health facilities need to use another alternative power source.

Balancing closure and discovery: adaptive expertise in the workplace

Residents must develop knowledge, skills, and attitudes to handle a rapidly developing clinical environment. To address this need, adaptive expertise has been suggested as an important framework for health professions education. However, research has yet to explore the relationship between workplace learning and adaptive expertise. This study sought to investigate how clinical supervision might support the development of adaptive expertise. The present study used a focused ethnography in two emergency departments. We observed 75 supervising situations with the 27 residents resulting in 116 pages of field notes. The majority of supervision was provided by senior physicians, but also included other healthcare professionals. We found that supervision could serve two purposes: closure and discovery. Supervision aimed at discovery included practices that reflected instructional approaches said to promote adaptive expertise, such as productive struggle. Supervision aimed at closure-included practices with instructional approaches deemed important for efficient and safe patient care, such as verifying information. Our results suggest that supervision is a shared practice and responsibility. We argue that setting and aligning expectations before engaging in supervision is important. Furthermore, results demonstrated that supervision was a dynamic process, shifting between both orientations, and that supervision aimed at discovery could be an an appropriate mode of supervision, even in the most demanding clinical situations.

Experiences of nurses working in nurse-led clinics in Traditional Chinese Medicine hospitals: A focused ethnographic study

BACKGROUND

Traditional Chinese Medicine (TCM) nurse-led clinics (NLC) is an innovative working model in China, representing the specialization and extension of nurses' role. However, as a pioneer in TCM nursing, this new model of working is facing both opportunities and challenges because it is known little about the operational status of NLCs.

AIMS

To explore the experiences of nurses who work in NLC in TCM hospitals.

MATERIALS & METHODS

A focused ethnographic study was conducted in three TCM hospitals affiliated with Guangzhou University of Chinese Medicine. We interviewed eleven nurses in those hospitals and observed seven of them working with patients. We used snowball sampling for data collection including interview, non-participant observation and documents from medical records. All the data were processed as following steps: (a) coding for descriptive labels; (b) sorting for patterns; (c) identifying outliers or negative cases; (d) generalizing with construction and theories and (e) noting reflective remarks.

RESULTS

Nurse-led clinics help nurses develop their skills and knowledge that are highly recognized by public since they meet the growing needs of patients and also relieve the workload of physicians in the hospitals. However, lack of specialization is still a major challenge in NLCs due to insufficiency of full-time staff with specialized education, nurse-led practice without standardized guidelines, restrictions on prescription right of nurses, and also inadequate support from hospitals.

DISCUSSIONS

As a revolutionary innovation of working model for nurses in TCM hospitals, NLCs could improve quality of care and lead to a comprehensive promotion of nursing career. However, there are several challenges on providing high quality care for patients whilst improving educational development of nurses. This study suggests that nurses, hospital administration and the government should cooperate with each other to develop standard nursing programs for NLCs.

CONCLUSIONS

It is imperative to identify nursing roles, collect available resources, and develop supportive policies and training programs to enhance the quality of NLCs.

Getting palliative medications right across the contexts of homes, hospitals and hospices: protocol to synthesise scoping review and ethnographic methods in an activity theory analysis

INTRODUCTION

Prescribing and medication use in palliative care is a multistep process. It requires systems coordination and is enacted through activities of patients, informal carers and professionals. This study compares practice to idealised descriptions of what should happen; identifying when, how and why process disturbances impact on quality and safety. Our objectives are to:Document an intended model (phase 1, scoping review).Refine the model with study of practice (phase 2, ethnography).Use the model to pinpoint 'hot' (viewed as problematic by participants) and 'cold' spots (observed as problematic by researchers) within or when patients move across three contexts-hospice, hospital and community (home).Create learning recommendations for quality and safety targeted at underlying themes and contributing factors.

METHODS AND ANALYSIS

The review will scope Ovid Medline, CINAHL and Embase, Google Scholar and Images-no date limits, English language only. The Population (palliative), Concept (medication use), Context (home, hospice, hospital) framework defines inclusion/exclusion criteria. Data will be extracted to create a model illustrating how processes ideally occur, incorporating multiple steps of typical episodes of prescribing and medication use for symptom control. Direct observations, informal conversations around acts of prescribing and medication use, and semistructured interviews will be conducted with a purposive sample of patients, carers and professionals. Drawing on activity theory, we will synthesise analysis of both phases. The analysis will identify when, how and why activities affect patient safety and experience. Generating a rich multivoiced understanding of the process will help identify meaningful targets for improvement.

ETHICS AND DISSEMINATION

Ethical approval granted by the Camden & Kings Cross NHS Regional Ethics Committee (21/LO/0459). A patient and public involvement (PPI) coinvestigator, a multiprofessional steering group and a PPI engagement group are working with the research team. Dissemination of findings is planned through peer-reviewed publications and a stakeholder (policymakers, commissioners, clinicians, researchers, public) report/dissemination event.

Interprofessional identity: an ethnography of clinical simulation learning in New Zealand

BACKGROUND

This article explores the experiences of clinical healthcare students on an interprofessional simulation course in Auckland, New Zealand. The four-day course aims to provide a formative learning experience for final year medical, pharmacy, nursing, and paramedicine students. It focuses on building skills in professionalism, communication, leadership and interprofessional safe teamwork through structured learning activities and clinical simulation scenarios.

METHODS

In 2018, we commenced focused ethnographic research involving participant observation, field notes, interviews, photography and ethnographic film.

RESULTS

A total of 112 students participated in this research from the disciplines of medicine (n = 53), nursing (n = 27), pharmacy (n = 17), and paramedicine (n = 15). In a revisit to Van Gennep's (1972) seminal work on liminality, we suggest that the course represents a liminal space where students' ideas about what it means to be a healthcare 'professional' are challenged, disrupted and reconstructed. We observed students emerging from the course with transformed professional and interprofessional identities.

CONCLUSIONS

We posit that the ritualised and liminal nature of the course plays a role in the development of interprofessional identities by interrupting the reproduction of siloed biomedical culture. Students are challenged to become effective team members alongside other students and experts from other professions. We discuss these findings as they relate to medical and health sciences education.

Transformative learning in the setting of religious healers: A case study of consultative mental health workshops with religious healers, Ethiopia

OBJECTIVE

Psychiatric interventions that consider the socio-cultural and spiritual traditions of patients are needed to address stigma and improve access to mental health services. Productive collaboration between traditional healers and biomedical practitioners hold promise in such efforts, and applying tenets of transformative learning hold potential for mitigating an overemphasis on biomedical models in such collaboration. We present a framework for how to engage in health system reform to enhance mental health services in communities that are distrustful of, or unfamiliar with biomedical approaches. Our research question was how to bridge two seemingly opposing paradigms of mental health care, and we sought to understand how the theory of transformational learning (TLT) can be applied to learning among Religious healers and biomedical practitioners in culturally appropriate ways to improve collaboration.

METHODS

TLT informed the development, implementation, and evaluation of an educational intervention in Addis Ababa, Ethiopia that aimed to improve delivery of mental health services at two Holy water sites. The initiative involved both psychiatrists and religious healers with extensive experience providing care to mentally ill patients. Using a focused ethnographic approach that incorporates document analysis methodology, this qualitative study examined recordings and minutes of stakeholder meetings, workshops and informal interviews with participants, analyzed for evidence of Mezirow's 11 stages of transformative learning. A participatory action approach was used to encourage practice change.

RESULTS

All participants exhibited a high degree of engagement with the of the collaborative project and described experiencing "disorienting dilemmas" by Mezirow's classic description. Opportunities to reflect separately and in large groups encouraged a re-examination of attitudes previously contributing to siloed approaches to care and led to instrumental changes in mental health care delivery and a higher degree of coordination and collaboration between psychiatrists and traditional healers.

CONCLUSION

Our study demonstrates the utility of TLT in both the design and evaluation of initiatives aiming to bridge cross-cultural and cross-professional divides. The learning process was further enhanced by a collaborative participatory action model adjusted to accommodate Ethiopian socio-political and cultural relations.

Balancing the needs of individuals and services in cancer treatment for people with dementia: A focused ethnographic study

BACKGROUND

Managing multiple conditions is difficult for patients and their families, increasing complexity in care. Two of the most common long-term conditions, cancer and dementia, both disproportionately affect older adults. However, little is known about the needs and experiences of those living with both conditions, which could inform practice in the area.

OBJECTIVES

This focused ethnographic study sought to understand how oncology services balance the unique and complex needs of these patients with those of the service more widely.

DESIGN

Focused ethnography.

SETTING

Two National Health Service hospital trusts.

PARTICIPANTS

Seventeen people with dementia and cancer, 22 relatives and 19 staff members participated.

METHODS

Participant observation, informal conversations, semi-structured interviews, and medical notes review.

RESULTS

Improved satisfaction and outcomes of care were reported when staff were delivering person-centred care. Staff tried to balance the need for personalised and flexible support for individuals with dementia with managing targets and processes of cancer care and treatment. The importance of continuity of people, places, and processes was consistently highlighted.

CONCLUSION

Navigating and managing the delicate balance between the needs of the individual and the needs of services more widely was difficult for both staff and patients. Improved awareness, identification and documentation of dementia would help to ensure that staff are aware of any specific patient needs. Consistency in staffing and appointment locations should develop familiarity and routine for people with dementia.

Bronchoscopy Teaching Without a Gold Standard: Attending Pulmonologists' Assessment of Learners, Supervisory Styles, and Variation in Practice

BACKGROUND

Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching.

RESEARCH QUESTION

How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety?

STUDY DESIGN AND METHODS

This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias.

RESULTS

We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy.

INTERPRETATION

Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.

Shifting From Sectoral to Integrated Surveillance by Changing Collaborative Practices: Application to West Nile Virus Surveillance in a Small Island State of the Caribbean

After spreading in the Americas, West Nile virus was detected in Guadeloupe (French West Indies) for the first time in 2002. Ever since, several organizations have conducted research, serological surveys, and surveillance activities to detect the virus in horses, birds, mosquitoes, and humans. Organizations often carried them out independently, leading to knowledge gaps within the current virus' situation. Nearly 20 years after the first evidence of West Nile virus in the archipelago, it has not yet been isolated, its impact on human and animal populations is unknown, and its local epidemiological cycle is still poorly understood. Within the framework of a pilot project started in Guadeloupe in 2019, West Nile virus was chosen as a federative model to apply the "One Health" approach for zoonotic epidemiological surveillance and shift from a sectorial to an integrated surveillance system. Human, animal, and environmental health actors involved in both research and surveillance were considered. Semi-directed interviews and a Social Network Analysis were carried out to learn about the surveillance network structure and actors, analyze information flows, and identify communication challenges. An information system was developed to fill major gaps: users' needs and main functionalities were defined through a participatory process where actors also tested and validated the tool. Additionally, all actors shared their data, which were digitized, cataloged, and centralized, to be analyzed later. An R Shiny server was integrated into the information system, allowing an accessible and dynamic display of data showcasing all of the partners' information. Finally, a series of virtual workshops were organized among actors to discuss preliminary results and plan the next steps to improve West Nile Virus and vector-borne or emerging zoonosis surveillance. The actors are willing to build a more resilient and cooperative network in Guadeloupe with improved relevance, efficiency, and effectiveness of their work.

Patient empowerment as capabilities: The perspective of patients with epilepsy at a medical-social center in France

The aim of the study was to develop a new conceptual framework of empowerment based upon the perspective of patients with refractory epilepsy at the medical-social center of La Teppe (France). A qualitative research methodology was used, which consisted of focused ethnography and in-depth interviews. The 19 patients interviewed came from three hospital services and were in the age range of 20-60. Ten interviews were also conducted with healthcare providers, which included neurologists, psychiatrists, nurses, and social educators. Results were analyzed via an intuitive process of thematic analysis. The researcher also constructed narrative cases of the patient interview to better understand patient responses in context. The results show that patients understood empowerment as the ability to develop and take advantage of opportunities in their overall lives. This included searching to be healthy by reducing their seizures, developing their practical reason in order to be able to make more autonomous life choices, and living with and toward others in positive social relationships. The patient's perspective on empowerment encompasses but also goes beyond their medical care. We therefore propose a novel conceptual framework for empowerment as the patient's capabilities to develop and make their life choices, with help as needed from their support network. In order to help patients toward empowerment, clinical care can include discussions and dedicate resources that help patients work toward their overall life projects. Several methodologies, including the use of a personalized project and therapeutic patient education, are elaborated to give ideas for empowerment programming in epilepsy care.

Chances for learning intraprofessional collaboration between residents in hospitals

CONTEXT

Intraprofessional collaboration (intraPC) between primary care (PC) doctors and medical specialists (MSs) is becoming increasingly important. Patient safety issues are often related to intraPC. In order to equip doctors well for their task of providing good quality and continuity of care, intraPC needs explicit attention, starting in postgraduate training. Worldwide, PC residents undertake a hospital placement during their postgraduate training, where they work in proximity with MS residents. This placement offers the opportunity to learn intraPC. It is yet unknown whether and how residents learn intraPC and what barriers to and opportunities for exist in learning intraPC during hospital placements.

METHODS

We performed an ethnographic non-participatory observational study in three emergency departments and three geriatric departments of five hospitals in the Netherlands. This was followed by 42 in-depth interviews with the observed residents and supervisors. The observations were used to feed the questions for the in-depth interviews. We analysed the interviews iteratively following the data collection using template analysis.

RESULTS

Hospital wards are rich in opportunities for learning intraPC. These opportunities, however, are seldom exploited for various reasons: intraPC receives limited attention when formulating placement goals, so purposeful learning of intraPC hardly takes place; residents lack awareness of the learning of intraPC; MS residents are not accustomed to searching for expertise from PC residents; PC residents adapt to the MS role and they contribute very little of their PC knowledge, and power dynamics in the hospital department negatively influence the learning of intraPC. Therefore, improvements in mindset, professional identity and power dynamics are crucial to facilitate and promote intraPC.

CONCLUSIONS

Intraprofessional collaboration is not learned spontaneously during hospital placements. To benefit from the abundant opportunities to learn intraPC, adjustments to the set-up of these placements are necessary. Learning intraPC is promoted when there is a collaborative culture, hierarchy is limited, and there is dedicated time for intraPC and support from the supervisor.

Untangling fear and eudaimonia in the healthcare provider-patient relationship

Ensuring patient participation in healthcare decision making remains a difficult task. Factors such as a lack of time in the consultation, medical objectivation, or the difficulties of translating individual patient experience into the treatment plan have been shown to limit patient contributions. Little research attention has focused however on how emotions experienced by both the patient and the healthcare provider may affect the ability of the patient to participate. In this research, patient's and healthcare provider's emotions were identified and analysed. The research method showed fear as a prominent emotion experienced. This included patient's fears both inside and outside the consultation, as well as the healthcare provider's fears in their professional practice. Using Martha Nussbaum's cognitive-evaluative theory of emotions as an additional means of analysis, the research looked at what this emotion could show about the importance of the object of this fear to the person's eudaimonia (flourishing). At the end of the article, several solutions were proposed to help mitigate this fear to keep it from becoming a destructive force in the healthcare provider-patient relationship.

Palliative care in its own discourse: a focused ethnography of professional messaging in palliative care

Background

Despite 50 years of modern palliative care (PC), a misunderstanding of its purpose persists. The original message that PC is focused on total care, helping to live until the person dies, is being replaced and linked to feelings of fear, anxiety and death, instead of compassion, support or appropriate care. Society is still afraid to speak its name, and specialized units are identified as “places of death” as opposed to “places of life” meant to treat suffering. This issue is prohibitive to the implementation and development of PC policies worldwide. It is imperative to identify what message PC professionals are relaying to patients and other health care specialists and how that message may condition understandings of the right to access PC.

Methods

A qualitative study, employing focused ethnography and participant observation (PO) of the daily interaction of PC professionals with patients and family members in three different PC services. Two researchers independently conducted a thematic analysis, followed by member checking with participants.

Results

A total of 242 h of participant observation revealed the following messages sent by PC professionals in their daily interaction with patients and families: i) We are focused on your wellbeing; ii) You matter: we want to get to know you; iii) Your family is important to us.

Conclusion

The complexity of PC discourses contributes to the difficulty of identifying a clear universal message between PC professionals, patients and families. The PC professionals observed transmit a simple message focused on their actions rather than their identity, which may perpetuate some social/cultural misunderstandings of PC. It seems there is a common culture, based on the same values and attitudes, within the messages that PC professionals transmit to patients and their families. PC teams are characterised by their availability.

Focused ethnography as an approach in medical education research

CONTEXT

Over recent decades, the use of qualitative methodologies has increased in medical education research. These include ethnographic approaches, which have been used to explore complex cultural norms and phenomena by way of long-term engagement in the field of research. Often, however, medical education consists of short-term episodes that are not bound to single sites, but take place in a myriad of locations and contexts such as classrooms, examination stations, clinical settings and online. This calls for methodologies that allow us to grasp what is at stake in an increasingly multifaceted and diverse field.

METHODS

In this article, we direct attention to focused ethnography, which has emerged as a useful, suitable and feasible applied qualitative research approach, and which uses adapted classic ethnographic methods, such as direct observation, to gain new insights and nuanced understandings of distinct phenomena, themes and interactions in specific settings in medical education (eg the learning potential of ward rounds, or how hierarchical positions affect learning situations). We introduce methodological key features of focused ethnography to give insights into how the approach can be used, and we offer examples of how the method has been used in medical education research to show how it has contributed in different ways to the field of medical education research. Furthermore, we address and discuss some of the main challenges and limitations of the approach.

CONCLUSIONS

Focused ethnography offers a methodological approach that sheds light over limited and well-defined social episodes and interactions. Precisely because the field of medical education consists to a large degree of such fragmented interactions, focused ethnography can be seen as a methodology tailored to these characteristics and should become an integrated part of the toolkit of medical education research.

Barriers for tuberculosis case finding in Southwest Ethiopia: A qualitative study

BACKGROUND

Ethiopia is one of the countries with a high burden of tuberculosis (TB). Jimma Zone has the lowest TB case notification rate compared to the national and World Health Organization's (WHO) targets. The aim of the present study was to identify barriers, and explore the origin of these barriers in relation to TB case finding.

METHODS

A qualitative study was conducted by using different data collection methods and sources. Sixty in-depth interviews with TB treatment providers, program managers and TB patients were included. In addition, 42 governmental health facilities were observed for availability of resources. Data obtained from the in-depth interviews were transcribed, coded, categorized and thematized. Atlas.ti version 7.1 software was used for the data coding and categorizing.

RESULTS

Inadequate resources for TB case finding, such as a shortage of health-care providers, inadequate basic infrastructure, and inadequate diagnostic equipment and supplies, as well as limited access to TB diagnostic services such as an absence of nearby health facilities providing TB diagnostic services and health system delays in the diagnostic process, were identified as barriers for TB case finding. We identified the absence of trained laboratory professionals in 11, the absence of clean water supply in 13 and the electricity in seven health facilities. Furthermore, we found that difficult topography, the absence of proper roads, an inadequate collaboration with other sectors (such as education), a turnover of laboratory professionals, and a low community mobilization, as the origin of some of these barriers.

CONCLUSION

Inadequate resources for TB case finding, and a limited access to diagnostic services, were major challenges affecting TB case finding. The optimal application of the directly observed treatment short course (Stop TB) strategy is crucial to increase the current low TB case notification rate. Practical strategies need to be designed to attract and retain health professionals in the health system.