Phenomenological study of medical interns reflecting on their experiences, of open disclosure communication after medication error: linking rationalisation to the conscious competency matrix

Introduction and objectives Errors are common within healthcare, especially those involving the prescribing of medications. Open disclosure is a policy stating doctors should apologise for such errors, discussing them with the harmed parties. Many junior doctors take part in open disclosure without any formal training or experience, which can lead to failure of the apology, and increased patient/family frustration. In this study, we explore the ways in which interns perceive the relationship between medication error and their experience of open disclosure. Methods Using known theoretical frameworks of apology and moral rationalisation, a qualitative study of medical interns who had been involved in open disclosure was conducted. Twelve medical interns volunteered, and were selected using purposive sampling. Face-to-face semi-structured interviews illuminated their clinical experiences of open disclosure after medication error. The data was coded and analysed using Interpretative Phenomenological Analysis. Our data supported three super-ordinate themes: (1) Rationalisation of medical error, (2) Culture of medical error and (3) Apology in practice. Results The interns in this study rationalised their observations, their subsequent actions and their language. Rather than reframing their thinking, they became part of a healthcare environment that culturally accepted, promoted and perpetuated error. Rationalisation can lead to loss of context in apologising, which can be perceived as unempathic by the patients/families. However, when reflection and unpacking of their errors, they acknowledged that their reasoning was problematic, recognised the reasons why and were able to reframe their approach to apology for a future occasion. Conclusion Our data suggests the utility of a learning framework around open disclosure following medication error, for having a supervisor conversation about aspects of the interns’ rationalisation of their clinical practice, in their contextualised clinical environment. Further research could clarify whether interns are ‘unconsciously incompetent’ or ‘consciously incompetent’, when addressing medication error and preparing to apologise

Contextualised reflective competence: a new learning model promoting reflective practice for clinical training

Background Reflection is a metacognitive process that allows self-regulation and the promotion of lifelong learning, and is an essential requirement to develop therapeutic relationships with patients and colleagues, as well as professional expertise. The medical literature is lacking on guidance for learners and educators to develop reflective abilities. Methods Based on our program of research into junior doctors delivering open disclosure communication after medical error, we developed a framework called contextualised reflective competence, to assist students/trainees and educators in developing, maintaining, and ensuring reflective practice in the context of professional experiences. Results The contextualised reflective competence framework has its origins in the conscious competency framework, an established learning paradigm within healthcare professions education, and it has been developed to encompass some of the vital concepts that the conscious competency matrix was lacking: the promotion of ongoing reflection practice, accurate assumptions of the learner’s original mindset, variations in everyday performance, and erosion of skills. The contextualised reflective competence framework progresses the conscious competence framework from a 2x2 box diagram to a two-pronged flowchart. In our framework, if the learner possesses appropriate reflective practice, contextualised reflective competence, they move through alearning process where they achieve unconscious competence. If the learner does not possess contextualised reflective competence, they move though a learning process where this display generalised reflective incompetence, characterised by cognitive dissonance and rationalisation, leading to errors and non-learning. Generalised reflective incompetence is usually a temporary state with appropriate supervision. Our program of research demonstrated that contextualised reflective competence was related to critical cognitive frameworks, such as intellectual humility, situational awareness, the development of a ‘growth mindset’, and belongingness. Conclusions The Contextualised Reflective Competence framework promotes learners’ understanding of their core competencies and provides opportunities for personal critical reflection. It provides educators and supervisors with a diagnostic pathway for those with reflective incompetence. We anticipate its use in the clinical environment where issues of competence are raised in professional experiences

Student Interprofessional Facilitator Training (SIFT) program: building capacity in clinical education leadership

Background: While there are many teacher training programs for health professional students, few are interprofessional, and few integrate assessment and feedback prior to participation as peer teachers. In 2021, The Student Interprofessional Facilitator Training (SIFT) program was developed to allow senior students, already trained in peer teaching, to revise, build on, and practice their newly acquired skills in an interprofessional context. The aim of this study was to explore participant perception and performance, and the contextual factors that influence student aspirations as clinical teachers. Methods: Alumni of the 2021 Peer Teacher Training program (n = 74) were invited to participate in the SIFT program. Those who participated were invited to attend individual semi-structured interviews. Thematic analysis was used to code and categorise data into themes, using Communities of Practice as a conceptual framework. Skills in interprofessional facilitation were observed, assessed and students were provided with individual feedback. Assessment data were analysed using descriptive statistics. Results: Sixteen students from six disciplines joined the SIFT program, and 13/16 (81%) completed. Students were from medicine, nursing, diagnostic radiography, medical imaging, dentistry and speech pathology. Students reported an increased recognition of teaching as a learned skill, development of clinician identity formation as educators, development of interprofessional communication skills, increased awareness of the roles of other health professions, and an increased understanding of leadership. Participants expressed a desire for additional opportunities for interprofessional networking and peer teaching. A good level of competence in facilitation skills was reached by participants. Conclusion: The SIFT program provided a sustainable framework for health professional students to develop and evidence their teaching and leadership skills in an interprofessional context. This study highlighted the important role of observation, assessment and feedback in student teacher training programs. The process of clear assessment guidelines, direct observation with feedback from supervisors provided a way to ensure quality improvement in peer teaching. The SIFT program will help to build capacity of interprofessional programs where large numbers of teachers are required for small group teaching. The next step will be to ensure a variety of opportunities within interprofessional contexts, and with face-to-face engagemen

Leadership behaviours in interprofessional student teamwork

Background Effective leaders support high-quality patient care and improve patient safety by embodying a collective leadership style. Training in leadership skills needs to be integrated longitudinally throughout a clinician’s career. Models of leadership drawn from organisational theories can provide a conceptual framework for cultivating student leadership qualities during teamwork and the evaluation of emergent outcomes. Using the conceptual framework of Situational Leadership Theory, we sought to explore the leadership qualities identified by students of their team members, during a large scale interprofessional learning activity. Methods In 2018, 1674 students from 11 health disciplines were required to participate in the “Health Collaboration Challenge” (HCC). The HCC required students to work in small interprofessional teams of five or six students. Following team activities, students were required to provide constructive written feedback to their team members. Peer feedback data were coded and categorised into themes using the conceptual framework of Situational Leadership Theory. Data were then quantified within each theme. Results A total of 1282 comments were analysed. The most frequent comments related to ‘delegating’ (456/1282, 36%) and ‘supporting’ (402/1282, 31%). This was followed by comments categorised as ‘directing’ (244/1282, 19%), and ‘coaching’ (180/1282, 14%) leadership styles. Notably, a total of 1112/2597 (43%) of comments were unconstructive. A total of 298 comments provided by students informed their peers of areas for self-improvement. The most frequent comments were recommendations relating to ‘active team member contribution’ (111/298; 37%), followed by ‘communication’ (83/298; 28%), ‘interprofessional practice’ (77/298; 26%), and ‘disciplinary knowledge’ (27/298; 9%). Conclusion Although most students demonstrated a reasonable ability to display leadership behaviours appropriate to teamwork, further development is needed through training. Leadership skills are an expectation of health professional graduates, and should be explicitly taught and vertically integrated within interprofessional education curricula. Further research is warranted in how students contribute to and understand the requirements of leadership within interprofessional teams

Designing health professional education curricula using systems thinking perspectives

Background Medical students navigate complex personal learning pathways from entry into medical school, through an educational program, and into life-long practice. However, many stakeholders have called for substantive reforms in contemporary curricula, citing concerns about the lack of key abilities amongst newly graduated doctors to work in complex healthcare environments. Despite the need for educators to focus on curricula design, there is a paucity of overarching perspectives that allow synthesis of the various curricular elements in a way that lends meaningfulness and appreciation to the students in terms of navigating the immediate program requirements and beyond. Without such guidance, educators risk creating fragmented program designs that can lead to both unintended and unactionable outcomes for students as well as curriculum designers. Using systems thinking, we set out to address this gap by providing an overarching perspective for curriculum designers to appreciate the relationships and the interactions of the various curricular elements that inform and impact student’s preparedness for practice. Methods By framing a curriculum as a complex adaptive system, we used soft systems thinking to develop an initial prototype of a conceptual curricular toolkit, underpinned by an appraisal of relevant literature within health professional education and the broader educational context. The prototype was further refined iteratively after critical reflection by the authors with a diverse range of national and international colleagues via posters, short communications, and workshops at several conferences, and through social media. Results We describe how the 3P-6Cs toolkit captures a learner’s personal journey through an educational program into a field of practice by logically linking the three key elements: the personal, the program, and the practice. We demonstrate its application in three examples related to contemporary health profession education curricula. These are: creating integrated educational designs to capture students’ developmental continua, conceptualising immersive clinical placements in non-traditional settings, and complexity-consistent evaluation of curricular interventions. Conclusion Applying the 3P-6Cs curricular toolkit to problems of curricula (re)design can provide overarching perspectives that enable educators to have a better understanding of how integration of elements within education programs can inform and impact student’s preparation for lifelong practice

Glacial landscape evolution in the Uummannaq region, West Greenland

The Uummannaq region is a mosaic of glacial landsystems, consistent with hypothesised landscape distribution resulting from variations in subglacial thermal regime. The region is dominated by selective linear erosion which has spatially and altitudinally partitioned the landscape. Low altitude areas are dominated by glacial scour, with higher elevations are dominated by plateaux or mountain valley and cirque glaciers. The appearance and nature of each landscape type varies locally with altitude and latitude, as a function of bedrock geology and average glacial conditions. Selective linear erosion has been a primary control on landscape distribution throughout Uummannaq, leading to plateau formation and the growth of a coalescent fjord system in the Uummannaq region. This has allowed the development of the Uummannaq ice stream’s (UIS) onset zone during glacial periods. Fjord development has been enhanced by a down-stream change in geology to less-resistant lithologies, increasing erosional efficiency and allowing a single glacial channel to develop, encouraging glacier convergence and the initiation of ice streaming. The landscape has been affected by several periods of regional uplift from 33 Ma to present, and has been subject to subsequent fluvial and glacial erosion. Uplift has removed surfaces from the impact of widespread warm-based glaciation, leaving them as relict landsurfaces. The result of this is a regional altitude-dependant continuum of glacial modification, with extreme differences in erosion between high and low elevation surfaces. This study indicates that processes of long-term uplift, glacial erosion/protection, and spatial variability in erosion intensity have produced a highly partitioned landscape

Controls upon the Last Glacial Maximum deglaciation of the northern Uummannaq Ice Stream System, West Greenland

The Uummannaq Ice Stream System (UISS) was a convergent cross-shelf ice stream system that operated in West Greenland during the Last Glacial Maximum (LGM). This paper presents new evidence constraining the geometry and evolution of the northern sector of the UISS and considers the factors controlling its dynamic behaviour. Geomorphological mapping, 21 new terrestrial cosmogenic nuclide (TCN) exposure ages, and radiocarbon dating constrain LGM warm-based ice stream activity in the north of the system up to 1400 m a.s.l. Intervening plateaux areas either remained ice free, or were covered by cold-based icefields. Beyond the inner fjords, topography and bathymetry forced ice flow southwards into the Uummannaq Trough, where it coalesced with ice from the south, and formed the trunk zone of the UISS. Deglaciation of the UISS began at 14.9 cal. ka BP. Rapid retreat from the LGM limit was forced by an increase in air temperatures and rising sea level, enhanced by the bathymetric over-deepening of the Uummannaq and Igdlorssuit Sund troughs. Ice reached the inner fjord confines in the northern Uummannaq area by 11.6 ka and experienced an ice marginal stabilisation in Rink–Karrat Fjord for up to 5 ka. This was a function of topographic constriction and bathymetric shallowing, and occurred despite continued climatic forcing. In the neighbouring Ingia Fjord this did not occur. Following this period of stability, ice within Rink–Karrat Fjord retreated, reaching the present ice margin or beyond after 5 ka. The presence of a major ice stream within a mid-fjord setting, during the mid-Holocene and the Holocene Thermal Maximum (∼11–5 ka) is in direct contrast to records of other ice streams throughout West Greenland, which suggest ice had retreated beyond its present margin by 9–7 ka. This demonstrates the potential importance of topographic control on calving margin stability, and its ability to override climatic forcing

The composition and oxidative stability of vegetarian omega-3 algal oil nanoemulsions suitable for functional food enrichment

Background: Long chain omega-3 polyunsaturated fatty acid (LCn3PUFA) nanoemulsion enriched foods offer potential to address habitually low oily fish intakes. Nanoemulsions increase LCn3PUFA bioavailability, but may cause lipid oxidation. This study examined oxidative stability of LCn3PUFA algal oil-in-water nanoemulsions created by ultrasound using natural and synthetic emulsifiers during 5-weeks of storage at 4, 20 and 40°C. Fatty acid composition, droplet size ranges and volatile compounds were analysed. Results: No significant differences were found for fatty acid composition at various temperatures and storage times. Lecithin nanoemulsions had significantly larger droplet size ranges at baseline and during storage regardless of temperatures. While combined Tween 40 and lecithin nanoemulsions had low initial droplet size ranges, there were significant increases at 40°C after 5-weeks storage. Gas chromatograms identified hexanal and propanal as predominant volatile compounds, along with 2-ethylfuran; propan-3-ol; valeraldehyde. The Tween 40 only nanoemulsion sample showed formation of lower concentrations of volatiles compared to lecithin samples. Formation of hexanal and propanal remained stable at lower temperatures although higher concentrations were found in nanoemulsions than bulk oil. The lecithin only sample had formation of higher concentrations of volatiles at increased temperatures despite having significantly larger droplet size ranges than the other samples. Conclusions: Propanal and hexanal were the most prevalent of five volatile compounds detected in bulk oil and lecithin and/or Tween 40 nanoemulsions. Oxidation compounds remained more stable at lower temperatures indicating suitability for enrichment of refrigerated foods. Further research to evaluate the oxidation stability of these systems within food matrices is warranted

Concerning the quark condensate

A continuum expression for the trace of the massive dressed-quark propagator is used to explicate a connection between the infrared limit of the QCD Dirac operator's spectrum and the quark condensate appearing in the operator product expansion, and the connection is verified via comparison with a lattice-QCD simulation. The pseudoscalar vacuum polarisation provides a good approximation to the condensate over a larger range of current-quark masses.Comment: 7 pages, LaTeX2e, revtex