Mylopoulos Maria, Farhat Walid
Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, ON, Canada,
Adv Health Sci Educ Theory Pract. 2015 May;20(2):371-83. doi: 10.1007/s10459-014-9533-5. Epub 2014 Aug 10.
Clinicians' purposeful improvement of practice is vital to maintaining excellence in patient care. This activity is understood as a core competency of adaptive expertise. As part of a broader program of research exploring adaptive expertise in healthcare, this study explored purposeful improvement in paediatric minimally invasive surgery. A cognitive ethnography was conducted, with the aim of identifying and elaborating distributed cognitive processes that occur when an individual enacts purposeful improvements in a clinical context. A saturation sample of data from weekly pre-operative meetings, 13 observed minimally invasive procedures and 12 semi-structured interviews was collected over 6 months. A concurrent analysis of field notes and transcribed interviews was done inductively to uncover emergent themes. An audit trail was maintained throughout the research. We analyzed the interview and observation data with particular attention to the ways in which the activity of purposeful improvement is distributed socially (e.g. patient families, health care team) and materially (e.g. procedure, patient position, instruments, OR equipment) as well as over time (i.e. before, during and after). These results made visible the distributed nature of purposeful improvement, building on our understanding of this important adaptive expert activity in clinical settings and suggesting implications for more effective training of future adaptive experts. In particular, our results inform how purposeful improvement can occur during daily work and highlight two related forms of integration that occur during this activity: integration of individual competencies and integration of individuals and their social and material context.
临床医生有目的地改进实践对于保持卓越的患者护理至关重要。这种活动被视为适应性专长的核心能力。作为探索医疗保健领域适应性专长的更广泛研究计划的一部分，本研究探讨了小儿微创手术中有目的的改进。进行了一项认知民族志研究，目的是识别和阐述个体在临床环境中进行有目的改进时发生的分布式认知过程。在6个月内收集了来自每周术前会议、13次观察到的微创手术和12次半结构化访谈的数据饱和样本。对实地笔记和转录访谈进行了归纳式的同步分析，以发现新出现的主题。在整个研究过程中保持了审计线索。我们分析了访谈和观察数据，特别关注有目的改进活动在社会层面（如患者家属、医疗团队）和物质层面（如手术、患者体位、器械、手术室设备）以及随时间（即手术前、手术中和手术后）的分布方式。这些结果揭示了有目的改进的分布式性质，基于我们对临床环境中这一重要适应性专家活动的理解，并为未来适应性专家的更有效培训提出了启示。特别是，我们的结果说明了有目的的改进如何在日常工作中发生，并突出了在此活动中发生的两种相关整合形式：个人能力的整合以及个人与其社会和物质环境的整合。
