Using reflexivity to optimize teamwork in qualitative research

'I was uncertain, but I was acting on it': A longitudinal qualitative study of medical students' responses to uncertainty

PURPOSE

Uncertainty is ubiquitous within medical practice. Accordingly, how individuals respond to uncertainty, termed uncertainty tolerance (UT), is increasingly considered a medical graduate competency. Despite this, aspects of the UT construct are debated, which may relate to research focused on measuring UT, rather than understanding students' experiences. Therefore, we asked (1) how do medical students describe their responses to uncertainty, (2) how (if at all) do described responses change over time and (3) how do described responses contribute to understanding the UT construct.

METHODS

Engaging an interpretivist worldview, we conducted a longitudinal qualitative study throughout 2020 with 41 clinical medical students at an Australian medical school. Participants completed reflective diary entries across six in-semester time-points (n = 41, 40, 39, 38, 37 and 35) and semi-structured interviews at the end of both semesters (n = 20 per semester). We analysed data using framework analysis.

RESULTS

Although participants communicated accepting health care uncertainties, described cognitive appraisals of uncertainty ranged from threatening (e.g. challenging credibility) to opportunistic (e.g. for learning and growth). Emotions in response to uncertainty were predominately described in negative terms, including worry and anxiety. Participants described a range of maladaptive and adaptive behavioural responses, including avoiding versus actively engaging with uncertainty. Despite describing typically negative emotions across time, participants' cognitive and behavioural response descriptions shifted from self-doubt and avoidance, towards acceptance of, and engagement despite uncertainty.

CONCLUSIONS

Students' descriptions of responses to uncertainty suggest existing UT conceptualisations may not holistically reflect medical students' experiences of what it means to be uncertainty 'tolerant', especially pertaining to conceptualisations of 'tolerance' centred on emotions (e.g. stress) rather than how uncertainty is ultimately managed. Extending from this study, the field could consider redefining characteristics of uncertainty 'tolerance' to focus on adaptive cognitive and behavioural responses, rather than emotional responses as key indicators of 'tolerance'.

How Preceptors Support Pharmacy Learner Professional Identity Formation

OBJECTIVE

Pharmacy preceptors play a role in helping learners form professional identities during experiential education (EE). However, it is not clear what specific roles and precepting strategies best foster professional identity formation (PIF). The objective of this study was to explore how preceptors support pharmacy learner PIF.

METHODS

This qualitative study employed an interpretative descriptive approach. Preceptors from five EE programs were recruited using purposive sampling for individual semi-structured interviews. Interviews were recorded, transcribed, coded, and analyzed by thematic analysis. Team members used a reflective and iterative approach for data analysis and generation of themes.

RESULTS

A total of 22 participants were interviewed from various pharmacy practice settings and precept a range of learners including introductory pharmacy practice experiences (IPPEs), advanced pharmacy practice experiences (APPEs) and residents. Four main themes were identified to support pharmacy leaner PIF: making learners part of the practice and team; preparing learners to assume the role of a pharmacist; helping learners navigate emotions during practice experiences; and supporting learners in finding the right fit within the profession. Specific precepting strategies associated with each theme were identified.

CONCLUSION

Preceptors play an important role in supporting learners in thinking and acting as professionals, while also helping navigate emotional experiences that may impact PIF and having conversations to help define learner's future aspirations of the pharmacist they want to become. Strategies identified can inform curricular approaches and preceptor development that intentionally supports PIF.

Mapping Educational uncertainty stimuli to support health professions educators' in developing learner uncertainty tolerance

Uncertainty is a feature of healthcare practice. In recognition of this, multiple health profession governing bodies identify uncertainty tolerance as a healthcare graduate attribute and evaluate uncertainty tolerance within new graduate cohorts. While it is clear that uncertainty tolerance development for healthcare learners is valued, gaps remain for practically addressing this within healthcare curricula. Guiding frameworks for practical approaches supporting uncertainty tolerance development in healthcare learners remains sparse, particularly outside of medicine and in certain geographical locations. As uncertainty tolerance is increasingly recognised as being, at least in part, state-based (e.g. contextually changeable)- a broader understanding of teaching practices supporting uncertainty tolerance development in diverse health professions is warranted. This study explored educators' teaching practices for purposefully stimulating learners' uncertainty tolerance. Semi-structured interviews investigated how academics at a single institution, from diverse fields and health professions, stimulate uncertainty across multiple learning contexts. Framework analysis identified three themes for stimulating uncertainty: Purposeful questioning, Forecasting uncertainty, and Placing learners in unfamiliar environments, with characterisation of these themes (and related subthemes) also described. Many of the identified themes align with aspects of existing learning theories suggesting that curricular frameworks supporting learner uncertainty tolerance development may be informed by theories beyond the boundaries of health professions education research.

'Beyond the Scale': A Qualitative Exploration of the Impact of Weight Stigma Experienced by Patients With Obesity in General Practice

OBJECTIVE

Obesity is a complex, chronic, relapsing disease that requires an individualised approach to treatment. However, weight stigma (WS) experienced in healthcare settings poses a significant barrier to achieving person-centred care for obesity. Understanding the experiences of people living with obesity (PwO) can inform interventions to reduce WS and optimise patient outcomes. This study explores how patients with obesity perceive WS in general practice settings; its impact on their psychological well-being and health behaviours, and the patients suggestions for mitigating it.

METHODS

In-depth semistructured interviews were conducted with 11 PwO who had experienced WS in general practice settings in Ireland. The interviews were conducted online via Zoom between May and August 2023; interviews lasted between 31 and 63 min (M = 34.36 min). Interviews were audio-recorded, transcribed verbatim and analysed using inductive reflexive thematic analysis.

RESULTS

Three overarching themes specific to participants' experience of WS in general practice were generated: (1) shame, blame and 'failure'; (2) eat less, move more-the go-to treatment; (3) worthiness tied to compliance. A fourth theme: (4) the desire for a considered approach, outlines the participants' suggestions for reducing WS by improving the quality of patient-provider interactions in general practice.

CONCLUSION

The findings call for a paradigm shift in the management of obesity in general practice: emphasising training for GPs in weight-sensitive communication and promoting respectful, collaborative, and individualised care to reduce WS and improve outcomes for people with obesity.

PATIENT OR PUBLIC CONTRIBUTION

PPI collaborators played an active and equal role in shaping the research, contributing to the development of the research questions, refining the interview schedule, identifying key themes in the data, and granting final approval to the submitted and published version of the study.

Paramedics as Researchers: A Systematic Review of Paramedic Perspectives of Engaging in Research Activity From Training to Practice

BACKGROUND

The need for a stronger evidence-base in paramedicine has precipitated a rapid development of prehospital research agendas. Paramedics are increasingly involved in research, leading to changes in their role. Yet, the integration of research responsibilities has proven to be challenging, resulting in varying attitudes and levels of engagement.

OBJECTIVE

This systematic review aimed to explore paramedics' views and experiences of research as researchers during training and within practice.

METHODS

A systematic search was performed across six databases. Qualitative empirical peer-reviewed articles that discussed paramedic perspectives on engaging with research activity were included. Of 10,594 articles identified initially, 11 were included in the final synthesis after quality appraisal. Data were extracted and subjected to narrative synthesis.

RESULTS

The following four themes were identified: motivation to engage, moral dilemmas, structural issues within the profession, and reflections on trial involvement. Attitudes toward research, understanding of related concepts, and the drive for patient benefit were interwoven core issues.

CONCLUSIONS

Research was highly valued when links to patient benefit were obvious, however, this review highlights some cultural resistance to research, particularly regarding informed consent and changes to standard practice. Paramedic research methods training should provide structured opportunities to explore concerns and emphasize the role of research in developing a high-quality evidence base to underpin safe practice. Currently, there is inadequate organizational support for paramedics to engage effectively in research activity, with minimal allocations of time, training, and remuneration. Without properly integrating research activity into the paramedic role, their capacity to engage with research activity is limited.

Private practice model of physiotherapy: professional challenges identified through an exploratory qualitative study

Introduction Community-based primary care physiotherapy has developed through private practice, fee-for-service model in Aotearoa New Zealand where independent businesses operate in competition. Aim We aimed to explore how the private practice model of physiotherapy impacts patient care, physiotherapists, and professional behaviour. Methods Six physiotherapists managing musculoskeletal conditions in a primary care private practice in Aotearoa New Zealand were recruited using maximum variation purposive sampling. In-depth individual face-to-face semi-structured interviews were audio-recorded, transcribed verbatim, and analysed using Interpretive Description. Inductive data analysis synthesised and contextualised data, creating a thematic framework that developed across interviews. Results All physiotherapy participants discussed concerns about culture and professionalism in private practice physiotherapy despite not being asked about these. Three themes were identified. 'Competitive business model and lack of collaboration' - participants thought that competition between practices resulted in a lack of trust, collegiality, and collaboration, and pressure on clinicians to maintain income. '(Un)professional behaviour' - participants thought that physiotherapists were defensive and averse to scrutiny, resulting in reluctance to admit when they needed help, or to undertake peer review or seek second opinions. 'Lack of support and mentoring' - the professional culture in private practice was perceived to reduce support and mentoring, with negative impacts that affected physiotherapists at all stages of career. Conclusion This exploratory qualitative study suggests that competition dominates communication and collaboration in private practice physiotherapy and may have wider implications for professionalism and the quality of patient care. Competitive business models and an aversion to scrutiny may reduce collegial interaction and professional behaviour.

Implementation of a crisis resolution team service improvement programme: a qualitative study of the critical ingredients for success

BACKGROUND

Crisis Resolution Teams (CRTs) offer home-based care for people in mental health crisis, as an alternative to hospital admission. The success of CRTs in England has been variable. In response to this, the CRT Optimization and RElapse prevention (CORE) study developed and trialled a 12-month Service Improvement Programme (SIP) based on a fidelity model. This paper describes a qualitative evaluation of the perspectives of CRT staff, managers, and programme facilitators. We identify barriers and facilitators to implementation, and mechanisms by which service improvements took place.

METHODS

Managers and staff from six purposively sampled CRTs were interviewed, as well as six facilitators who were employed to support the implementation of service improvement plans. Semi-structured focus groups and individual interviews were conducted and analysed using thematic analysis.

FINDINGS

A majority of participants viewed all components of the SIP as helpful in improving practice, although online resources were under-used. Perceived barriers to implementation centred principally around lack of staff time and ownership. Support from both senior staff and facilitators was essential in enabling teams to undertake the work associated with the SIP. All participating stakeholder groups reported that using the fidelity model to benchmark their CRT work to best practice and feel part of a 'bigger whole' was valuable.

CONCLUSION

CRT staff, managers and programme facilitators thought that a structured service improvement programme helped to increase fidelity to a best practice model. Flexibility (from all stakeholders) was key to enable service improvement actions to be manageable within time- and resource-poor teams.

Making assessment a team sport: a qualitative study of facilitated group feedback in internal medicine residency

Purpose

Competency-based medical education relies on feedback from workplace-based assessment (WBA) to direct learning. Unfortunately, WBAs often lack rich narrative feedback and show bias towards Medical Expert aspects of care. Building on research examining interactive assessment approaches, the Queen's University Internal Medicine residency program introduced a facilitated, team-based assessment initiative ("Feedback Fridays") in July 2017, aimed at improving holistic assessment of resident performance on the inpatient medicine teaching units. In this study, we aim to explore how Feedback Fridays contributed to formative assessment of Internal Medicine residents within our current model of competency-based training.

Method

A total of 53 residents participated in facilitated, biweekly group assessment sessions during the 2017 and 2018 academic year. Each session was a 30-minute facilitated assessment discussion done with one inpatient team, which included medical students, residents, and their supervising attending. Feedback from the discussion was collected, summarized, and documented in narrative form in electronic WBA forms by the program's assessment officer for the residents. For research purposes, verbatim transcripts of feedback sessions were analyzed thematically.

Results

The researchers identified four major themes for feedback: communication, intra- and inter-personal awareness, leadership and teamwork, and learning opportunities. Although feedback related to a broad range of activities, it showed strong emphasis on competencies within the intrinsic CanMEDS roles. Additionally, a clear formative focus in the feedback was another important finding.

Conclusions

The introduction of facilitated team-based assessment in the Queen's Internal Medicine program filled an important gap in WBA by providing learners with detailed feedback across all CanMEDS roles and by providing constructive recommendations for identified areas for improvement.

'We all have a stake in this': a phenomenological inquiry into integrating suicide intervention in home-delivered meal service contexts

OBJECTIVES

Late-life suicide is a public health concern, yet many older adults do not have access to traditional mental health services. The present study sought to explore how suicide intervention is integrated into home-delivered meal (HDM) contexts following volunteer training in an evidence-based suicide first responder program.

METHODS

Using phenomenological inquiry, we examined the experiences of 20 HDM volunteers trained in ASIST.

RESULTS

Three primary themes emerged: (a) Logistics influencing integration of Suicide Intervention into HDM Systems, describing HDM program logistics; (b) Intrapersonal Context, describing HDM volunteer characteristics influencing intervention utilization and HDM client concerns; and (c) Interpersonal Context, describing HDM relationship characteristics that influenced intervention utilization.

CONCLUSION

HDM and other nutrition services have potential for addressing late life suicide, particularly when volunteers best equipped to address risk receive training and HDM policies reflect the needs of their clients. Implications for HDM services, as well as the Aging Services Network, are discussed.

A qualitative exploration of the lived experience of mothers caring for a child with narcolepsy

STUDY OBJECTIVES

Parents/carers of a child with narcolepsy are often required to become experts in narcolepsy and navigate health care, education, and welfare systems on behalf of their child. Managing pediatric narcolepsy is complex and challenges the child and the entire family, yet few studies have explored carers' experiences.

METHODS

Twenty mothers (50% had a child with narcolepsy < 18 years at the time of interview; 85% narcolepsy with cataplexy) participated in a 1:1 semistructured interview. Participation from fathers was sought; however, none were recruited. A multidisciplinary team of researchers/clinicians analyzed interview transcripts using thematic analysis.

RESULTS

Mothers perceived that most people misunderstood the whole-person impact of narcolepsy, including their child's peers, teachers, and support networks. Narcolepsy had a substantial psychological impact on both the child and the whole family yet was largely unaddressed by health care professionals, leaving mothers unsure of where to turn for help. Most parents described negative experiences with their child's specialist, often perceiving the specialists to lack knowledge specific to narcolepsy. Information about illness trajectory and support services was limited or inaccessible, fueling many mothers' hopes and fears for their child's future. Mothers also frequently described feelings of abandonment by the health care system.

CONCLUSIONS

Our results contextualize the whole-person impact of narcolepsy from the perspective of parents and carers, highlighting the need for proactive inclusion of parents/carers in developing health care policy and practice. It calls for developing tools and resources to capture "well-managed" narcolepsy from the perspective of parents/carers for use in research and clinical practice.

CITATION

Schokman A, Cheung J, Klinner C, et al. A qualitative exploration of the lived experience of mothers caring for a child with narcolepsy. J Clin Sleep Med. 2024;20(5):699-707.

"I'm still in the lap of the gods… I don't know whether I'm going to improve or not": listening to people with dementia or cognitive impairment and their support people, talking about inpatient rehabilitation experiences

PURPOSE

People with dementia often experience poor outcomes in hospital and prolonged lengths of stay. They are sometimes labelled as having "poor rehabilitation potential". This study aimed to understand the inpatient rehabilitation experiences of people with dementia or cognitive impairment, and their support people, to inform future work to improve rehabilitation access and outcomes.

MATERIALS AND METHODS

An exploratory qualitative study from an interpretivist perspective. Participants were inpatients of a geriatric rehabilitation unit in Australia, and their chosen support people. Semi-structured interviews were audio-recorded and transcribed. An analytical framework was developed and indexed to the dataset, followed by charting and thematic analysis.

RESULTS

Ten people with dementia or cognitive impairment and nine support people participated (n = 19). Four themes were identified representing an interpretation of the analysis intended to inform clinical practice: Support patients to engage in the rehabilitation process; create a hospitable environment; recognise and work with care partners; and ensure staff have adequate dementia knowledge.

CONCLUSIONS

Practical, emotional, process-related, and dementia-specific factors may influence the experiences of people living with dementia or cognitive impairment when participating in inpatient rehabilitation. Future research could investigate whether improvements focused on these factors might enhance quality of care for people with dementia.

Exploring Data Collection Priorities of Community Partners in Early Psychosis Care

OBJECTIVE

Learning health care networks can significantly improve the effectiveness, consistency, and cost-effectiveness of care delivery. As part of a data harmonization process, incorporation of the perspectives of community partners to maximize the relevance and utility of the data is critical.

METHODS

A mixed-methods focus group study was conducted with early psychosis program providers, leadership, service users, and family members to explore their priorities regarding data collection in early psychosis care. Focus group transcripts were analyzed through thematic analysis.

RESULTS

Twenty-two focus groups comprising 178 participants were conducted across 10 early psychosis programs. Participants considered functioning, quality of life, recovery, and symptoms of psychosis as key outcomes to assess, although variation by participants' roles was also evident. Participants emphasized the clinical utility of assessing a broad range of predictors of care outcomes, favored a broad conceptualization of the constructs assessed, and indicated a preference for client-reported measures. Participants also emphasized the importance of surveys adopting a recovery-oriented, strengths-based approach.

CONCLUSIONS

Large-scale aggregation of health care data collected as part of routine care offers opportunities for research and may have a positive impact on care delivery and quality improvement activities. However, these benefits are contingent on the data being both relevant and accessible to those who deliver and receive such care. This study highlights an approach that may inform the development of core assessment batteries used, optimizing the utility of such data for all community partners.

The importance of creating the right conditions for group intervision sessions among medical residents- a qualitative study

BACKGROUND

The burnout rates among residents urge for adequate interventions to improve resilience and prevent burnout. Peer reflection, also called group intervision sessions, is a potentially successful intervention to increase the resilience of young doctors. We aimed to gain insight into the perceived added value of intervision sessions and the prerequisite conditions to achieve this, according to residents and intervisors. Our insights might be of help to those who think of implementing intervision sessions in their institution.

METHODS

An explorative, qualitative study was performed using focus groups and semi-structured interviews with both residents (n = 8) and intervisors (n = 6) who participated in intervision sessions in a university medical center in the Netherlands. The topic list included the perceived added value of intervision sessions and factors contributing to that. The interviews were transcribed verbatim and coded using NVivo. Thematic analysis was subsequently performed.

RESULTS

According to residents and intervisors, intervision sessions contributed to personal and professional identity development; improving collegiality; and preventing burn-out. Whether these added values were experienced, depended on: (1) choices made during preparation (intervisor choice, organizational prerequisites, group composition, workload); (2) conditions of the intervision sessions (safety, depth, role of intervisor, group dynamics, pre-existent development); and (3) the hospital climate.

CONCLUSIONS

Intervision sessions are perceived to be of added value to the identity development of medical residents and to prevent becoming burned out. This article gives insight in conditions necessary to reach the added value of intervision sessions. Optimizing preparation, meeting prerequisite conditions, and establishing a stimulating hospital climate are regarded as key to achieve this.

Exploring perspectives of personal learning plans in a residency programme

BACKGROUND

Personal learning plans (PLPs) have gained traction in postgraduate medical education as an avenue for enhancing resident learning. However, implementing PLPs in real-world education settings presents unique challenges. To realise the potential of PLPs, we must understand the factors that influence the quality of PLP implementation. The purpose of this study was to explore the use and implementation of PLPs during residency training from the residents' and academic advisors' perspectives within a competency-based residency programme.

METHODS

We conducted semi-structured interviews with residents (n = 18) and academic advisors (n = 9) in an Internal Medicine residency programme at a Canadian academic centre. Interviews were audio recorded, transcribed verbatim and analysed using open coding.

FINDINGS

Three higher order themes were developed to represent the participants' perceptions of implementing PLPs in a competency-based residency programme: (a) setting the stage for learning, (b) fostering meaningful engagement and (c) learning through reflection. Results indicated that implementing PLPs requires collaboration between residents and academic advisors and supports from the broader programme and institution. PLP implementation is an iterative process that can provide a salient avenue for reflection and the development of self-regulation skills.

DISCUSSION AND CONCLUSION

PLPs can be a useful tool to foster self-regulated learning skills in residency education. It is imperative to consider how social and environmental supports can be enacted to facilitate engagement with, and implementation of, PLPs.

Making sense of narcolepsy: A qualitative exploration of how persons with narcolepsy perceive symptoms and their illness experience

INTRODUCTION

Understanding how persons with narcolepsy conceptualize symptoms, daily impact and illness experience is key to facilitating dialogue between patients and healthcare professionals. These concepts are usually explored from the perspective of healthcare professionals/researchers and rarely from the perspective of those with narcolepsy.

METHODS

127 self-reported persons with narcolepsy were recruited from an Australian patient support group. A short demographic survey was completed. All agreed to participate in a subsequent 1:1 semi-structured interview. Saturation was reached after 24 interviews (mean age = 33 years (SD 11) with 44% reporting cataplexy). A multidisciplinary team of researchers/clinicians analyzed interview transcripts using thematic analysis.

RESULTS

Participants perceived physical fatigue, sleepiness, and two separate experiences of 'falling asleep/sleep attacks' as distinct symptoms rather than a multidimensional construct (i.e. excessive daytime sleepiness). We also identified two experiences of cataplexy, one triggered by acute emotion and another by a stressor. Participants determined their narcolepsy to be 'well-managed' by the level of functional impairment rather than the frequency of any symptom. Almost all participants described experiencing anticipated stigma and internalized or 'self-' stigma, likely stemming from societal devaluation of sleep and the conflation of sleepiness with laziness.

CONCLUSION

Descriptions of common symptoms often differed between participants and the existing literature. These differences likely impact patient-physician communication, with both parties utilizing the same terminology to communicate different concepts. The characterization of stigma in narcolepsy presents opportunities for future research exploring the impact and possible development of interventions to reduce the substantial psychological comorbidity in persons with narcolepsy.

Toward identification and intervention to address financial toxicity and unmet health-related social needs among adolescents and emerging adults with cancer and their caregivers: A cross-cultural perspective

PURPOSE

We qualitatively explored the unique needs and preferences for financial toxicity screening and interventions to address financial toxicity among adolescents and emerging adults (younger AYAs: 15-25 years) with cancer and their caregivers.

METHODS

We recruited English- or Spanish-speaking younger AYAs who were treated for cancer within the past 2 years and their caregivers. Semi-structured interviews were conducted to explore preferences for screening and interventional study development to address financial toxicity. The data were coded using conventional content analysis. Codes were reviewed with the study team, and interviews continued until saturation was reached; codes were consolidated into categories and themes during consensus discussions.

RESULTS

We interviewed 17 participants; nine were younger AYAs. Seven of the 17 preferred to speak Spanish. We identified three cross-cutting themes: burden, support, and routine, consistent, and clear. The burden came in the form of unexpected costs such as transportation to appointments, as well as emotional burdens such as AYAs worrying about how much their family sacrificed for their care or caregivers worrying about the AYA's physical and financial future. Support, in the form of familial, community, healthcare institution, and insurance, was critical to mitigating the effects of financial toxicity in this population. Participants emphasized the importance of meeting individual financial needs by routinely and consistently asking about financial factors and providing clear guidance to navigate these needs.

CONCLUSION

Younger AYAs and their caregivers experience significant financial challenges and unmet health-related social needs during cancer treatment and often rely on key supports to alleviate these unmet needs. When developing interventions to mitigate financial toxicity, clinicians and health systems should prioritize clear, consistent, and tailorable approaches to support younger AYA cancer survivors and their families.

The implementation of a perioperative medicine for older people undergoing surgery service: a qualitative case study

BACKGROUND

The international scale and spread of evidence-based perioperative medicine for older people undergoing surgery (POPS) services has not yet been fully realised. Implementation science provides a structured approach to understanding factors that act as barriers and facilitators to the implementation of POPS services. In this study, we aimed to identify factors that influence the implementation of POPS services in the UK.

METHODS

A qualitative case study at three UK health services was undertaken. The health services differed across contextual factors (population, workforce, size) and stages of POPS service implementation maturity. Semi-structured interviews with purposively sampled clinicians (perioperative medical, nursing, allied health, and pharmacy) and managers (n = 56) were conducted. Data were inductively coded, then thematically analysed using the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Fourteen factors across all five CFIR domains were relevant to the implementation of POPS services. Key shared facilitators included stakeholders understanding the rationale of the POPS service, with support from their networks, POPS champions, and POPS clinical leads. We found substantial variation and flexibility in the way that health services responded to these shared facilitators and this was relevant to the implementation of POPS services.

CONCLUSIONS

Health services planning to implement a POPS service should use health service-specific strategies to respond flexibly to local factors that are acting as barriers or facilitators to implementation. To support implementation of a POPS service, we recommend health services prioritise understanding local networks, identifying POPS champions, and ensuring that stakeholders understand the rationale for the POPS service. Our study also provides a structure for future research to understand the factors associated with 'unsuccessful' implementation of a POPS service, which can inform ongoing efforts to implement evidence-based perioperative models of care for older people.

The die-hards, negotiators and migrants: Portraits of doctors' career pathways through specialisation

INTRODUCTION

Global workforce shortages in medical specialties strain healthcare systems, jeopardising patient outcomes. Enhancing recruitment strategies by supporting professional identity (PI) development may be one way to address this workforce gap-yet little research has explored this topic. The goal of the current study was to explore specialty-specific recruitment through considering PI. As proposed causes of workforce shortages in anatomical pathology (AP) bear similarities to many other specialties, this study uses the field of AP as a model for specialist PI development and asks: (1) why, how and when do doctors choose to pursue AP training and (2) what can be learned from this for recruitment to AP and other specialties?

METHODS

A qualitative research approach was undertaken using narrative inquiry. Interviews with junior doctors interested in AP, AP registrars and AP consultants from Australia and New Zealand were interpreted as stories via 're-storying'. Narrative synthesis of participants' collective stories identified chronological key events (i.e. 'turning points') in choosing AP.

RESULTS

Narrative synthesis resulted in identification of three portraits entering medical specialist training: (1) die-hards, deciding upon initial exposure; (2) negotiators, choosing after comparing specialties; and (3) migrants, seeking to move away from non-pathology specialties. The negotiators and migrants cemented their decision to pursue AP as a postgraduate doctor, whereas the die-hards made this decision during medical school.

CONCLUSIONS

Given the similarities in portrait traits between AP and other specialties across the literature, our results suggest ways to support specialty recruitment using PI development. We propose a medical specialist recruitment framework to support the PI development of doctors with die-hard, negotiator and migrant traits. Use of this framework could enhance current specialty-specific recruitment approaches, particularly in fields challenged by workforce shortages.

Developing a national undergraduate medical education pain management and substance use disorder curriculum to address the opioid crisis: a program evaluation pilot study

BACKGROUND

Pain and addiction are one of the most common reasons for adults to seek health care, yet educational programs focused on pain are often underrepresented in medical school curricula. In January 2021, the Association of Faculties of Medicine of Canada (AFMC) launched an online national, bilingual, competency-based curriculum for undergraduate medical (UGME) students in pain management and substance use in response to the opioid crisis and to bridge the content gaps in programs across Canada. The purpose of this study is to evaluate the pilot of this national curriculum.

METHODS

UGME students, from across Canada, participated in the program evaluation by completing online pre- and post-program surveys that assessed the influence of the curriculum on participants' knowledge as well as the value, usability, and feasibility of this curriculum.

RESULTS

Participants' perceived confidence in their new knowledge and in utilizing resources required to maintain their knowledge significantly increased (75% and 51% respectively). Their perceived knowledge that addressed the 72 learning objectives within the curriculum significantly increased from pre- to post-program. Over 90% of participants reported that the curriculum was valuable, feasible, and usable. The most frequently discussed program strengths were the clear and comprehensive content, interactive and well-organized design, and relevance of curriculum content for future clinical practice. The overall weakness of the curriculum included the length, repetition of content, the lack of clarity and relevance of the assessment questions, end-user technology issues, and French translation discrepancies. Participant's recommendations for improving the curriculum included streamlining content, addressing technology issues, and enhancing the clarity and relevance of assessment questions embedded within each of the modules.

CONCLUSION

Participants agreed that an online pain management and substance use curriculum is a valuable, usable, and feasible learning opportunity. Given the severity of the opioid crisis in Canada, these online modules provide a curriculum that can be integrated into existing UGME programs or can provide self-directed learning.

Responding to the healthcare workforce shortage: A scoping review exploring anatomical pathologists' professional identities over time

Anatomical pathology (AP) is an anatomy-centric medical specialty devoted to tissue-based diagnosis of disease. The field faces a current and predicted workforce shortage, likely increasing diagnostic wait times and delaying patient access to urgent treatment. A lack of AP exposure is proposed to preclude recruitment to the field, as medical students are afforded only a limited understanding of who a pathologist is and what they do (their professional identity/PI and role). Anatomical sciences educators may be well placed to increase student understanding of anatomical pathologists' PI features, but until features of anatomical pathologists' PI are understood, recommendations for anatomy educators are premature. Thus, this scoping review asked: "What are the professional identity features of anatomical pathologists reported in the literature, and how have these changed over time?" A six-stage scoping review was performed. Medline and PubMed, Global Health, and Embase were used to identify relevant studies (n = 74). Team-based framework analysis identified that features of anatomical pathologists' professional identity encompass five overarching themes: professional practice, views about the role, training and education, personal implications, and technology. Technology was identified as an important theme of anatomical pathologists' PI, as it intersected with many other PI feature themes, including diagnosis and collaboration. This review found that pathologists may sometimes perceive professional competition with technology, such as artificial intelligence. These findings suggest unique opportunities for integrating AP-specific PI features into anatomy teaching, which may foster student interest in AP, and potentially increase recruitment into the field.

Stereotype Threat and Gender Bias in Internal Medicine Residency: It is Still Hard to be in Charge

BACKGROUND

Despite similar numbers of women and men in internal medicine (IM) residency, women face unique challenges. Stereotype threat is hypothesized to contribute to underrepresentation of women in academic leadership, and exploring how it manifests in residency may provide insight into forces that perpetuate gender disparities.

OBJECTIVE

To quantify the prevalence of stereotype threat in IM residency and explore experiences contributing to that stereotype threat.

DESIGN

We used a mixed methods study design. First, we surveyed IM residents using the Stereotype Vulnerability Scale (SVS) to screen for stereotype threat. Second, we conducted focus groups with women who scored high on the SVS to understand experiences that led to stereotype threat.

PARTICIPANTS

The survey was sent to all IM residents at University of California, San Francisco (UCSF), in September-November 2019. Focus groups were conducted at UCSF in Spring 2020.

APPROACH

The survey included an adapted version of the SVS. For focus groups, we developed a focus group guide informed by literature on stereotype threat. We used a thematic approach to data analysis. The mixed methods design enabled us to draw metainferences by integrating the two data sources.

KEY RESULTS

Survey response rate was 61% (110/181). Women were significantly more likely than men to have a score indicating stereotype threat vulnerability (77% vs 0%, p < 0.001). Four themes from focus groups characterized women's experiences of gender bias and stereotype threat: gender norm tension, microaggressions and sexual harassment, authority questioned, and support and allyship.

CONCLUSIONS

Gender-based stereotype threat is highly prevalent among women IM residents. This phenomenon poses a threat to confidence and ability to execute patient care responsibilities, detracting from well-being and professional development. These findings indicate that, despite robust representation of women in IM training, further attention is needed to address gendered experiences and contributors to women's vulnerability to stereotype threat.

'No one else understands', 'I wouldn't want to pity myself over something that's not really my problem': siblings' experiences of their adolescent brothers and sisters' inpatient treatment for mental health difficulties

BACKGROUND

Family life is disrupted when a child experiences mental health difficulties. This can have long-standing effects on sibling relationships. This study explores the lived experiences of young people who have an adolescent sibling hospitalised for treatment of a mental health difficulty.

METHOD

Semi-structured interviews of 45-60 min were conducted to explore the experiences of 10 siblings (6 sisters/4 brothers aged 13-22) of nine patients (5 sisters/4 brothers aged 15-17) receiving treatment for a mental health difficulty in a child and adolescent inpatient unit (IPU). Interpretative phenomenological analysis was used to analyse the data.

RESULTS

Two superordinate themes were identified: 'Who am I if I'm not supporting them?' and 'On the fringes: actively involved but from the outside'. The interplay of these two super-ordinate themes was found to influence the five sub-ordinate themes: 'Confusion and disbelief', 'Don't worry about me, focus on them.', 'Powerless when I need to be powerful.', 'Helping or hindering- what is this place??' and 'Knowledge is power.'

CONCLUSION

Siblings described experiencing conflicting and confusing emotions which may impact their attendance in IPU and engagement in siblings' treatment. Siblings of adolescents in inpatient treatment for mental health difficulties may be at increased risk of experiencing psychological distress. The mental well-being of siblings must be borne in mind by child and adolescent inpatient services supporting families in crisis.

Striking fear into students' hearts: Unforeseen consequences of prescribing education

PURPOSE

Undergraduate medical education (UGME) has to prepare students to do safety-critical work (notably, to prescribe) immediately after qualifying. Despite hospitals depending on them, medical graduates consistently report feeling unprepared to prescribe and they sometimes harm patients. Research clarifying how to prepare students better could improve healthcare safety. Our aim was to explore how students experienced preparing for one of their commonest prescribing tasks: intravenous fluid therapy (IVFT).

METHODS

Complexity assumptions guided the research, which used a qualitative methodology oriented towards hermeneutic phenomenology. The study design was an uncontrolled and unplanned complex intervention: judicial review of the iatrogenic death of five children due to hyponatraemia in our region had resulted in the recommendation that students' education in 'the implementation of important clinical guidelines' relevant to fluid and electrolyte balance should be intensified. An opportunity sample of 40 final-year medical students drew and gave audio-recorded commentaries on rich pictures. We completed two template analyses: one of participants' transcribed commentaries on the pictures and one using a novel heuristic to analyse the pictures themselves. We then reconciled the two analyses into a single template.

RESULTS

There were four themes: affects, teaching and learning, contradictions, and the curriculum as a journey. To explore interconnections between themes, we chose the picture best exemplifying each of the four themes and interpreted the curriculum journey depicted in each of them. These interpretations were grounded in each participant's picture, verbal account of the picture, and the aggregate findings of the template analysis. Participants' experiences were influenced by the situated complexity of IVFT. Layered on top of that, contradictions, overlaps, and gaps within the curriculum introduced extraneous complexity. Confusion and apprehension resulted.

CONCLUSIONS

After spending five years preparing to prescribe IVFT, participants felt unprepared to do so. We conclude that intensive teaching had not achieved its avowed goal of improving students' preparedness for safe practice. Merton's seminal work on the 'unanticipated consequences of purposive social action' suggests that intensive teaching may even have contributed to their unpreparedness.

Constraints and affordances for UK doctors-in-training to exercise agency: A dialogical analysis

INTRODUCTION

The goal of medical education is to develop clinicians who have sufficient agency (capacity to act) to practise effectively in clinical workplaces and to learn from work throughout their careers. Little research has focused on experiences of organisational structures and the role of these in constraining or affording agency. The aim of this study was to identify priorities for organisational change, by identifying and analysing key moments of agency described by doctors-in-training.

METHODS

This was a secondary qualitative analysis of data from a large national mixed methods research programme, which examined the work and wellbeing of UK doctors-in-training. Using a dialogical approach, we identified 56 key moments of agency within the transcripts of 22 semi-structured interviews with doctors based across the UK in their first year after graduation. By analysing action within the key moments from a sociocultural theoretical perspective, we identified tangible changes that healthcare organisations can make to afford agency.

RESULTS

When talking about team working, participants gave specific descriptions of agency (or lack thereof) and used adversarial metaphors, but when talking about the wider healthcare system, their dialogue was disengaged and they appeared resigned to having no agency to shape the agenda. Organisational changes that could afford greater agency to doctors-in-training were improving induction, smoothing peaks and troughs of responsibility and providing a means of timely feedback on patient care.

CONCLUSIONS

Our findings identified some organisational changes needed for doctors-in-training to practise effectively and learn from work. The findings also highlight a need to improve workplace-based team dynamics and empower trainees to influence policy. By targeting change, healthcare organisations can better support doctors-in-training, which will ultimately benefit patients.

Family carers' experiences and perceived roles in interprofessional collaborative practice in primary care: A constructivist grounded theory study

BACKGROUND

Chronic conditions can lead to physical, cognitive and social decline; thus, increasing an individual's dependence on family who assist with activities of daily living. Interprofessional collaborative practice (IPCP), involving two or more health professionals working with the patient and their family, is one model of care for the high-quality management of individuals with chronic conditions in primary care. Nevertheless, family carers have reported a disconnect between themselves and healthcare providers in previous research. This study aimed to explore the experiences and perspectives of family carers for individuals with chronic conditions, regarding their involvement in IPCP.

METHODS

Aspects of constructivist grounded theory methodology were used. Family carers of individuals with chronic conditions were invited to participate in a one-on-one, semistructured interview about their experiences with IPCP in the care of their loved one. Interview transcripts were analysed using Charmaz's four-step iterative process: (1) line-by-line coding, (2) focused coding, (3) categorisation of codes and (4) potential theme and subtheme development with memo writing to support each phase of analysis. The research team collaborated on reflexivity exercises, the conceptualisation of categories and the development of themes.

RESULTS

Constructivist data analysis of interviews (average 40 min) with 10 family carers resulted in two themes. (1) Stepping in for my loved one represents the notion that carers take on external roles on behalf of their loved ones (subthemes: working with interprofessional teams, supporting independence and learning as I go). (2) Taking on the carer role, represents the internal factors that influence the external roles described in theme 1 (subthemes: feeling obligated to be involved and changing relationship dynamics).

CONCLUSION

This study outlines the external actions and internal influences on family carer involvement in an interprofessional team. The required knowledge and support to care for their loved ones is currently learned in an ad hoc manner, and carers' resources should be better promoted by health professionals. Additionally, the relationship dynamics between a carer and their loved one change as the carer becomes more involved in IPCP and influences how and the extent health professionals involve family carers.

PATIENT OR PUBLIC CONTRIBUTION

Carers were the study population involved in this qualitative study. Patient advocates who have chronic conditions, and are informal family carers, were involved in the creation and design of this study, including a review of the research question, participant information sheet and the interview guide.

Barriers to community healthcare delivery in urban China: a nurse perspective

PURPOSE

There is considerable research on China's community healthcare, but little examining its delivery from a nurse perspective. This article, set in the context of Shenzhen, elicits community nurses' views on barriers to healthcare delivery, providing an initial evidence framework to improve community nursing practice at organizational and policy levels.

METHODS

We used qualitative methods. Data from semi-structured interviews with 42 community nurses in Shenzhen underwent inductive content analysis. Consolidated criteria for reporting qualitative research were consulted to structure our reporting.

RESULTS

Our analysis suggests four elements discouraging community nurses in care delivery: lack of equipment, stressful work environments, staff incompetence, and patient distrust. Centralized means of procurement, management indifference to nurses' well-being, unsystematic training and reluctance to enter the community healthcare sector, and public prejudices against nursing contributed to these constraints, preventing community nurses from performing patient-centred care, devoting energy to caring, freeing themselves from heavy workloads, and building trust-based care relationships.

CONCLUSIONS

Delivery barriers devalued community health services systematically and undermined nurses' professional advancement and psychological well-being. Targeted management and policy inputs are necessary to reduce caring barriers and enhance the ability of community nursing to safeguard population health.

Is thematic analysis used well in health psychology? A critical review of published research, with recommendations for quality practice and reporting

Despite the persistent dominance of a 'scientific psychology' paradigm in health psychology, the use of qualitative research continues to grow. Qualitative approaches are often based on fundamentally different values from (post)positivistempiricism, raising important considerations for quality, and whether qualitative work adheres to, and is judged by, appropriate publication standards. Thematic analysis (TA) has become a particularly popular method in qualitative health psychology, but poor practice is widespread. To support high quality, methodologically coherent TA practice and reporting, we critically reviewed 100 systematically selected papers reporting TA, published in five prominent health psychology journals. Our review assessed reported practice, and considered this in relation to methodological and quality recommendations. We identified 10 common areas of problematic practice in the reviewed papers, the majority citing reflexive TA. Considering the role of three 'arbiters of quality' in a peer review publication system - authors, reviewers, and editors - we developed 20 recommendations for authors, to support them in conducting and reporting high quality TA research, with associated questions for reviewers and editors to consider when evaluating TA manuscripts for publication. We end with considerations for facilitating better qualitative research, and enriching the understandings and knowledge base from which health psychology is practiced.

From Eggshells to Action: A Qualitative Study of Faculty Experience Responding to Microaggressions Targeting Medical Students

PURPOSE

Microaggressions targeting clinical learners cause harm and threaten learning. Clinical supervisors can be powerful allies by intervening when microaggressions occur. This study explored general and student-nominated skilled supervisors' perspectives on responding to microaggressions targeting clinical learners.

METHOD

This single-institution, qualitative study within a constructivist paradigm explored faculty supervisor experiences with bystander response to microaggressions targeting learners. Clinical supervisors in medicine and surgery departments and those across departments nominated by students as skilled microaggression responders were invited to discuss microaggression scenarios targeting students in semistructured focus groups in the U.S. in 2020-2021. Investigators applied the framework method of thematic analysis to identify themes.

RESULTS

Forty-two faculty (31 medicine and surgery ["general"], 11 "student-nominated" as skilled responders) joined 10 focus groups (6 "general," 3 "student-nominated," 1 mixed). Four themes characterized experiences responding to microaggressions targeting learners: bystander goals, noticing, acting, and continuous learning. Participants' response goals were protecting learners, safeguarding learning, and teaching microaggression response skills. Noticing was influenced by past experiences with microaggressions and acculturation to clinical environments. Bystander action stemmed from (1) microaggression type, (2) personal emotional vulnerability, (3) knowledge of student preferences for supervisor response, and (4) clinical and educational context. Bystander action was more common when participants regarded all microaggressions as harmful, understood student preferences for faculty response, expected to err (growth mindset), and framed microaggressions as opportunities for humble reflection, intellectual candor, and teaching. Microaggression response required continuous learning through informal and formal skills development.

CONCLUSIONS

Complex factors govern faculty bystander response to microaggressions targeting clinical learners. Efforts to strengthen faculty bystander response should incorporate skill-building around preemptive discussions with learners and using intellectual candor to promote psychological safety, learning, and bystander action. Additional investigation is needed on how to incorporate these skills into team workflows and to assess outcomes of specific response strategies.

Reluctant heroes: New doctors negotiating their identities dialogically on social media

BACKGROUND

Ensuring that students transition smoothly into the identity of a doctor is a perpetual challenge for medical curricula. Developing professional identity, according to cultural-historical activity theory, requires negotiation of dialectic tensions between individual agency and the structuring influence of institutions. We posed the research question: How do medical interns, other clinicians and institutions dialogically construct their interacting identities?

METHODS

Our qualitative methodology was rooted in dialogism, Bakhtin's cultural-historical theory that accounts for how language mediates learning and identity. Reasoning that the COVID pandemic would accentuate and expose pre-existing tensions, we monitored feeds into the Twitter microblogging platform during medical students' accelerated entry to practice; identified relevant posts from graduating students, other clinicians and institutional representatives; and kept an audit trail of chains of dialogue. Sullivan's dialogic methodology and Gee's heuristics guided a reflexive, linguistic analysis.

RESULTS

There was a gradient of power and affect. Institutional representatives used metaphors of heroism to celebrate 'their graduates', implicitly according a heroic identity to themselves as well. Interns, meanwhile, identified themselves as incapable, vulnerable and fearful because the institutions from which they had graduated had not taught them to practise. Senior doctors' posts were ambivalent: Some identified with institutions, maintaining hierarchical distance between themselves and interns; others, along with residents, acknowledged interns' distress, expressing empathy, support and encouragement, which constructed an identity of collegial solidarity.

CONCLUSIONS

The dialogue exposed hierarchical distance between institutions and the graduates they educated, which constructed mutually contradictory identities. Powerful institutions strengthened their identities by projecting positive affects onto interns who, by contrast, had fragile identities and sometimes strongly negative affects. We speculate that this polarisation may be contributing to the poor morale of doctors in training and propose that, to maintain the vitality of medical education, institutions should seek to reconcile their projected identities with the lived identities of graduates.

The Experience of Loneliness Among Gay Men in Israel: A Qualitative Study

The aim of this qualitative study is to explore the experience of loneliness among Israeli gay men in their early and mid-adulthood, ages 30-50 (N = 14). The findings demonstrate three main categories of loneliness that study participants experienced: childhood loneliness as an initial experience of gay identity; loneliness in the context of other gay men, via sexual encounters, friendships, and the use of dating apps; and loneliness in the context of heterosexual society. The findings point to the centrality of the experience of loneliness among Israeli gay men in their mid-adulthood years and emphasize how this loneliness is rooted in socio-cultural and political perceptions concerning hetero-normative as well as gay identities.

Using contribution analysis to evaluate health professions and health sciences programs

Introduction/background

Course evaluation in health education is a common practice yet few comprehensive evaluations of health education exist that measure the impact and outcomes these programs have on developing health graduate capabilities.

Aim/objectives

To explore how curricula contribute to health graduate capabilities and what factors contribute to the development of these capabilities.

Methods

Using contribution analysis evaluation, a six-step iterative process, key stakeholders in the six selected courses were engaged in an iterative theory-driven evaluation. The researchers collectively developed a postulated theory-of-change. Then evidence from existing relevant documents were extracted using documentary analysis. Collated findings were presented to academic staff, industry representatives and graduates, where additional data was sought through focus group discussions - one for each discipline. The focus group data were used to validate the theory-of-change. Data analysis was conducted iteratively, refining the theory of change from one course to the next.

Results

The complexity in teaching and learning, contributed by human, organizational and curriculum factors was highlighted. Advances in knowledge, skills, attitudes and graduate capabilities are non-linear and integrated into curriculum. Work integrated learning significantly contributes to knowledge consolidation and forming professional identities for health professional courses. Workplace culture and educators' passion impact on the quality of teaching and learning yet are rarely considered as evidence of impact.

Discussion

Capturing the episodic and contextual learning moments is important to describe success and for reflection for improvement. Evidence of impact of elements of courses on future graduate capabilities was limited with the focus of evaluation data on satisfaction.

Conclusion

Contribution analysis has been a useful evaluation method to explore the complexity of the factors in learning and teaching that influence graduate capabilities in health-related courses.

"It's All About the Trust And Building A Foundation:" Evaluation of a Longitudinal Medical Student Coaching Program

Coaching is increasingly implemented in medical education to support learners' growth, learning, and wellbeing. Data demonstrating the impact of longitudinal coaching programs are needed.

We developed and evaluated a comprehensive longitudinal medical student coaching program designed to achieve three aims for students: fostering personal and professional development, advancing physician skills with a growth mindset, and promoting student wellbeing and belonging within an inclusive learning community. We also sought to advance coaches' development as faculty through satisfying education roles with structured training. Students meet with coaches weekly for the first 17 months of medical school for patient care and health systems skills learning, and at least twice yearly throughout the remainder of medical school for individual progress and planning meetings and small-group discussions about professional identity. Using the developmental evaluation framework, we iteratively evaluated the program over the first five years of implementation with multiple quantitative and qualitative measures of students' and coaches' experiences related to the three aims.

The University of California, San Francisco, School of Medicine, developed a longitudinal coaching program in 2016 for medical students alongside reform of the four-year curriculum. The coaching program addressed unmet student needs for a longitudinal, non-evaluative relationship with a coach to support their development, shape their approach to learning, and promote belonging and community.

In surveys and focus groups, students reported high satisfaction with coaching in measures of the three program aims. They appreciated coaches' availability and guidance for the range of academic, personal, career, and other questions they had throughout medical school. Students endorsed the value of a longitudinal relationship and coaches' ability to meet their changing needs over time. Students rated coaches' teaching of foundational clinical skills highly. Students observed coaches learning some clinical skills with them - skills outside a coach's daily practice. Students also raised some concerns about variability among coaches. Attention to wellbeing and belonging to a learning community were program highlights for students. Coaches benefited from relationships with students and other coaches and welcomed the professional development to equip them to support all student needs.

Students perceive that a comprehensive medical student coaching program can achieve aims to promote their development and provide support. Within a non-evaluative longitudinal coach relationship, students build skills in driving their own learning and improvement. Coaches experience a satisfying yet challenging role. Ongoing faculty development within a coach community and funding for the role seem essential for coaches to fulfill their responsibilities.

Evaluation of the "Shifting Weight using Intermittent Fasting in night-shift workers" weight loss interventions: a mixed-methods protocol

Introduction

Shift workers are at a greater risk for obesity-related conditions. The impacts of working at night presents a challenge for designing effective dietary weight-loss interventions for this population group. The Shifting Weight using Intermittent Fasting in night-shift workers (SWIFt) study is a world-first, randomized controlled trial that compares three weight-loss interventions. While the trial will evaluate the effectiveness of weight-loss outcomes, this mixed-methods evaluation aims to explore for who weight-loss outcomes are achieved and what factors (intervention features, individual, social, organisational and wider environmental) contribute to this.

Methods

A convergent, mixed-methods evaluation design was chosen where quantitative and qualitative data collection occurs concurrently, analyzed separately, and converged in a final synthesis. Quantitative measures include participant engagement assessed via: dietary consult attendance, fulfillment of dietary goals, dietary energy intake, adherence to self-monitoring, and rates for participant drop-out; analyzed for frequency and proportions. Regression models will determine associations between engagement measures, participant characteristics (sex, age, ethnicity, occupation, shift type, night-shifts per week, years in night shift), intervention group, and weight change. Qualitative measures include semi-structured interviews with participants at baseline, 24-weeks, and 18-months, and fortnightly audio-diaries during the 24-week intervention. Interviews/diaries will be transcribed verbatim and analyzed using five-step thematic framework analysis in NVivo. Results from the quantitative and qualitative data will be integrated via table and narrative form to interrogate the validity of conclusions.

Discussion

The SWIFt study is a world-first trial that compares the effectiveness of three weight-loss interventions for night shift workers. This mixed-methods evaluation aims to further explore the effectiveness of the interventions. The evaluation will determine for who the SWIFt interventions work best for, what intervention features are important, and what external factors need to be addressed to strengthen an approach. The findings will be useful for tailoring future scalability of dietary weight-loss interventions for night-shift workers.Clinical trial registration: This evaluation is based on the SWIFt trial registered with the Australian New Zealand Clinical Trials Registry [ACTRN 12619001035112].

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

AIMS

Diet-related chronic disease contributes significantly to the global burden of disease. Dietitians are best placed to address this disease burden, yet graduate dietitians may struggle to find employment. This study aimed to explore dietetics graduates' experiences of employment and employability, up to 6-month post-degree completion.

METHODS

Secondary data analysis of in-depth qualitative interview data and longitudinal audio-diaries was undertaken. An interpretivist approach was employed whereby knowledge was viewed as subjective and multiple realities exist. A total of five entrance interviews, 31 audio-diaries and three exit interviews, from nine graduates were included in the analysis. This comprised 12 h of longitudinal audio data. Thematic analysis was undertaken using a framework analysis method.

RESULTS

Four key themes were identified: (1) The tumultuous process of applying for jobs demonstrated that graduates struggled with repeated rejections. (2) The uncertain journey to employment indicated that job-seeking was a limbo stage marked by uncertainty. (3) Feeling the pressure showed that graduates experienced pressure from multiple sources. (4) Enhancing employability explained that graduates were not prepared for available employment opportunities, but utilised resources to increase their employability.

CONCLUSION

Diverse placement experiences may better prepare graduates for available employment opportunities. To enhance employability, it may be beneficial to assist students to develop job-seeking skills, and to engage in networking and volunteering experiences during their education.

Design and development of an eHealth intervention to support self-management in people with musculoskeletal disorders - 'eHealth: It's TIME': a study protocol

Background: Musculoskeletal disorders (MSDs) are a leading cause of global morbidity, with the burden expected to increase in the near future. Self-management, with the support of healthcare professionals, is recommended for many MSDs. However, frequent clinical contact is not feasible. Previous research has highlighted the need for a co-designed eHealth-mediated self-management follow-up support intervention which integrates remote monitoring and behavioural change. Thus, the current study aims to develop and design a user-centred, eHealth-mediated self-management support prototype for people with MSDs. Methods: A three-step, iterative system development cycle will be utilised to develop and design the "eHealth: It's TIME prototype". The three-step process will include creating website features and content using two sequential focus groups with people with MSDs (n = 6 - 8); heuristic testing using the 10 heuristic principles of Nielsen (n = 5); and usability testing through in-person 60-minute interviews with people with MSDs (n = 3 - 5) and musculoskeletal physiotherapists (n = 3 - 5). Conclusion: The eHealth: It's TIME prototype will be a systematically developed, follow-up self-management support intervention guided by behavioural change theory and the preferences of end users.

How clinicians discuss patients' donor registrations of consent and presumed consent in donor conversations in an opt-out system: a qualitative embedded multiple-case study

BACKGROUND

The Netherlands introduced an opt-out donor system in 2020. While the default in (presumed) consent cases is donation, family involvement adds a crucial layer of influence when applying this default in clinical practice. We explored how clinicians discuss patients' donor registrations of (presumed) consent in donor conversations in the first years of the opt-out system.

METHODS

A qualitative embedded multiple-case study in eight Dutch hospitals. We performed a thematic analysis based on audio recordings and direct observations of donor conversations (n = 15, 7 consent and 8 presumed consent) and interviews with the clinicians involved (n = 16).

RESULTS

Clinicians' personal considerations, their prior experiences with the family and contextual factors in the clinicians' profession defined their points of departure for the conversations. Four routes to discuss patients' donor registrations were constructed. In the Consent route (A), clinicians followed patients' explicit donation wishes. With presumed consent, increased uncertainty in interpreting the donation wish appeared and prompted clinicians to refer to "the law" as a conversation starter and verify patients' wishes multiple times with the family. In the Presumed consent route (B), clinicians followed the law intending to effectuate donation, which was more easily achieved when families recognised and agreed with the registration. In the Consensus route (C), clinicians provided families some participation in decision-making, while in the Family consent route (D), families were given full decisional capacity to pursue optimal grief processing.

CONCLUSION

Donor conversations in an opt-out system are a complex interplay between seemingly straightforward donor registrations and clinician-family interactions. When clinicians are left with concerns regarding patients' consent or families' coping, families are given a larger role in the decision. A strict uniform application of the opt-out system is unfeasible. We suggest incorporating the four previously described routes in clinical training, stimulating discussions across cases, and encouraging public conversations about donation.

Assessing the Needs of Those Who Serve the Underserved: A Qualitative Study among US Oncology Clinicians

BACKGROUND

The American Society of Clinical Oncology established the 'Supporting Providers Serving the Underserved' (SUS) Task Force with a goal to develop recommendations to support cancer clinicians who deliver care for populations at risk for cancer disparities. As a first step, the Task Force explored barriers and facilitators to equitable cancer care delivery.

METHODS

Clinicians across the United States who deliver care predominantly for low-income and racially and ethnically minoritized populations were identified based on lists generated by the Task Force and the Health Equity Committee. Through purposive sampling based on geographical location, clinicians were invited to participate in 30-60 min semi-structured interviews to explore experiences, barriers, and facilitators in their delivery of cancer care. Interviews were recorded, transcribed, imported into qualitative data management software, and analyzed using thematic analysis.

RESULTS

Thematic analysis revealed three major themes regarding barriers (lack of executive leadership recognition of resources; patient-related socio-economic needs; clinician burnout) and two major themes regarding facilitators (provider commitment, experiential training).

CONCLUSIONS

Findings reveal modifiable barriers and potential solutions to facilitate equitable cancer care delivery for populations at risk for cancer disparities.

Identifying Beneficial Training Elements: Clinician Perceptions of Learning the Evidence-Based GenerationPMTO Intervention

Improving the process through which mental health professionals are trained in evidence-based practices (EBPs) represents an important opportunity for extending the implementation of EBPs in community settings. In this study, we used a qualitative approach to examine the specific training elements that were beneficial to clinicians' experiences learning an evidence-based intervention. Individual, semi-structured interviews were conducted with mental health professionals completing training in the GenerationPMTO parenting intervention. Data were analyzed using the tenets of thematic analysis. Overall, participants reported positive experiences in the training and growth in their attitudes, knowledge, and confidence in GenerationPMTO. The qualitative findings also suggested seven specific training elements that participants perceived as beneficial: support, role plays, engagement, structure, writing/visuals, working with training families, and experiencing the GenPMTO model. These results are discussed within the context of the existing literature on EBP training and more broadly as they relate to expanding the implementation of evidence-based interventions. We also suggest implications for practice meant to enhance future EBP training efforts.

Care Partner Inclusion of People Hospitalized With Alzheimer Disease and Related Dementias: Protocol for a Mixed Methods Systems Engineering Approach to Designing a Health Care System Toolkit

BACKGROUND

Research and policy demonstrate the value and need for the systematic inclusion of care partners in hospital care delivery of people living with Alzheimer disease and related dementias (ADRD). Support provided to care partners through information and training regarding caregiving responsibilities is important to facilitating their active inclusion and ultimately improving hospital outcomes of people living with ADRD. To promote care partners' active inclusion, a toolkit that guides health systems in the identification, assessment, and training of care partners is needed. User-centered approaches can address this gap in practice by creating toolkits that are practical and responsive to the needs of care partners and their hospitalized family members and friends living with ADRD.

OBJECTIVE

This paper describes the study protocol for the development and refinement of the ADRD Systematic Hospital Inclusion Family Toolkit (A-SHIFT). A-SHIFT will provide health care systems with guidance on how to effectively identify, assess, and train care partners of hospitalized persons living with ADRD.

METHODS

The A-SHIFT study protocol will use a 3-aimed, convergent mixed method approach to iteratively develop and refine the toolkit. In Aim 1, we will use a systems-engineering approach to characterize patterns of care partner inclusion in hospital care for people living with ADRD. In Aim 2, we will partner with stakeholders to identify and prioritize health care system facilitators and barriers to the inclusion for care partners of hospitalized people living with ADRD. In Aim 3, we will work with stakeholders to co-design an adaptable toolkit to be used by health systems to facilitate the identification, assessment, and training of care partners of hospitalized people living with ADRD. Our convergent mixed method approach will facilitate triangulation across all 3 aims to increase the credibility and transferability of results. We anticipate this study to take 24 months between September 1, 2022, and August 31, 2024.

RESULTS

The A-SHIFT study protocol will yield (1) optimal points in the hospital workflow for care partner inclusion, (2) a prioritized list of potentially modifiable barriers and facilitators to including care partners in the hospitalization of people living with ADRD, and (3) a converged-upon, ready for feasibility testing of the toolkit to guide the inclusion of care partners of people living with ADRD in hospital care.

CONCLUSIONS

We anticipate that the resultant A-SHIFT will provide health systems with a readiness checklist, implementation plan, and resources for identifying, assessing, and training care partners on how to fulfill their caregiving roles for people living with ADRD after hospital discharge. A-SHIFT has the potential to not only improve care partner preparedness but also help reduce health and service use outcomes for people living with ADRD after hospital discharge.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45274.

Learning collaboration at the primary-secondary care interface: a dual-method study to define design principles for interventions in postgraduate training programmes

BACKGROUND

Collaboration between primary and secondary care (PSCC) is important to provide patient-centered care. Postgraduate training programmes should provide training to learn PSCC. With a design based research (DBR) approach design principles can be formulated for designing effective interventions in specific contexts. The aim of this study is to determine design principles for interventions aimed to learn PSCC in postgraduate training programmes.

METHODS

DBR is characterised by multi-method studies. We started with a literature review on learning collaboration between healthcare professionals from different disciplines within the same profession (intraprofessional) to extract preliminary design principles. These were used to inform and feed group discussions among stakeholders: trainees, supervisors and educationalists in primary and secondary care. Discussions were audiotaped, transcribed and analysed using thematic analysis to formulate design principles.

RESULTS

Eight articles were included in the review. We identified four preliminary principles to consider in the design of interventions: participatory design, work process involvement, personalised education and role models. We conducted three group discussions with in total eighteen participants. We formulated three design principles specific for learning PSCC in postgraduate training programmes: (1) The importance of interaction, being able to engage in a learning dialogue. (2) Facilitate that the learning dialogue concerns collaboration. (3) Create a workplace that facilitates engagement in a learning dialogue. In the last design principle we distinguished five subcategories: intervention emphasises the urge for PSCC and is based on daily practice, the presence of role models, the work context creates time for learning PSCC, learning PSCC is formalised in curricula and the presence of a safe learning environment.

CONCLUSION

This article describes design principles for interventions in postgraduate training programmes with the aim to learn PSCC. Interaction is key in learning PSCC. This interaction should concern collaborative issues. Furthermore, it is essential to include the workplace in the intervention and make adjacent changes in the workplace when implementing interventions. The knowledge gathered in this study can be used to design interventions for learning PSCC. Evaluation of these interventions is needed to acquire more knowledge and adjust design principles when necessary.

Delivery of index-linked HIV testing for children: learnings from a qualitative process evaluation of the B-GAP study in Zimbabwe

BACKGROUND

Index-linked HIV testing for children, whereby HIV testing is offered to children of individuals living with HIV, has the potential to identify children living with undiagnosed HIV. The "Bridging the Gap in HIV Testing and Care for Children in Zimbabwe" (B-GAP) study implemented and evaluated the provision of index-linked HIV testing for children aged 2-18 years in Zimbabwe. We conducted a process evaluation to understand the considerations for programmatic delivery and scale-up of this strategy.

METHODS

We used implementation documentation to explore experiences of the field teams and project manager who delivered the index-linked testing program, and to describe barriers and facilitators to index-linked testing from their perspectives. Qualitative data were drawn from weekly logs maintained by the field teams, monthly project meeting minutes, the project coordinator's incident reports and WhatsApp group chats between the study team and the coordinator. Data from each of the sources was analysed thematically and synthesised to inform the scale-up of this intervention.

RESULTS

Five main themes were identified related to the implementation of the intervention: (1) there was reduced clinic attendance of potentially eligible indexes due to community-based differentiated HIV care delivery and collection of HIV treatment by proxy individuals; (2) some indexes reported that they did not live in the same household as their children, reflecting the high levels of community mobility; (3) there were also thought to be some instances of 'soft refusal'; (4) further, delivery of HIV testing was limited by difficulties faced by indexes in attending health facilities with their children for clinic-based testing, stigma around community-based testing, and the lack of familiarity of indexes with caregiver provided oral HIV testing; (5) and finally, test kit stockouts and inadequate staffing also constrained delivery of index-linked HIV testing.

CONCLUSIONS

There was attrition along the index-linked HIV testing cascade of children. While challenges remain at all levels of implementation, programmatic adaptations of index-linked HIV testing approaches to suit patterns of clinic attendance and household structures may strengthen implementation of this strategy. Our findings highlight the need to tailor index-linked HIV testing to subpopulations and contexts to maximise its effectiveness.

"Where my responsibility lies": Reflecting on medicine during the Holocaust to support personal and professional identity formation in health professions education

Objectives

Physicians and the medical/scientific establishment during Nazism and the Holocaust committed egregious ethical violations including complicity with genocide. Critical reflection on this history serves as a powerful platform for scaffolding morally resilient professional identity formation (PIF) with striking relevance for contemporary health professions education and practice. Study aim was to explore the impact of an Auschwitz Memorial study trip within the context of a medicine during Nazism and the Holocaust curriculum on students' personal and PIF.

Methods

The authors analyzed 44 medical and psychology students' reflective writings from a 2019 Auschwitz Memorial study trip using immersion-crystallization qualitative thematic analysis.

Results

Six distinct themes and 22 subthemes were identified and mapped to a reflective learning process model: 1. "What am I bringing?" 2. "What am I experiencing through the curriculum?" 3. "What am I initially becoming aware of as a first response?" 4./5. "How and what am I processing?" 6. "What am I taking with me?" Particularly compelling subthemes of power of the place, emotional experience, reflection on myself as a moral person, and contemporary relevance referred to impactful course elements.

Conclusions

This curriculum catalyzed a critically reflective learning/meaning-making process supporting personal and PIF including critical consciousness, ethical awareness, and professional values. Formative curriculum elements include narrative, supporting emotional aspects of learning, and guided reflection on moral implications. The authors propose Medicine during Nazism and the Holocaust curriculum as a fundamental health professions education component cultivating attitudes, values, and behaviors for empathic, moral leadership within inevitable healthcare challenges.

Growth mindset in young people awaiting treatment in a paediatric mental health service: A mixed methods pilot of a digital single-session intervention

BACKGROUND

Wait times are significant in child mental health services but may offer opportunity to promote growth mindsets in young people with physical and mental health needs. A digital growth mindset single-session intervention is effective in young people, but its use in paediatric settings has not been examined. This mixed methods pilot aimed to assess the intervention's feasibility, acceptability, and impact in this population.

METHOD

Patients aged 8-18 on waiting lists in a paediatric hospital's specialist mental health service were offered the intervention remotely. Treatment completion and retention rates, symptoms of depression and anxiety, perceived control, and personality mindset were assessed at baseline, post-treatment, and follow-ups. Semi-structured interviews to explore the intervention's acceptability were conducted post-treatment.

RESULTS

Twenty-five patients completed the intervention and 17 patients and three carers/parents were interviewed. Outcomes showed small to large improvements across time-points. Most patients reported finding the intervention enjoyable, accessible, and instilled a hope for change. They valued elements of the intervention but made suggestions for improvement.

CONCLUSIONS

The digital growth mindset single-session intervention is feasible, acceptable, and potentially beneficial for young people with physical and mental health needs on waiting lists. Further research is warranted to examine its effectiveness and mechanism of change.

Shifting the narrative and practice of assessing professionalism in dietetics education: An Australasian qualitative study

AIM

We aimed to explore current approaches to assessing professionalism in dietetics education in Australia and New Zealand, and asked the questions what is working well and what needs to improve?

METHOD

We employed a qualitative interpretive approach and conducted interviews with academic and practitioner (workplace-based) educators (total sample n = 78) with a key stake in dietetics education across Australia and New Zealand. Data were analysed using team-based, framework analysis.

RESULTS

Our findings suggest significant shifts in dietetics education in the area of professionalism assessment. Professionalism assessment is embedded in formal curricula of dietetics programs and is occurring in university and placement settings. In particular, advances have been demonstrated in those programs assessing professionalism as part of the programmatic assessment. Progress has been enabled by philosophical and curricula shifts; clearer articulation and shared understandings of professionalism standards; enhanced learner agency and reduced power distance; early identification and intervention of professionalism lapses; and increased confidence and capabilities of educators.

CONCLUSIONS

These findings suggest there have been considerable advances in professionalism assessment in recent years with shifts in practice in approaching professionalism through a more interpretivist lens, holistically and more student-centred. Professionalism assessment in dietetics education is a shared responsibility and requires further development and transformation to more fully embed and strengthen curricula approaches across programs. Further work should investigate strategies to build safer learning cultures and capacity for professionalism conversations and in strengthening approaches to remediation.

'For Want of a Nail': developing a transparent approach to retroduction and early initial programme theory development in a realist evaluation of community end of life care services

A crucial part of theory-driven realist thinking is retroduction, the process of looking backwards for explanation of how and why things may be. Conducted early in the realist evaluation process, it provides a foundation for evidenced 'theory gleaning'. Despite retroduction being an inherent part of the realist process, it is often 'hidden' in realist reports. This paper explains the thinking behind, alongside an example of, a framework created by the authors to make transparent the retroductive process as used in a realist evaluation of two community End of Life Care services. The approach makes visible the application of the 'sociological imagination' and lends robustness to hypotheses by establishing how the authors utilised: wide-ranging potential generative causation; stakeholder and Patient and Public Involvement feedback; literature scoping; and substantive theories at the middle range, specifically Transitions Theory. These stages led to the development of Initial Programme Theories, with a clear history of genesis.

"Walking on both sides of the fence": A qualitative exploration of the challenges and opportunities facing emergent clinician-scientists in child health

RATIONALE, AIMS, AND OBJECTIVES

While paediatric clinician-scientists are ideally positioned to generate clinically relevant research and translate research evidence into practice, they face challenges in this dual role. The authors sought to explore the unique contributions, opportunities, and challenges of paediatric clinician-scientists, including issues related to training and ongoing support needs to ensure their success.

METHOD

The authors used a qualitative descriptive approach with thematic analysis to explore the experiences of clinician-scientist stakeholders in child health (n = 39). Semi-structured interviews (60 min) were conducted virtually and recorded. Thematic analysis was conducted according to the phases outlined by Braun and Clarke (2006).

RESULTS

The analysis resulted in the creation of three themes: (1) "Walking on both sides of the fence": unique positioning of clinician-scientists for advancing clinical practice and research; (2) the clinician-scientist: a specialized role with significant challenges; and (3) beyond the basics of clinical and research training programmes: essential skill sets and knowledge for future clinician-scientists.

CONCLUSIONS

While clinician-scientists can make unique contributions to the advancement of evidence-based practice, they face significant barriers straddling their dual roles including divergent institutional cultures in healthcare and academia and a lack of infrastructure to effectively support clinician-scientist positions. Training programmes can play an important role in mentoring and supporting early-career clinician-scientists.

Fostering uncertainty tolerance in anatomy education: Lessons learned from how humanities, arts and social science (HASS) educators develop learners' uncertainty tolerance

Uncertainty tolerance, individuals' perceptions/responses to uncertain stimuli, is increasingly recognized as critical to effective healthcare practice. While the Covid-19 pandemic generated collective uncertainty, healthcare-related uncertainty is omnipresent. Correspondingly, there is increasing focus on uncertainty tolerance as a health professional graduate "competency," and a concomitant interest in identifying pedagogy fostering learners' uncertainty tolerance. Despite these calls, practical guidelines for educators are lacking. There is some initial evidence that anatomy education can foster medical students' uncertainty tolerance (e.g., anatomical variation and dissection novelty), however, there remains a knowledge gap regarding robust curriculum-wide uncertainty tolerance teaching strategies. Drawing upon humanities, arts and social sciences (HASS) educators' established uncertainty tolerance pedagogies, this study sought to learn from HASS academics' experiences with, and teaching practices related to, uncertainty pedagogy using a qualitative, exploratory study design. Framework analysis was undertaken using an abductive approach, wherein researchers oscillate between inductive and deductive coding (comparing to the uncertainty tolerance conceptual model). During this analysis, the authors analyzed ~386 min of data from purposively sampled HASS academics' (n = 14) discussions to address the following research questions: (1) What teaching practices do HASS academics' perceive as impacting learners' uncertainty tolerance, and (2) How do HASS academics execute these teaching practices? The results extend current understanding of the moderating effects of education on uncertainty tolerance and supports prior findings that the anatomy learning environment is ripe for supporting learner uncertainty tolerance development. This study adds to growing literature on the powerful moderating effect education has on uncertainty tolerance and proposes translation of HASS uncertainty tolerance teaching practices to enhance anatomy education.

Enhancing robotic efficiency through the eyes of robotic surgeons: sub-analysis of the expertise in perception during robotic surgery (ExPeRtS) study

BACKGROUND

Robotic technology affords surgeons many novel and useful features, but two stereotypes continue to prevail: robotic surgery is expensive and inefficient. To identify educational opportunities and improve operative efficiency, we analyzed expert commentary on videos of robotic surgery.

METHODS

Expert robotic surgeons, identified through high case volumes and contributions to the surgical literature, reviewed eight anonymous video clips portraying key portions of two robotic general surgery procedures. While watching, surgeons commented on what they saw on the screen. All interactions with participants were in person, recorded, transcribed, and subsequently analyzed. Using content analysis, researchers double-coded each transcript applying a consensus developed codebook.

RESULTS

Seventeen surgeons participated. The average participant was male (82.4%), 47 (SD = 6.6) years old, had 13.2 (SD = 8.23) years of teaching experience, worked in urban academic hospitals (64.7%) and had performed 643 (SD = 467) robotic operations at the time of interviews. Emphasis on efficiency (or lack thereof) surfaced across three main themes: overall case progression, robotic capabilities, and instrumentation. Experts verbally rewarded purposeful and "ergonomically sound" movements while language reflecting impatience with repetitive and indecisive movements was attributed to presumed inexperience. Efficient robotic capabilities included enhanced visualization, additional robotic arms to improve exposure, and wristed instruments. Finally, experts discussed instrument selection with regards to energy modality, safety features, cost, and versatility.

CONCLUSION

This study highlights three areas for improved efficiency: case progression, robotic capabilities, and instrumentation. Development of education materials within these themes could help surgical educators overcome one of robotic technology's persistent challenges.

Coalescing, Cross-Pollinating, Crystalising: Developing and Evaluating an Art Installation About Health Knowledge

The HIVE is an arts-based knowledge translation (ABKT) project that showcases work undertaken across Maridulu Budyari Gumal: the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE). Here, we present two distinct forms of data (reflective and evaluative) to tell the story of The HIVE and outline the project's achievements and shortcomings. Reflective data are used to describe the process of establishing a creative, cross-disciplinary collaboration, in order to devise and produce The HIVE. Evaluative data are used to assess the impact of The HIVE on audiences. By presenting reflective and evaluative data together, we highlight that impact in ABKT cannot be reduced to an assessment of audience engagement with an ABKT end-product. Although audience impact is vital, in our experience, The HIVE also had a powerful impact on the researchers, health service users, artists and others who worked together to create it. The process of creating The HIVE informed research- and art-practice change, forged interdisciplinary networks, and enabled the growth of new patterns of knowledge sharing and collaboration. The reflective and evaluative data we present attest to different forms of impact resulting from the creation and exhibition of an ABKT project.

Experiences of service transitions in Australian early intervention psychosis services: a qualitative study with young people and their supporters

BACKGROUND

Different Early Intervention Psychosis Service (EIPS) models of care exist, but many rely upon community-based specialist clinical teams, often with other services providing psychosocial care. Time-limited EIPS care creates numerous service transitions that have potential to interrupt continuity of care. We explored with young people (YP) and their support people (SP) their experiences of these transitions, how they affected care and how they could be better managed.

METHODS

Using purposive sampling, we recruited twenty-seven YP, all of whom had been hospitalised at some stage, and twelve SP (parents and partners of YP) from state and federally funded EIPS in Australia with different models of care and integration into secondary mental health care. Audio-recorded interviews were conducted face-to-face or via phone. A diverse research team (including lived experience, clinician and academic researchers) used an inductive thematic analysis process. Two researchers undertook iterative coding using NVivo12 software, themes were developed and refined in ongoing team discussion.

RESULTS

The analysis identified four major service-related transitions in a YP's journey with the EIPS that were described as reflecting critical moments of care, including: transitioning into EIPS; within service changes; transitioning in and out of hospital whilst in EIPS care; and, EIPS discharge. These service-related transition affected continuity of care, whilst within service changes, such as staff turnover, affected the consistency of care and could result in information asymmetry. At these transition points, continuity of care, ensuring service accessibility and flexibility, person centredness and undertake bio-psychosocial support and planning were recommended. State and federally funded services both had high levels of service satisfaction, however, there was evidence of higher staff turnover in federally funded services.

CONCLUSION

Service transitions were identified as vulnerable times in YP and SP continuity of care. Although these were often well supported by the EIPS, participants provided illustrative examples for service improvement. These included enhancing continuity and consistency of care, through informed and supportive handovers when staff changes occur, and collaborative planning with other services and the YP, particularly during critical change periods such as hospitalisation.