Our findings suggest that to draw meaningful conclusions about reflective capacity as a stable construct in individuals requires 14 writing samples per student, each assessed by four or five raters. This calls into question the feasibility and utility of using reflective writing rigorously as an assessment tool in undergraduate medical education.

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Research indicates a decline in mental health service utilization between the ages of 16 to 25, leaving emerging adults with mental illness at risk for worsening outcomes. The authors utilized a community-based participatory research (CBPR) approach to explore the mental health landscape for youth aged 16–25 in London, Canada. Interviews and focus groups (n = 30) with community and hospital system leaders, youth and caregivers were transcribed and coded using an approach informed by constructivist grounded theory. There was consensus regarding difficulties in the current system including wait times and crisis-driven services leading to powerlessness among youth and caregivers. Solutions include delivery of services through a flexible, real-time system that emphasizes patient and caregiver engagement, youth centric services and recovery-oriented care across the hospital/community continuum. The results highlight that disparate stakeholders agree regarding the need for transformational change shifting away from traditional medical models.

Background: Most laypeople have not engaged in any advance care planning. Yet they are expected to articulate choices for life-sustaining interventions when they need admission to an acute care hospital in Canada. Aim: To describe how laypeople understand and make decisions for life-sustaining interventions when engaging in advance care planning. Design: Semi-structured interviews using constructivist grounded theory methodology and purposive sampling. Setting: Mid-size Canadian urban community Participants: In total, 20 healthy laypeople, 55 years and older, participated in in-depth semi-structured face-to-face interviews. Theoretical sampling was used to explore findings from the first round of interviews. Ten participants were invited for repeat interviews. Results: Four major themes were identified. Most participants claimed at the outset that they had engaged in advance care planning, but they were unfamiliar with contemporary life-sustaining interventions and had not factored these into their decisions. Participants’ confidence in their substitute decision makers precluded them from having explicit discussions with these individuals. Participants expressed their values and preferences in terms of unacceptable functional outcomes from serious illness, rather than desired interventions. The process of articulating their preferences within the interviews was subject to decision conflicts, which in turn helped them re-evaluate and refine their decisions. Conclusion: Advance care planning for the healthy older adult is challenging. Meaningful engagement may lead to conflicts in decision-making. Efforts to improve engagement must reflect what patients know and understand, their focus on unacceptable negative outcomes rather than interventions, and the need for iterative discussions with health-care providers.

IntroductionStigmatizing attitudes and behaviours towards patients with mental illness have negative consequences on their health. Despite research regarding educational and social contact-based interventions to reduce stigma, there are limitations to the success of these interventions for individuals with deeply held stigmatizing beliefs. Our study sought to better understand the process of implicit mental illness stigma in the setting of a paediatric emergency department to inform the design of future educational interventions.MethodsWe conducted a qualitative exploration of mental illness stigma with interviews including physician, nurse, service user, caregiver and administrative staff participants (n = 24). We utilized the implicit association test as a discussion prompt to explore stigma outside of conscious awareness. We conducted our study utilizing constructivist grounded theory methodology, including purposeful theoretical sampling and constant comparative analysis.ResultsOur study found that the confluence of socio-cultural, cognitive and emotional forces results in labelling of patients with mental illness as time-consuming, unpredictable and/or unfixable. These labels lead to unintentional avoidance behaviours from staff which are perceived as prejudicial and discriminatory by patients and caregivers. Participants emphasized education as the most useful intervention to reduce stigma, suggesting that educational interventions should focus on patient-provider relationships to foster humanizing labels for individuals with mental illness and by promoting provider empathy and engagement.DiscussionOur results suggest that educational interventions that target negative attributions, consider socio-cultural contexts and facilitate positive emotions in healthcare providers may be useful. Our findings may inform further research and interventions to reduce stereotypes towards marginalized groups in healthcare settings.