Elise Paradis

While science policymakers and university administrators in Canada have been pushing interdisciplinary research and greater collaboration between the social sciences, humanities and health research, social scientists and humanists face several cultural and material hurdles that limit their ability to participate fully in the health research field. In this chapter, we use neo-institutionalist theory and Pierre Bourdieu's social theory to shed light on these challenges. We argue, based on institutional data and qualitative interviews with social scientists and humanists in medicine-related programs, that merely wishing for successful interdisciplinarity does not erase the tensions between different doxa (i.e. field logics) and leads to decoupling. Our research suggests that for social scientists and humanists to succeed in the health research fields, they often have to adapt to their new field and transform their work to align with the doxa of medicine. This necessary adaptation c...

This paper explores social scientists' and humanities (SSH) scholars' integration within the academic medical research environment. Three questions guided our investigation: Do SSH scholars adapt to the medical research environment? How do they navigate their career within a culture that may be inconsistent with their own? What strategies do they use to gain legitimacy? The study builds on three concepts: decoupling, doxa, and epistemic habitus. Twenty-nine semi-structured interviews were conducted with SSH scholars working in 11 faculties of medicine across Canada. Participants were selected through purposeful and snowball sampling. The data were analyzed by thematic content analysis. For most of our participants, moving into medicine has been a challenging experience, as their research practices and views of academic excellence collided with those of medicine. In order to achieve some level of legitimacy more than half of our participants altered their research practices. ...

Page 1. 1 Bourdieu, Bodies and Boxing: The Multidimensionality of Bodily Capital EliseParadis Ph.D. Candidate, MA Sociology Stanford University School of Education http://www.stanford.edu/~eparadis eparadis@stanford.edu Page 2. 2 Abstract. ...

Although effective interprofessional collaboration is a key component of patient safety and quality improvement initiatives, little is known about the nature of collaboration in ICU settings. Through ethnographic research, this study will explore interprofessional care in 8 ICUs (6 based in the United States and 2 based in Canada), develop an empirically based readiness/diagnostic tool to assess the quality of team-based care delivery, and develop interventions to strengthen team-based care and patient family involvement. Our study has 3 iterative phases and will involve: a scoping review of the literature on team dynamics in the ICU, an ethnographic study (observation, shadowing, interviews) across 8 sites over 2 years and the collection of clinical outcomes data to inform the development of a “diagnostics” tool for interprofessional collaboration and family member involvement in ICU care, as well as interprofessional intervention development. The importance of ethnographic and other forms of qualitative research for the improvement of health care delivery has already been recognized. This study’s comparative design and the richness of its data have the potential to generate a multidimensional understanding of the processes of interprofessional collaboration and patient family member involvement. The creation of generally applicable, empirically grounded tools also has the potential to enhance these processes.

At the heart of safe cultures are effective interactions within and between interprofessional teams. Critical care clinicians see severely ill patients who require coordinated interprofessional care. In this scoping review, we asked: "What do we know about processes, relationships, organizational and contextual factors that shape the ability of clinicians to deliver interprofessional care in adult ICUs?" Using the 5-stage process established by Levac et al. (2010), we reviewed 981 abstracts to identify ethnographic articles that shed light on interprofessional care in the intensive care unit. The quality of selected articles is assessed using best practices in ethnographic research; their main insights evaluated in light of an interprofessional framework developed by Reeves et al (Interprofessional Teamwork for Health and Social Care. San Francisco, CA: Wiley-Blackwell; 2010). Overall, studies were of mixed quality, with an average (SD) score of 5.8 out of 10 (1.77). Insights into intensive care unit cultures include the importance of paying attention to workflow, the nefarious impact of hierarchical relationships, the mixed responses to protocols imposed from the top down, and a general undertheorization of sex and race. This review highlights several lessons for safe cultures and argues that more needs to be known about the context of critical care if quality and safety interventions are to succeed.

Translating and scaling healthcare quality improvement (QI) and patient safety interventions remains a significant challenge. Context has been identified as a major factor in this. QI and patient safety research have begun to focus on context, with ethnography seen as a promising methodology for understanding the professional, organisational and cultural aspects of context. While ethnography is used to investigate the context of a variety of QI and safety interventions, the challenges inherent in effectively importing a qualitative methodology and its social science practitioners into this work have been largely unexamined.
We explain ethnography as a research practice grounded in theory and dependent on observations gathered and interpreted in particular ways. We then review the approach of health services literature to evaluating this sort of qualitative research. Although the study of context is an interest shared by both social scientists and healthcare QI and safety researchers, we identify three key points at which those 'exporting' ethnography as a methodology and those 'importing' it to deal with QI and safety challenges may diverge. We describe perspectival divergences on the methodology's mission, form and scale. At the level of mission we demonstrate how ethnography has been adapted to a 'describe and feed back' role in the service of QI. At the level of form, we show how the long-term embedded observation at the heart of ethnography can be adapted only so far to accommodate QI interests if both data quality and ethical standards are to be upheld. Finally, at the level of scale, we demonstrate one ethnographic study design that balances breadth of exposure with depth of experience in its observations and so generates a particular type of scalable findings.
The effective export of ethnography into QI and safety research requires discussion and negotiation between social scientific and health services research perspectives, as well as creative approaches to producing self-reflexive data that will allow clinicians to understand their own context and so improve their own processes.

Background The sustained clinical and policy interest in the United States and worldwide in quality and safety activities initiated by the release of To Err Is Human has resulted in some high-profile successes and much disappointment. Despite the energy and good intentions poured into developing new protocols and redesigning technical systems, successes have been few and far between, leading some to argue that more attention should be given to the context of care.

Objective To examine the insights provided by qualitative studies of interprofessional care delivery in intensive care.

Methods A total of 532 article abstracts were reviewed. Of these, 24 met the inclusion criteria.

Results Articles focused on the nurse-physician relationship, patient safety, patients’ families and end-of-life care, and learning and cognition. The findings indicated the complexities and nuances of interprofessional life in intensive care and also that much needs to be learned about team processes.

Conclusion The fundamental insight that interprofessional interactions in intensive care do not happen in a historical, social, and technological vacuum must be brought to bear on future research in intensive care if patient safety and quality of care are to be improved.

The sustained clinical and policy interest in the United States and worldwide on quality and safety activities1 initiated by the release of To Err Is Human2 has resulted in some high-profile successes3,4 and much disappointment. Both clinicians and the social scientists seeking to help clinicians have begun to call for more attention to interprofessional care and the context in which quality and safety interventions are implemented.5 Interprofessional care is a collaborative, team-based approach to providing optimal patient care and has been celebrated as a way to transform health care and the context of health care.6 In contrast, the general tendency to focus on technical and technological fixes has been described as a distraction, diverting attention from how safer care is really achieved.7 Understanding the social factors that help build a safety culture by changing the norms, values, and routine interactions of clinical teams has been identified as the next frontier in creating sustainable, scalable quality and safety improvements.8

At the heart of safe cultures are effective interactions among interprofessional teams and effective interactions with patients and patients’ families. For example, interprofessional care and the involvement of patients’ families have been identified as critical elements in the provision of high-quality palliative care.9,10 The need for effective team-based care to reduce duplication of effort, restrict clinical errors, improve safety, and enhance the quality of patient care is now widely acknowledged.2,11,12 An understanding of the interprofessional relationships that shape care delivery in intensive care units (ICUs) is fundamental to improving the relationships.13,14

Several authors have encouraged greater use of qualitative research methods in confronting health care challenges generally15–19 and critical care quality and safety projects more specifically.20,21 Ethnography is the study, through a systematic collection of detailed observations and interviews, of social interactions, behaviors, and perceptions that occur within teams, organizations, and communities.16 Of the range of qualitative research methods available, ethnography is recognized as the most appropriate for understanding how phenomena such as team dynamics, information technology, and the involvement of patients’ families affect and transform the goals and practices of quality improvement.

In this scoping review, we present the main insights of recent ethnographic research. We evaluate the nature, strengths, and weaknesses of the research and suggest new avenues for the study of team dynamics and patient care in the ICU.

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Methods

A scoping review is a review in which the extent, range, and nature of research in a specific area are examined to identify key concepts and main sources of evidence.22 This scoping review was undertaken to identify and examine the empirical ethnographic literature related to delivering care in adult ICUs. A total of 3 major databases (PubMed, CINAHL, and Scopus) were searched for ethnographic studies that were conducted in adult ICUs and focused on teams. Teams were defined broadly to include health care providers and patients’ family members. The abstracts of 532 articles were reviewed. Of these, 193 were of articles on team dynamics in ICUs. Extra articles were selected from the reference lists of these 193 articles. Of the set of articles thus identified, 24 met the inclusion criteria: the study was conducted in an industrialized country and published in English, included observational fieldwork as part of the data collection, and covered interprofessional interactions (between 2 or more professional groups). One autoethnographic article23 was excluded, for a final sample size of 23. Articles were coded by 1 investigator (E.P.) according to year of publication, country of origin, number of sites covered, whether or not data were analyzed across sites, duration of fieldwork, topic, and focus. Two investigators (E.P. and S.R.) met regularly to discuss the evolution of the coding scheme and the choice of topics, which clustered around 4 topics: the nurse-physician relationship; patient safety; end-of-life care and patients’ families; and learning, decision making, and cognition. The topics covered by each article were noted and served as the organizing principle for the narrative review. Articles covering more than a single topic were reviewed under each topic. The focus was a 1-sentence overview of each reviewed article that distilled the main contribution of the article.

Context
Interprofessional education (IPE) aspires to enable collaborative practice. Current IPE offerings, although rapidly proliferating, lack evidence of efficacy and theoretical grounding.

Objectives
Our research aimed to explore the historical emergence of the field of IPE and to analyse the positioning of this academic field of inquiry. In particular, we sought to investigate the extent to which power and conflict – elements central to interprofessional care – figure in the IPE literature.

Methods
We used a combination of deductive and inductive automated coding and manual coding to explore the contents of 2191 articles in the IPE literature published between 1954 and 2013. Inductive coding focused on the presence and use of the sociological (rather than statistical) version of power, which refers to hierarchies and asymmetries among the professions. Articles found to be centrally about power were then analysed using content analysis.

Results
Publications on IPE have grown exponentially in the past decade. Deductive coding of identified articles showed an emphasis on students, learning, programmes and practice. Automated inductive coding of titles and abstracts identified 129 articles potentially about power, but manual coding found that only six articles put power and conflict at the centre. Content analysis of these six articles revealed that two provided tentative explorations of power dynamics, one skirted around this issue, and three explicitly theorised and integrated power and conflict.

Conclusions
The lack of attention to power and conflict in the IPE literature suggests that many educators do not foreground these issues. Education programmes are expected to transform individuals into effective collaborators, without heed to structural, organisational and institutional factors. In so doing, current constructions of IPE veil the problems that IPE attempts to solve.

This article presents emerging findings from the first year of a two-year study, which employed ethnographic methods to explore the culture of interprofessional collaboration (IPC) and family member involvement in eight North American intensive care units (ICUs). The study utilized a comparative ethnographic approach - gathering observation, interview and documentary data relating to the behaviors and attitudes of healthcare providers and family members across several sites. In total, 504 hours of ICU-based observational data were gathered over a 12-month period in four ICUs based in two US cities. In addition, 56 semi-structured interviews were undertaken with a range of ICU staff (e.g. nurses, doctors and pharmacists) and family members. Documentary data (e.g. clinical guidelines and unit policies) were also collected to help develop an insight into how the different sites engaged organizationally with IPC and family member involvement. Directed content analysis enabled the identification and categorization of major themes within the data. An interprofessional conceptual framework was utilized to help frame the coding for the analysis. The preliminary findings presented in this paper illuminate a number of issues related to the nature of IPC and family member involvement within an ICU context. These findings are discussed in relation to the wider interprofessional and health services literature.

Morning interprofessional rounds (MIRs) are used in critical care medicine to improve team-based care and patient outcomes. Given existing evidence of conflict between and dissatisfaction among rounds participants, this study sought to better understand how the operational realities of care delivery in the intensive care unit (ICU) impact the success of MIRs. We conducted a year-long comparative ethnographic study of interprofessional collaboration and patient and family involvement in four ICUs in tertiary academic hospitals in two American cities. The study included 576 h of observation of team interactions, 47 shadowing sessions and 40 clinician interviews. In line with best practices in ethnographic research, data collection and analysis were done iteratively using the constant comparative method. Member check was conducted regularly throughout the project. MIRs were implemented on all units with the explicit goals of improving team-based and patient-centered care. Operational conditions on the units, despite interprofessional commitment and engagement, appeared to thwart ICU teams from achieving these goals. Specifically, time constraints, struggles over space, and conflicts between MIRs' educational and care-plan-development functions all prevented teams from achieving collaboration and patient-involvement. Moreover, physicians' de facto control of rounds often meant that they resembled medical rounds (their historical predecessors), and sidelined other providers' contributions. This study suggests that the MIRs model, as presently practiced, might not be well suited to the provision of team-based, patient-centered care. In the interest of interprofessional collaboration, of the optimization of clinicians' time, of high-quality medical education and of patient-centered care, further research on interprofessional rounds models is needed.

The field of interprofessional research has grown both in size
and in importance since the 1970s. In this paper, we use
a macrosociological approach and a Bourdieusian theoretical
framework to investigate this growth and the changing nature
of the field’s research. We investigate publication trends at the
aggregate (field) level, using an original dataset of 100 488
interprofessional-related articles published between 1970 and
2010 and recorded in the PubMed database. Articles were
coded using a list of 638 codes that were then analyzed
thematically and longitudinally. Our results are presented in
two main sections. Initially, we consider the growth and reach
of the interprofessional field. Second, we explore the five
different trends (“terminological issues”, “rising management
rhetoric”, “expansion of psychometrics”, “shift from
individualism to collectivism” and “emerging issues”) that
emerged out of our thematic analysis of publications over time.
These findings are discussed in the light of Bourdieu’s
framework to provide an indication of what we argue
is a growing legitimacy of the field of interprofessional research
as a scholarly domain in its own right.

Medical education does not occur in isolation - it is inextricably linked to the society in which the institutions of medical
education are based. This chapter explains why it is important to see medical education in the context of societies and
examines the implications of different social science traditions that have been brought to bear on medical education. First, it
frames medicine and medical education within a broader social context. A quick review of medicalisation theory and of the
recent history of medical education in the West is presented. Second, the chapter reviews the conceptual apparatus developed
by key social theorists: Goffman, Foucault and Bourdieu. The central concepts developed by each theorist to make sense of
the world are discussed; practical examples of how their perspectives could be applied to medical education research are
suggested; and previous literature using these perspectives to throw light on medical education are discussed. Third, the
chapter explores current hot topics in medical education research and reviews the contributions made by the social sciences in
these areas, This chapter concludes with suggestions as to the areas of medical education where social scientific insights could
be next applied. Overall, this chapter aims to: enrich the readers’ understanding of the present and future of medical education
by offering a range of lenses through which it can be investigated and stimulate the sociological imagination of researchers
through a review of some of sociology’s key texts on medical education.

In this ethnography of Full Contact, a San Francisco Bay Area boxing gym, I use Bourdieu’s theory of practice to illustrate how ‘rules of the game’ shape people’s perceptions, interactions and positions (capital). First, I show how the unwritten, unspoken rules of boxing as a field (its doxa) impact readings of bodies and bodily capital, readings that then have an impact on micro-level interactions and hierarchies at Full Contact. Second, I show the micro-level consequences of hysteresis – delays in the realignment of habitus and field that result from change at the field level – on social interactions and hierarchies. Gender is at the core of my analysis, for it is both a fundamental part of my and others’ habitus, and a symbolic trait of significance in the hypermasculine doxa of boxing as a field.

Sexual and gender minority youth currently aged 13–21 grew up with the Internet, and online resources and environments are important sources of information and socialization for them. Using data from a survey of 696 such minority youth from across the United States, this chapter answers three main questions: What features of lesbian, gay, bisexual, transgender, queer and questioning- (LGBTQ) specific online environments do these youth use? Why do they participate in LGBTQ online environments? What roles can adult allies play in facilitating positive online experiences for sexual and gender minority youth? Findings confirm sexual and gender minority youth’s need for identity development, belonging and community, and suggest potential, positive adult involvement.

Introduction: While there is a robust understanding of what patient and family engagement and involvement mean in chronic care out-patient settings, there is much less agreement on what these terms mean or how they ought to be operationalized in critical care. A systematic baseline study of how clinicians on intensive care units (ICUs) conceptualize patients and families may help develop ways to appropriately engage and involve them. Methods: A multi-site comparative ethnography (a qualitative study including observations, interviews and document analysis) was carried out to examine ICU clinicians' ways of thinking about and interacting with patients and family members. 4 MICUs in 4 teaching hospitals across 2 major urban areas in the US were recruited for this research. Data included more than 600 hours of observations, job shadowing and interviews; it was coded using an iterative analytic process in NVivo 10 (QSR International). Results: 5 different types of patients were identified, with each type varying along the two dimensions of technical and emotional difficulty. These typical patients were given the label: diagnostic mystery, anatomical oddity, psychosocial conundrum, iatrogenic casualty and the 'sweetie.' Similarly, 5 different types of families were identified: the complicated families, the irritant 'fakExperts,' the unwarranted hopers, the different folks, and the once bitten. Clinicians' negative emotional response to 'difficult' patients and families is often the most salient feature of care delivery, and tends to define relationships. Conclusions: Definitions and examples of these types of patients and families will be presented to illustrate clinicians' perspectives and suggest implications for patient and family care in the ICU. We argue that in order to develop ways to appropriately engage and involve patients and families we need to understand how they are conceptualized by clinicians: we need to open the black box.

Introduction: Broad policy and local healthcare organization have recently favored computerized case notes, care charting, order writing, and specialty service consultation/referral in Critical Care Units (CCUs). Methods: Data on the impact of IT on CCUs were extracted from a multi-site comparative ethnography. 4 CCUs with varying levels of computerization located in 2 major urban areas in the US were recruited for this qualitative research. Ethnographers carried out 600+ hours of observations, and 70+ semi-structured interviews between December 2012 and December 2013. A subset of the observation time - 90+ hours - was structured to quantify how long clinicians spent working on computers to chart care, keep case notes, and issue or acknowledge prescriptions. These data were used to supplement the study's qualitative focus on how IT influences team interactions and care delivery. The data were coded using NVivo software in an iterative analytic process. Results: Clinicians on the high computerization units spent between 35 and 50 per cent of their time on computers. Clinicians on the low computerization unit spent between 5 and 15 per cent of their time on computers. Key intended consequences of delivering care and coordinating teamwork and information with IT were achieved and these included the elimination of handwriting legibility issues, and improved access to clinical information. Unintended consequences included negative impacts on team coordination and communication. Some clinicians were 'siloed' by their IT work, and expressed concerns that they had less meaningful interactions with other members of their team and patients. Some clinicians felt these degraded interactions impeded their teams' abilities to develop trust and identify and prevent errors. Conclusions: This pilot study suggests the unintended teamwork consequences of computerization in CCUs are an important object of study, with IT implementation design likely to be of central importance in the future.