Using Loose Coupling Theory to Understand Interprofessional Collaborative Practice on a Transplantation Team

Background: A central paradox dwells at the heart of interprofessional care: the tension between autonomy and interdependence. This report uses an ethnographic study to understand how this tension shapes collaborative practice on a distributed, interprofessional transplant team in a Canadian teaching hospital.Methods & Findings: Over four months, two trained observers conducted an ethnography through 162 observation hours, 30 field interviews and 17 formal interviews with 39 consented participants. Data collection and inductive analysis proceeded iteratively. Loose coupling theory was used as a resource to make sense of key themes. We describe the transplant team as a constellation made up of core, inter-service, and outside hospital dimensions. Next, we trace the nature of coupling activities within and across these dimensions of the team constellation, focusing on recurring communication challenges which can signal the relationship between autonomy and interdependence in collaborative acts.Conclusions: We conclude that coupling is fluid and subject to human agency, and that the tension between autonomy and interdependence can be highly productive. Team members, including patients, may negotiate and construct their relations on an autonomy/interdependence axis for strategic purposes. Far from being trapped in a paradox, team members use autonomy and interdependence as resources to achieve complex goals in collaborative settings.&nbsp

Похибка розрахунку характеристик гармонійного сигналу

Встановлено основні джерела похибок програм визначення коефіцієнта гармонік для звичайної та подвійної точності розрахунку. Аналізуються похибки заокруглення, пов’язані із знаходженням тригонометричних функцій стандартними програмами, похибки розрахунку коефіцієнта гармонік гармонійного сигналу, на який накладено постійний складник, похибки розрахунку коефіцієнта гармонік від кількості дискретних відліків на періоді сигналу, похибки квантування по рівню, величина яких залежить від розрядності аналогово-цифрового перетворювача (АЦП). Шляхом моделювання визначено величину порогу чутливості по коефіцієнту гармонік.The basic sources of the errors of software for calculation of the harmonic factor for an ordinary and double accuracy of calculation are established. Errors in rounding, related to the calculation of trigonometric functions by standard programs, errors of calculation of the harmonic factor of a harmonic signal with an imposed permanent constituent, errors of calculation of the harmonic factor from the number of discrete counts on the signal period, errors of quantum by level the value which depends from the value ADC bits are analyzed. The threshold value of sensitivity by a harmonic factor was evaluated by modelling.Рассмотрены основные источники погрешностей программ расчета коэффициента гармоник с обычной и двойной точностью вычислений. Анализируются погрешности округления, связанные с вычислением тригонометрических функций стандартными программами, погрешности расчета коэффициента гармоник гармонического сигнала с постоянной составляющей, погрешности расчета коэффициента гармоник от количества дискретных отсчетов на периоде гармонического сигнала, погрешности квантования по уровню, величина которых зависит от разрядности аналого-цифрового преобразователя (АЦП). Путем моделирования определена величина порога чувствительности по коэффициенту гармоник

Techne or Artful Science and the Genre of Case Presentations in Healthcare Settings

This paper presents a qualitative study that investigated the role of case presentations in the socialization of medical and optometry students. Using the debate from classical rhetoric around the term techne (art or science), we observed that genre theory helps explain the way case presentations mediate the development of professional identity through the interaction of certain knowledge (techne 1), “savvy” knowledge (techne 2), and ethical reflection (phronesis). We noted that these mediated scenes of learning are necessary but problematic because they can lead students to yearn for certainty and to exclude outsiders (other healthcare providers, patients). Finally, our research challenges the binary opposition that exists between art and science especially for professions that bring their disciplinary knowledge into practice

The Rhetoric of Patient Voice: Reported Talk with Patients in Referral and Consultation Letters

Referral and consultation letters are written to enable the exchange of patient information and facilitate the trajectory of patients through the healthcare system. Yet, these letters, written about yet apart from patients, also sustain and constrain professional relationships and influence attitudes towards patients. We analysed 35 optometry referral letters and 35 corresponding ophthalmology consultation letters for reported \u27patient voice\u27 coded as \u27experience\u27 or \u27agenda\u27 and we interviewed 15 letter writers (eight optometry students, six optometrists, and one community ophthalmologist). There were 80 instances of reported \u27patient voice\u27 in 35 letters. The majority (68%) of the instances occurred in referral letters, likely due to differences in both \u27letter function\u27 and \u27professional stance.\u27 Reported \u27patient voice\u27 occurred predominantly as \u27experience\u27 (81%) rather than \u27agenda\u27 instances. Letters writers focused on their readers\u27 needs, thus a biomedical voice dominated the letters and instances of reported \u27patient voice\u27 were recontextualized for the professional audience. While reporting \u27patient voice\u27 was not the norm in these letters, its inclusion appeared to accomplish specific work: to persuade reader action, to question patient credibility, and to highlight patient agency. These letter strategies reflect professional attitudes about patients and their care

Working off the Record: Physicians\u27 and Nurses\u27 Transformations of Electronic Patient Record-based Patient Information

BACKGROUND: Electronic patient records (EPRs) are increasingly being used in health care, but little is known about how EPR-based patient information is used in daily care activities, nor about its potential influence on novice training. METHOD: Seventy-two physicians and nurses participated in an eight-month study on a single pediatric ward. Eighty hours of nonparticipant observations and 20 interviews were conducted. Data were analyzed using constructivist grounded theory and visual rhetoric. RESULTS: Three main features of participant interactions with EPR-based information were identified: (1) EPR-based information was routinely transformed into paper documents; (2) these transformations were organized by profession-specific guiding principles; and (3) transformation strategies were learned through an informal curriculum. CONCLUSIONS: This study describes how and why health care professionals work around EPR-based patient information, and suggests that an EPR\u27s visual organization may be incompatible with professional activities. The study addresses the socializing implications of these activities, and highlights their educational potential

Working off the Record: Physicians\u27 and Nurses\u27 Transformations of Electronic Patient Record-based Patient Information

BACKGROUND: Electronic patient records (EPRs) are increasingly being used in health care, but little is known about how EPR-based patient information is used in daily care activities, nor about its potential influence on novice training. METHOD: Seventy-two physicians and nurses participated in an eight-month study on a single pediatric ward. Eighty hours of nonparticipant observations and 20 interviews were conducted. Data were analyzed using constructivist grounded theory and visual rhetoric. RESULTS: Three main features of participant interactions with EPR-based information were identified: (1) EPR-based information was routinely transformed into paper documents; (2) these transformations were organized by profession-specific guiding principles; and (3) transformation strategies were learned through an informal curriculum. CONCLUSIONS: This study describes how and why health care professionals work around EPR-based patient information, and suggests that an EPR\u27s visual organization may be incompatible with professional activities. The study addresses the socializing implications of these activities, and highlights their educational potential

Look Who’s Talking: Teaching and Learning Using the Genre of Medical Case Presentations

In a pediatric teaching hospital, the authors examined 16 novice medical case presentations that were classified as instances of a hybrid apprenticeship genre. In contrast to strict school and workplace genres, an apprenticeship genre results from the sometimes competing activity systems of student education and patient care. The authors examined these novice case presentations for the amount and patterns of time devoted to student learning and expert teaching, the difficulties created for participants, the sometimes misunderstood implicit messages delivered by experts, and the opportunities to address educational objectives. This study offers professional communication researchers a model that combines quantitative and qualitative methodologies to assess the effects of competing activity systems in the development of communication expertise

Towards Embracing Clinical Uncertainty: Lessons from Social Work, Optometry and Medicine

Summary: The oral transmission and transformation of client information in an apprenticeship setting provides a rich environment in which to observe students and their expert supervisors managing uncertainty. In this Canadian-based study, we examined the communicative features of 12 social work supervisions involving social work students and their supervisors and enriched our observations with subsequent interviews of the participants. Findings: Social work students viewed the acknowledgement and examination of uncertainty as a touchstone of competent social work. This observation contrasted with our past study of medical and optometry students who focused on personal deficit and a distrust of acknowledging uncertainty. Our observations and interviews revealed a unique professional signature to the novice rhetoric of uncertainty (seeking guidance, deflecting criticism, owning limits, showing competence) that suggests differing professional identities and contextual settings. Applications: An attitudinal shift toward accepting and trusting uncertainty in medicine and optometry may facilitate an enriched educational environment for students and a more open dialogue with patients about uncertainty. The unique professional signatures of this rhetoric offer insights into how professional identity shapes attitudes and behaviors toward uncertainty and suggest a source of tension within interdisciplinary healthcare teams