An Ethical Façade? Medical Students' Miscomprehensions of Substituted Judgment

Background: We studied how well first-year medical students understand and apply the concept of substituted judgment, following a course on clinical ethics. Method: Students submitted essays on one of three ethically controversial scenarios presented in class. One scenario involved a patient who had lost decisional capacity. Through an iterative process of textual analysis, the essays were studied and coded for patterns in the ways students misunderstood or misapplied the principle of substituted judgment. Results: Students correctly articulated course principles regarding patient autonomy, substituted judgment, and nonimposition of physician values. However, students showed misunderstanding by giving doctors the responsibility of balancing the interests of the patient against the interests of the family, by stating doctors and surrogates should be guided primarily by a best-interest standard, and by suggesting that patient autonomy becomes the guiding principle only when patients can no longer express their wishes. Conclusion: Students did not appear to internalize or correctly apply the substituted judgment standard, even though they could describe it accurately. This suggests the substituted judgment standard may run counter to students ’ moral intuitions

Community participation and recovery for mental health service users: An action research inquiry

Introduction: The social inclusion of individuals with mental health problems is an issue for mental health services, for the individuals who experience stigma, discrimination and exclusion, and for society at large. To develop community-orientated services that are capable of promoting inclusion it will, therefore, be advantageous to all parties to understand what service users find most helpful. Method: A 2-year action research project explored the recovery journeys of a group of assertive outreach service users who had progressed from being socially excluded and occupationally deprived to being participants in their local communities. The research aimed to understand how these outcomes were produced and to use this knowledge to inform local service development. Findings: This paper focuses on eight qualitative interviews, where service users recounted their stories of community participation and inclusion. The findings show how assertive outreach practitioners harnessed occupation as a basis for building relationships between practitioners and service users, and how this became a conduit towards participation in the mainstream community. Conclusion: Facilitating engagement in community-based occupations through creative collaboration helped participants reconnect with cherished roles, achieve long-standing goals and develop feelings of self-efficacy, belonging and wellbeing.© The College of Occupational Therapists Ltd

If you build it, they still may not come: outcomes and process of implementing a community-based integrated knowledge translation mapping innovation

<p>Abstract</p> <p>Background</p> <p>Maps and mapping tools through geographic information systems (GIS) are highly valuable for turning data into useful information that can help inform decision-making and knowledge translation (KT) activities. However, there are several challenges involved in incorporating GIS applications into the decision-making process. We highlight the challenges and opportunities encountered in implementing a mapping innovation as a KT strategy within the non-profit (public) health sector, reflecting on the processes and outcomes related to our KT innovations.</p> <p>Methods</p> <p>A case study design, whereby the case is defined as the data analyst and manager dyad (a two-person team) in selected Ontario Early Year Centres (OEYCs), was used. Working with these paired individuals, we provided a series of interventions followed by one-on-one visits to ensure that our interventions were individually tailored to personal and local decision-making needs. Data analysis was conducted through a variety of qualitative assessments, including field notes, interview data, and maps created by participants. Data collection and data analysis have been guided by the Ottawa Model of Research Use (OMRU) conceptual framework.</p> <p>Results</p> <p>Despite our efforts to remove all barriers associated with our KT innovation (maps), our results demonstrate that both individual level and systemic barriers pose significant challenges for participants. While we cannot claim a causal association between our project and increased mapping by participants, participants did report a moderate increase in the use of maps in their organization. Specifically, maps were being used in decision-making forums as a way to allocate resources, confirm tacit knowledge about community needs, make financially-sensitive decisions more transparent, evaluate programs, and work with community partners.</p> <p>Conclusions</p> <p>This project highlights the role that maps can play and the importance of communicating the importance of maps as a decision support tool. Further, it represents an integrated knowledge project in the community setting, calling to question the applicability of traditional KT approaches when community values, minimal resources, and partners play a large role in decision making. The study also takes a unique perspective--where research producers and users work as dyad-pairs in the same organization--that has been under-explored to date in KT studies.</p

Good Care in Ongoing Dialogue. Improving the Quality of Care Through Moral Deliberation and Responsive Evaluation

Recently, moral deliberation within care institutions is gaining more attention in medical ethics. Ongoing dialogues about ethical issues are considered as a vehicle for quality improvement of health care practices. The rise of ethical conversation methods can be understood against the broader development within medical ethics in which interaction and dialogue are seen as alternatives for both theoretical or individual reflection on ethical questions. In other disciplines, intersubjectivity is also seen as a way to handle practical problems, and methodologies have emerged to deal with dynamic processes of practice improvement. An example is responsive evaluation. In this article we investigate the relationship between moral deliberation and responsive evaluation, describe their common basis in dialogical ethics and pragmatic hermeneutics, and explore the relevance of both for improving the quality of care. The synergy between the approaches is illustrated by a case example in which both play a distinct and complementary role. It concerns the implementation of quality criteria for coercion in Dutch psychiatry

Multiple sclerosis outpatient future groups: improving the quality of participant interaction and ideation tools within service improvement activities

BackgroundImproving the patient experience is a key focus within the National Health Service. This has led us to consider how health services are experienced, from both staff and patient perspectives. Novel service improvement activities bring staff and patients together to use design-led methods to improve how health services are delivered. The Multiple Sclerosis Outpatient Future Group study aimed to explore how analogies and props can be used to facilitate rich interactions between staff and patients within these activities. This paper will consider how these interactions supported participants to share experiences, generate ideas and suggest service improvements. MethodQualitative explorative study using ‘future groups,’ a reinterpretation of the recognised focus groups method directed towards exploring future alternatives through employing analogies and physical props to engage participants to speculate about future service interactions and health experiences. Participants were people with multiple sclerosis (PwMS) and outpatient staff: staff nurses, nursing assistants, junior sisters and reception staff. ResultsUse of future groups, analogies and physical props enabled PwMS and outpatient staff to invest their own ideas and feelings in the service improvement activity and envisage alternative health care scenarios. The combination of participants in the groups with their diverse perspectives and knowledge of the service led to a collaborative approach in which staff highlighted potential practical problems and patients ensured ideas were holistic. Service improvements were prototyped and tested in the outpatient clinic. ConclusionDesign-led methods such as future groups using analogies and physical props can be used to facilitate interactions between staff and patients in service improvement activities, leading to the generation of meaningful ideas. It is hoped that improving the quality of ideation tools within design-led methods can contribute to developing successful service interventions in service improvement activities. <br/

The Usefulness of the Person-Environment-Occupation Model in an Acute Physical Health Care Setting

Background: Limited evidence is available to illustrate the use of theory to underpin\ud occupational therapy practice in acute physical health care settings.\ud Methods: A generic qualitative method investigated the views, knowledge and\ud perceptions of seven Scottish occupational therapists about the potential usefulness\ud of the Person-Environment-Occupation Model (PEO Model) in acute care. This\ud convenience sample participated in two focus groups: the first to examine and\ud understand the PEO Model and the second to explore further reflections of the\ud strengths and limitations of its use in practice.\ud Findings: The PEO Model has the potential to provide a meaningful framework\ud in which to conceptualise patients in an acute physical health care setting.\ud Conclusions: The PEO Model offers flexibility regarding the extent to which\ud occupational performance is addressed, in a setting characterised by short\ud hospital admission stays. Also, a range of occupation-focused models was valued\ud to practise effectively in this setting

Chances for learning intraprofessional collaboration between residents in hospitals

Contains fulltext : 229569.pdf (Publisher’s version ) (Open Access)CONTEXT: Intraprofessional collaboration (intraPC) between primary care (PC) doctors and medical specialists (MSs) is becoming increasingly important. Patient safety issues are often related to intraPC. In order to equip doctors well for their task of providing good quality and continuity of care, intraPC needs explicit attention, starting in postgraduate training. Worldwide, PC residents undertake a hospital placement during their postgraduate training, where they work in proximity with MS residents. This placement offers the opportunity to learn intraPC. It is yet unknown whether and how residents learn intraPC and what barriers to and opportunities for exist in learning intraPC during hospital placements. METHODS: We performed an ethnographic non-participatory observational study in three emergency departments and three geriatric departments of five hospitals in the Netherlands. This was followed by 42 in-depth interviews with the observed residents and supervisors. The observations were used to feed the questions for the in-depth interviews. We analysed the interviews iteratively following the data collection using template analysis. RESULTS: Hospital wards are rich in opportunities for learning intraPC. These opportunities, however, are seldom exploited for various reasons: intraPC receives limited attention when formulating placement goals, so purposeful learning of intraPC hardly takes place; residents lack awareness of the learning of intraPC; MS residents are not accustomed to searching for expertise from PC residents; PC residents adapt to the MS role and they contribute very little of their PC knowledge, and power dynamics in the hospital department negatively influence the learning of intraPC. Therefore, improvements in mindset, professional identity and power dynamics are crucial to facilitate and promote intraPC. CONCLUSIONS: Intraprofessional collaboration is not learned spontaneously during hospital placements. To benefit from the abundant opportunities to learn intraPC, adjustments to the set-up of these placements are necessary. Learning intraPC is promoted when there is a collaborative culture, hierarchy is limited, and there is dedicated time for intraPC and support from the supervisor