Navigating complexity in team‐based clinical settings

Abstract

Context Educators must prepare learners to navigate the complexities of clinical care. Training programmes have, however, traditionally prioritised teaching around the biomedical and the technical, not the socio‐relational or systems issues that create complexity. If we are to transform medical education to meet the demands of 21st century practice, we need to understand how clinicians perceive and respond to complex situations. Methods Constructivist grounded theory informed data collection and analysis; during semi‐structured interviews, we used rich pictures to elicit team members’ perspectives about clinical complexity in neurology and in the intensive care unit. We identified themes through constant comparative analysis. Results Routine care became complex when the prognosis was unknown, when treatment was either non‐existent or had been exhausted or when being patient and family centred challenged a system's capabilities, or participants’ training or professional scope of practice. When faced with complexity, participants reported that care shifted from relying on medical expertise to engaging in advocacy. Some physician participants, however, either did not recognise their care as advocacy or perceived it as outside their scope of practice. In turn, advocacy was often delegated to others. Conclusions Our research illuminates how expert clinicians manoeuvre moments of complexity; specifically, navigating complexity may rely on mastering health advocacy. Our results suggest that advocacy is often negotiated or collectively enacted in team settings, often with input from patients and families. In order to prepare learners to navigate complexity, we suggest that programmes situate advocacy training in complex clinical encounters, encourage reflection and engage non‐physician team members in advocacy training.

Autoethnography as a Strategy for Engaging in Reflexivity

“…These patient encounters provided me with an opportunity to critique my actions when patients requested care outside standard guidelines, generating thoughts of how to truly implement patient-centered care (PCC). One of the rich picture interviews was originally collected as part of a research study examining complexity in health care; with permission from the principal investigator, the visual and interview data were then re-purposed for this AE (Ladonna et al, 2018). The other rich picture interview represented a new care initiative regarding transitioning individuals with congenital chronic illnesses from a pediatric to an adult clinic setting.…”

Rich pictures: a companion method for qualitative research in medical education

“…For instance, in one study about navigating complexity in the intensive care unit, we first purposively sampled expert clinicians to understand how they define complexity and to explore how they use their clinical judgement during a complex clinical case. Next, we invited consenting participants to approach colleagues who could provide different perspectives about each case . Across different research projects our approach has been to ask participants to recall a memorable situation related to the specific research question and draw everything that they deem important.…”

“…Next, we invited consenting participants to approach colleagues who could provide different perspectives about each case. 32 Across different research projects our approach has been to ask participants to recall a memorable situation related to the specific research question and draw everything that they deem important. We explain to participants what a rich picture is, and show them an example of a rich picture.…”

“…For instance, we ask them to elaborate on behaviours or feelings evoked during the particular situation, as well as ideas and perceptions they have developed around the specific topic under investigation (e.g. advocacy ).…”

Exploring patients’ and physicians’ perspectives about competent health advocacy

“…Recognising this, the Royal College of Physicians and Surgeons of Canada has explicitly named advocacy as one of seven physician roles for which trainees must demonstrate competence 1 . Myriad challenges roadblock advocacy training 2‐4 however, namely clinical teachers’ uncertainty about what it means to advocate, and whether health advocacy is distinct from the everyday work of good doctoring 5,6 . Because clinician teachers do not have a sufficient frame of reference for either recognising their own work as advocates, or for translating it into effective teaching, many programmes struggle to demonstrate how they prepare trainees for this critical aspect of care.…”