A Sociomaterial Analysis of Team-based Care for Patients with Advanced Heart Failure

This dissertation explores team-based care for patients with advanced heart failure (HF), especially care practices associated with integrating palliative care. Its three integrated articles explore advanced HF care as a team-based health care phenomena, focusing on both objects and people as integral for team activity. The dissertation utilizes the theoretical framework of sociomaterialism to explore the overarching research question: how do materials mediate and influence the integration of palliative and cardiac care for patients with HF? Study data take the form of 15 team sampling units (TSU), each of which consists of a patient interview and an interview with at least one caregiver and one health professional identified by that patient as members of their care team. Data were analyzed through the lens of actor-network theory (ANT). The first study delves into the sociomaterial underpinnings of HF self-care, focusing on patients and caregivers involved with fluid management in their domestic lives. The study highlights the material effects of fluid and its management for patients and caregivers, as well as the way these material effects build into wider network effects. The manuscript discusses how ANT can enrich recent calls in the HF self-care literature for increased attention to `context\u27 in HF self-care. The second study explores how our understanding of health care teamwork shifts when materials, like fluid, are described as actors on the HF team. The paper describes the agency of fluid, a heretofore taken-for-granted material in descriptions of team-based HF care. Fluid is a matter of concern at the centre of interprofessional collaboration between cardiologists and nephrologists. The study advances one of the core theoretical insights of my dissertation,---collaborative entanglement---an innovative construct for understanding and reconceptualizing phenomena that researchers and policymakers frequently label `interprofessional collaborative tensions\u27. The third study directly engages the ideas and values of palliative care integration for HF. The paper argues that while sociological explanations are crucial to policy programming around palliative care (PC) integration, they are insufficient for fully appreciating the challenges faced by HF care teams who are actively trying to integrate PC. The paper attempts to answer the question: why does palliative care integration fail even when human roles are clear, local culture is supportive, and team knowledge is accurate? ANT is invoked to re-frame the discussion about `under-utilization\u27 of PC services for patients with HF. Each of these three analytic projects contributes to a growing interest in sociomaterialism amongst medical education researchers in Europe and North America. In the final chapter, key ideas from the overarching analysis are explored alongside methodological reflections. While the focus of this study is fluid, hopefully these results and insights can inspire further innovative sociomaterial inquiry in medical education

The journalism of Neil Munro: fiction, criticism and cultural comment

In a period of over thirty years from the mid 1890s, Neil Munro occupied a unique position in Scotland’s literary and social scenes. Although perhaps now best known as a novelist, short-story writer or essayist Munro was primarily a journalist, mainly with Glasgow’s Evening News and later in life with the Daily Record, and in this role he cast a wide and critical eye over Scottish life and letters. This research focuses primarily on Neil Munro’s journalistic output in the (Glasgow) Evening News and seeks to determine his views on literature, his literary and artistic peers and contemporary and current affairs in two specific periods gathered from prime records (from 22nd August 1895 to 27th January 1898 and at the resumption of the columns after the Great War, 19th June 1919 to 28th June 1920) and from published compilations of articles gathered throughout his career until 1927. In compiling two weekly columns in the Evening News, The Looker-On on the Monday and Views and Reviews on the Thursday, Munro influenced the opinions and reading habits of a large section of the population of the west of Scotland. In Views and Reviews he set out his views on the meaning of art and literature, nationally and internationally; in The Looker-On Munro sketched the world around him, whether local or national or international, through his eclectic choice of topics and his personable and endearing style. The thesis is structured in three main parts, each one dealing, in short, focussed episodes, on topics arising from the journalism. Part One deals mainly with material before the First World War; Part Two with issues which straddle the pre- and post-War periods; Part Three considers the episodic fiction found in The Looker-On columns. Rather than adopt a general, over-arching argument, this approach allows us to take shorter, sharper assessments of Munro’s views of particular aspects of the culture that was his context. These then gradually accumulate to allow us to draw general conclusions only after we have allowed each one its particular value and place. This consideration of a range of subjects builds up a picture of a journalist with strong views on the state of literature, of Scotland, of all the arts. His opinions are founded on Victorian and Edwardian sensibilities, in the sense that he is open to the working of arts and science in society as a whole, and the romantic tradition, in that he engages emotionally as well as intellectually with his subjects, seeking passion in the work of others rather than intellectual rigour. Crucial to the structure of the thesis is the argument that by considering these two periods of his journalism, pre-War (1895 – 98) and post-War (1919 – 1927), two different aspects of Munro’s character can be understood more profoundly. Pre-war, his journalism expresses his healthy curiosity in human nature, his comfort in tradition and the effect of scientific and social progress and a creeping globalism on the citizens of his adopted city. Post-war, acknowledging the changes caused by the Great War, he seems to become paralysed, trying to respond to new literary and social structures, rejecting the experimentalism of modernism and seeing no need or value in an organised “Scottish Renaissance”. And yet, as the research for this thesis should make clear, the late nineteenth- and early twentieth-century sensibility that is evident in Munro’s journalism does in fact carry him forward into the context of the modern world in his three series of episodic fiction, Erchie (1902-1926), Para Handy (1905-1924) and Jimmy Swan (1911-1917 and then 1923-1926). In conclusion, I will suggest that the essential literary value and popularity of these stories lies in their emergence from the pre-War sensibility and their characters’ humble sympathy for the pre-War world

Le pouvoir et l’appropriation des discours dans les constructions parlementaires au Canada : Le cas des débats sur la Loi sur l’Accord définitif Nisga’a

Cet article examine la ratification vivement contestée d’un traité entre l’État du Canada et la Première nation Nisga’a, communauté autochtone localisée sur la côte ouest de la Colombie-Britannique. Les thèmes de l’analyse sont la forme du débat parlementaire, l’invocation par les membres d’une autorité supposée et le choix de la langue en tant qu’outil stratégique. Le Parlement canadien se compose de deux assemblées, la Chambre des Communes, élue, et le Sénat, dont les membres sont nommés. En analysant le contexte idéologique entourant les débats sur la Loi sur l’Accord définitif Nisga’a, nous avons découvert des différences significatives entre les deux Chambres, dues, en grande partie, aux contextes structurellement différents des deux forums.This paper examines the hotly-contested ratification of a treaty between the state of Canada and the Nisga’a First Nation, an aboriginal community located in the west coast province of British Columbia. The form of Parliamentary debate in the bicameral legislature, the invocation of assumed authority by the members and the choice of language as a strategic tool provide themes in the analysis. The Canadian Parliament is comprised of two Houses, the elected House of Commons and the appointed Senate. In our analysis of the ideological context surrounding the debates on the Nisga’a Final Agreement, we found significant differences between the two Houses, in large part due to the differing structural contexts of the fora.Este artículo examina la ratificación fuertemente contestada de un Tratado entre Canadá y la Primera nación Nisga’a, comunidad autóctona localizada en la costa oriental de la Colombia británica. Los temas del análisis son: la forma del debate parlamentario, la invocación de una supuesta autoridad de sus miembros, y la selección de la lengua en tanto que herramienta estratégica. El parlamento canadiense está compuesto por dos asambleas: la Cámara de los Comunes, elegidos. Y el Senado, cuyos miembros son nombrados. Al analizar el contexto ideológico en torno de los debates sobre la Ley sobre el Acuerdo definitivo con los Nisga’a, hemos descubierto diferencias significativas entre las dos Cámaras, debidas en gran parte a los contextos estructuralmente diferentes de los dos foro

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

Étude qualitative sur l’expérience des résidents canadiens du modèle d’éducation médicale fondée sur les compétences

Background: Competency-based medical education (CBME) is an outcomes-based curricular paradigm focused on ensuring that graduates are competent to meet the needs of patients. Although resident engagement is key to CBME’s success, few studies have explored how trainees have experienced CBME implementation. We explored the experiences of residents in Canadian training programs that had implemented CBME. Methods: We conducted semi-structured interviews with 16 residents in seven Canadian postgraduate training programs, exploring their experiences with CBME. Participants were equally divided between family medicine and specialty programs. Themes were identified using principles of constructivist grounded theory. Results: Residents were receptive to the goals of CBME, but in practice, described several drawbacks primarily related to assessment and feedback. For many residents, the significant administrative burden and focus on assessment led to performance anxiety. At times, residents felt that assessments lacked meaning as supervisors focused on “checking-boxes” or provided overly broad, non-specific comments. Furthermore, they commonly expressed frustration with the perceived subjectivity and inconsistency of judgments on assessments, especially if assessments were used to delay progression to greater independence, contributing to attempts to "game the system". Faculty engagement and support improved resident experiences with CBME. Conclusion: Although residents value the potential for CBME to improve the quality of education, assessment and feedback, the current operationalization of CBME may not be consistently achieving these objectives. The authors suggest several initiatives to improve how residents experience assessment and feedback processes in CBME.Contexte : L’éducation médicale fondée sur les compétences (EMFC) est un paradigme dans lequel le programme de formation est axé sur les résultats et vise à garantir que les diplômés aient les compétences nécessaires pour répondre aux besoins des patients. Bien que l’engagement des résidents soit la clé du succès de l’EMFC, peu d’études ont exploré comment ils vivent son introduction. Nous nous sommes penchés sur l’expérience des résidents dans les programmes de formation canadiens qui ont mis en œuvre l’EMFC. Méthodes : Nous avons mené des entrevues semi-structurées avec 16 résidents de sept programmes de formation postdoctorale canadiens, afin de sonder leur expérience de l’EMFC. Les participants étaient répartis de façon égale entre la médecine familiale et les programmes de spécialité. Les thèmes ont été dégagés en appliquant les principes de la théorie enracinée constructiviste. Résultats : Bien que réceptifs aux objectifs de l’EMFC, les résidents décrivent des inconvénients de sa mise en pratique, notamment sur le plan de l’évaluation et de la rétroaction. Pour beaucoup d’entre eux, la focalisation sur l’évaluation et le fardeau administratif qui y est lié ont été une source d’anxiété de performance. Les résidents ont l’impression que les évaluations manquent parfois de pertinence, car les superviseurs, se sentant contraints de « cocher des cases », font des commentaires trop généraux et peu ciblés. De plus, un sentiment de frustration a été fréquemment exprimé face à la subjectivité et l’incohérence perçues des jugements dans les évaluations, surtout lorsque ces dernières sont utilisées pour retarder le cheminement vers une plus grande indépendance, constituant ainsi une tentative de « déjouer le système ». L’implication et le soutien du corps professoral ont aidé à bonifier l’expérience des résidents. Conclusion : Bien que les résidents apprécient le potentiel de l’EMFC pour rehausser la qualité de l’éducation, de l’évaluation et de la rétroaction, son opérationnalisation actuelle ne permet pas d’atteindre ces objectifs de façon systématique. Les auteurs proposent quelques initiatives pour améliorer la façon dont les résidents vivent les processus d’évaluation et de rétroaction dans le cadre de l’EMFC

Depressed Affect And Historical Loss Among North American Indigenous Adolescents

This study reports on the prevalence and correlates of perceived historical loss among 459 North American Indigenous adolescents aged 11–13 years from the northern Midwest of the United States and central Canada. The adolescents reported daily or more thoughts of historical loss at rates similar to their female caretakers. Confirmatory factor analysis indicated that our measure of perceived historical loss and the Center for Epidemiologic Studies Depression scale were separate but related constructs. Regression analysis indicated that, even when controlling for family factors, perceived discrimination, and proximal negative life events, perceived historical loss had independent effects on adolescent’s depressive symptoms. The construct of historical loss is discussed in terms of Indigenous ethnic cleansing and life course theory

Patterns and trends among physicians-in-training named in civil legal cases: a retrospective analysis of Canadian Medical Protective Association data from 1993 to 2017

BACKGROUND: Medico-legal data show opportunities to improve safe medical care; little is published on the experience of physicians-in-training with medical malpractice. The purpose of this study was to examine closed civil legal cases involving physicians-in-training over time and provide novel insights on case and physicians characteristics. METHODS: We conducted a retrospective descriptive study of closed civil legal cases at the Canadian Medical Protective Association (CMPA), a mutual medico-legal defence organization for more than 105 000 physicians, representing an estimated 95% of physicians in Canada. Eligible cases involved at least 1 physician-in-training and were closed between 1993 and 2017 (for time trends) or 2008 and 2017 (for descriptive analyses). We analyzed case rates over time using Poisson regression and the annualized change rate. Descriptive analyses addressed case duration, medico-legal outcome and patient harm. We explored physician specialties and practice characteristics in a subset of cases. RESULTS: Over a 25-year period (1993-2017), 4921 physicians-in-training were named in 2951 closed civil legal cases, and case rates decreased significantly (β = -0.04, 95% confidence interval -0.05 to -0.03, where β was the 1-year difference in log case rates). The annualized change rate was -1.1% per year. Between 2008 and 2017, 1901 (4.1%) of 45 967 physicians-in-training were named in 1107 civil legal cases. Cases with physicians-in-training generally involved more severe patient harm than cases without physicians-in-training. In a subgroup with available information (n = 951), surgical specialties were named most often (n = 531, 55.8%). INTERPRETATION: The rate of civil legal cases involving physicians-in-training has diminished over time, but more recent cases featured severe patient harm and death. Efforts to promote patient safety may enhance medical care and reduce the frequency and severity of malpractice issues for physicians-in-training

Early Spanish meteorological records (1780-1850)

This article summarizes recent efforts on early instrumental data recovery in Spain conducted under the Salvà-Sinobas project. We have retrieved and digitized more than 100 000 meteorological observations prior to 1850 in Spain. This data set contains measurements of air temperature, atmospheric pressure, wind direction and state of the atmosphere in 16 places located in Iberia and the Balearic Islands. Most of the observations are made on a daily basis. However, monthly and annual information has also been retrieved. The time coverage of the series is not homogeneous, with the earliest records starting in Seville in 1780. Prior to this work only two series were available in Spain (i.e. Cádiz and Barcelona), so this data set represents a great advance in the early data availability for Spain. Due to the lack of metadata in most of the series, their interpretation must be made with caution

Gene Transcription Changes in Asthmatic Chronic Rhinosinusitis with Nasal Polyps and Comparison to Those in Atopic Dermatitis

Asthmatic chronic rhinosinusitis with nasal polyps (aCRSwNP) is a common disruptive eosinophilic disease without effective medical treatment. Therefore, we sought to identify gene expression changes, particularly those occurring early, in aCRSwNP. To highlight expression changes associated with eosinophilic epithelial inflammation, we further compared the changes in aCRSwNP with those in a second eosinophilic epithelial disease, atopic dermatitis (AD), which is also closely related to asthma.Genome-wide mRNA levels measured by exon array in both nasosinus inflamed mucosa and adjacent polyp from 11 aCRSwNP patients were compared to those in nasosinus tissue from 17 normal or rhinitis subjects without polyps. Differential expression of selected genes was confirmed by qRT-PCR or immunoassay, and transcription changes common to AD were identified. Comparison of aCRSwNP inflamed mucosa and polyp to normal/rhinitis tissue identified 447 differentially transcribed genes at > or = 2 fold-change and adjusted p-value < 0.05. These included increased transcription of chemokines localized to chromosome 17q11.2 (CCL13, CCL2, CCL8, and CCL11) that favor eosinophil and monocyte chemotaxis and chemokines (CCL18, CCL22, and CXCL13) that alternatively-activated monocyte-derived cells have been shown to produce. Additional transcription changes likely associated with Th2-like eosinophilic inflammation were prominent and included increased IL1RL1 (IL33 receptor) and EMR1&3 and decreased CRISP2&3. A down-regulated PDGFB-centric network involving several smooth muscle-associated genes was also implicated. Genes at 17q11.2, genes associated with alternative activation or smooth muscle, and the IL1RL1 gene were also differentially transcribed in AD.Our data implicate several genes or gene sets in aCRSwNP and eosinophilic epithelial inflammation, some that likely act in the earlier stages of inflammation. The identified gene expression changes provide additional diagnostic and therapeutic targets for aCRSwNP and other eosinophilic epithelial diseases