Learning clinical communication on ward-rounds: an ethnographic case study.

OBJECTIVE: To explore what factors influence student-doctors' learning of clinical communication on ward-rounds and how such learning can be enhanced. METHODS: Adopting a qualitative ethnographic approach, the author audio recorded and observed 63 bedside episodes within 18 ward-rounds on four different wards over an 8-week period. Nine fourth year student-doctors and four clinicians also participated in semi-structured interviews. The combination of observations, audio-recordings, transcriptions, field notes, and interview data allowed us to produce a detailed description of the case. RESULTS: Each bedside episode offered opportunities for learning about clinical communication. However, the student-doctors did not always recognise that they were learning about clinical communication, since in this context, they were not being explicitly taught about communication. Student-doctors were rarely invited to participate in the ward-round and clinicians overlooked opportunities for learning. Some student-doctors questioned the educational value of ward-rounds and did not always attend. CONCLUSIONS: Ward-rounds are a rich site for learning clinical communication but opportunities for learning are often overlooked. PRACTICE IMPLICATIONS: By being alert to the power of role modelling and the importance of inclusion and participation, student-doctors' learning of clinical communication can be enhanced even on busy ward rounds.This is the final published version of the article and will be under embargo until the 26th of August 2015. This version was first published in Medical Teacher here: http://informahealthcare.com/doi/abs/10.3109/0142159X.2014.947926

In the lion's den? Experiences of interaction with research ethics committees

Research ethics review is an important process, designed to protect participants in medical research. However, it is increasingly criticised for failing to meet its aims. Here, two researchers reflect on their experiences of applying for ethical approval of observational research in clinical settings. They highlight some problems faced by reviewers and researchers and propose a two-stage ethical review process that would alert researchers to the committee's concerns and allow them to give a more considered response

Enabling fourth year student-doctors to learn through participation on ward rounds : an action research study

This thesis develops the concept of apprenticeship to capture and explore how the learning of\ud student doctors takes place in hospital ward rounds, with the aim of developing pedagogical\ud approaches that enable and improve learning. The research pays particular attention to the\ud shifting complexities of the hospital and ward-round environment and the ambiguous status\ud of student-doctors as participants.\ud Using action research the study sets up a collaborative inquiry with eleven student-doctors\ud who use audio-diaries and reflective learning sessions to harness learning from ward-round\ud experiences, explore the nature of their participation and facilitate critical reflection both on\ud and through the workplace. Exploration enables the student-doctors to see that learning\ud needs to be understood not simply as an intellectual activity but as participation in social\ud practice and that this necessitates focusing upon development of their agency and\ud professional identity.\ud Changes were identified at three levels: in the student-doctors' practice, in their\ud understandings of practice and in the conditions under which they practised. Nine of the\ud students were enabled to learn through active participation on the ward round. Eight studentdoctors\ud came to understand they were learning about becoming a doctor. By changing their\ud own understandings of forms of knowledge, of their role and opportunities for learning they\ud influenced the way other clinicians responded to them and were offered more opportunities\ud to participate.\ud The thesis as a whole represents an original and distinct contribution to the growing sociocultural\ud literature in medical education and specifically points to the need for changes in the\ud way learning in the workplace is conceptualised. It challenges medical educators and policy\ud makers to think not just about the individual, but also the culture and power relationships\ud which shape select and legitimise what learning affordances the student-doctors attend to;\ud that is the relational interdependence between personal and social agency.\u

Caring for quality of care: symbolic violence and the bureaucracies of audit.

BACKGROUND: This article considers the moral notion of care in the context of Quality of Care discourses. Whilst care has clear normative implications for the delivery of health care it is less clear how Quality of Care, something that is centrally involved in the governance of UK health care, relates to practice. DISCUSSION: This paper presents a social and ethical analysis of Quality of Care in the light of the moral notion of care and Bourdieu's conception of symbolic violence. We argue that Quality of Care bureaucracies show significant potential for symbolic violence or the domination of practice and health care professionals. This generates problematic, and unintended, consequences that can displace the goals of practice. SUMMARY: Quality of Care bureaucracies may have unintended consequences for the practice of health care. Consistent with feminist conceptions of care, Quality of Care 'audits' should be reconfigured so as to offer a more nuanced and responsive form of evaluation