Abstract
Advancing Qualitative Approaches in Health Professions Education Research
Mary Ellen Macdonald PhD
McGill University
While qualitative research approaches are being increasingly used in health research, their role in health professions education is advancing more slowly. The goal of this symposium is to provide three examples of qualitative approaches used in research across the continuum of medical education. Our first example describes an analysis of admissions processes for undergraduate medical students; the second explores medical residents' perceptions of clinical mentorship across different specialties; and the third examines why busy physicians take the time to teach students and residents. These studies range in paradigmatic stances (from constructivist to critical theories of pedagogy) and use unique methodological approaches (discourse analysis, qualitative description, and phenomenology). Following these three presentations, we will discuss the value as well as challenges of using qualitative research in health professions education research.
Session One: A Discourse Analysis of Websites Related to Medical Student Recruitment and Selection Using Complementary Conceptual Lenses
Saleem Razack
McGill University
Brian Hodges
University of Toronto
Yvonne Steinert
McGill University
Mary Maguire
McGill University
We performed a discourse analysis of the websites related to medical student recruitment and selection of Canada's 17 medical schools, with attention to representations of ‘excellence’ (both institutional and in potential medical students), ‘diversity’, and ‘equity’. We sought to enhance our interpretive understandings by analyzing the data through the conceptual lenses of three social theorists: Foucault, Bourdieu, and Bakhtin. Methodologies aimed at combining theoretical lenses in this manner have variably been called ‘theoretical triangulation,’ ‘complementarity,’ and even ‘bricolage.’ Institutional prestige and applicant excellence were generally represented through discourses of research, innovation, & global positioning. Diversity discourses emerged primarily as appeals to institutions' ‘cosmopolitan sophistication.’ Equity was vaguely defined. Analyzing the identified discourses through the three theoretical lenses enriched our understandings of the texts: Through the Foucauldian lens we analyzed excellence definitions in terms of knowledge-power relationships (“value”). Through the Bourdieuvian lens, we were able to appreciate how “value” might translate into “capital” required for competitive prospective applicants to medical school. Through the Bakhtinian lens we were able to understand how “transactions” of “value” and “capital” might occur through the use of language and voice. In this presentation we will discuss the multiple theoretical lens approach used in this study as a means for potentially deepening understandings of the discourses identified. We posit that this approach has the potential to enhance interpretive understandings, which, in turn, may assist with the transferability and resonance of the work within the medical education community.
Session Two: A Descriptive Analysis of Residents' Perceptions of Mentorship in the Clinical Context
Michelle Elizov
McGill University
Shelley Rohar
McGill University
Miriam Boillat
McGill University
Mary Ellen Macdonald
McGill University
Peter McLeod
McGill University
Yvonne Steinert
McGill University
Although the characteristics and usefulness of mentorship have been frequently described in a number of professional domains, mentorship in medicine's clinical context, where direct patient care sets the stage for teaching and learning, has been largely unexplored. Given the importance of mentorship in the formation of physicians and the lack of extant research on this topic, we elected to use a qualitative descriptive methodology in order to explore and provide rich descriptions of residents' perceptions and experiences of mentorship within the clinical context. Individual semi-structured interviews were conducted with 31 participants (residents, faculty and administrative stakeholders) from four McGill University-affiliated teaching hospitals. Interviews were transcribed verbatim and analyzed thematically. This presentation will focus on the nine resident interviews drawn from the larger data set of participants. Analysis indicates that mentorship plays a critical and complementary role in the learning and development of residents. Learning from a mentor's experience, constructive feedback, and a mentee-centered approach were deemed key aspects of effective mentorship. Although we sought to explore what may be unique to mentorship within the clinical setting, what also emerged from our data was that many of the perceived benefits of mentorship had less to do with clinical skills than with the non-clinical aspects of medicine. In clinical medicine, mentorship is highly valued by trainees as they pursue clinical excellence and balanced personal and professional development. In this session we will discuss both our findings as well as the pertinence of the research method chosen given the objective of the study and its usefulness for health professions education more broadly.
Session Three: Why Physicians Teach: Preliminary Findings from a Phenomenological Study
Yvonne Steinert
McGill University
Mary Ellen Macdonald
McGill University
The education of future physicians is highly dependent upon teaching in the clinical environment, a setting which is marked by competing demands, conflicting priorities, and the constant pressure of patient care. And yet, despite the pace and intensity of this environment, many physicians carve out time for teaching medical students and residents. Why is this so? What motivates clinicians to teach, and in so doing, balance the needs of patients and learners in order to contribute to the development of future generations of health care professionals? To understand the meaning of teaching, as well as perceived rewards, challenges, motivations, and expectations, we conducted semi-structured interviews with 12 physicians in the fields of Medicine, Surgery and Pediatrics. A phenomenological analytic method, based on Benner's interpretive framework, guided the data analysis. Initial findings were presented to a second group of clinical teachers for member checking. Preliminary findings suggest that physicians enjoy – and are motivated by – clinical teaching for a number of reasons: They believe that teaching makes their jobs as clinicians more interesting and allows them to learn and stay up-to-date; they also value the interaction – and connectedness – with students and residents and like to see them develop. In addition, they see teaching as part of their identity as well as their contractual and moral obligation, and they want to leave a legacy for future generations of heath care professionals. These findings hold important implications for the design and delivery of faculty development programs as well as the recruitment, retention, and renewal of faculty members.
Intersectionality-Based Policy Analysis: a New Framework for Understanding Health Inequities
Olena Hankivsky
Simon Fraser University
There is growing recognition that governments should be evaluated by their ability to deliver and implement policy that can correct power imbalances and address differential and distributional health impacts including avoidable, unnecessary, inequitable and unjust differences in the health of diverse groups of people. An intersectionality-based policy analysis (IBPA) Framework has been developed through a collaborative process at Simon Fraser University, Institute for Intersectionality Research and Policy, to facilitate the analysis of complex issues of health policy and inequity. In this symposium we first provide a review of the IBPA framework explaining its essential features, development, theoretical grounding and the existing assessment tools it seeks to improve upon. Next, two case studies that apply this critical framework to HIV/AIDS policy issues in Canada will be presented in order to explore the strengths and limitations of intersectionality-based analysis for qualitative health researchers and diverse policy actors.
Session One: Introduction to the Intersectionality-Based Policy Analysis Framework
Olena Hankivisky
Simon Fraser University
Techniques for conducting health policy analysis range from simplified step-by-step linear models, to more specialized tools that are organized around conceptions of the policy making process, ‘problem’ definition or focused on specific questions about the nature and types of policy, the process of making policies, and the effects of policy in the everyday world. An IBPA Framework is intended to improve current Health Impact Assessments (HIAs) which seek to tackle health inequities when making health and health-related decisions at the level of policy and programming. IBPA is founded on what HIAs commonly overlook: reflexivity, relationality, processes of differentiation and accounting for resistance and resilience. We argue that the theory of intersectionality holds much promise in constructing an improved method for policy analysis which can generate knowledge necessary for achieving more inclusive, just, effective and efficient health policies. The IBPA framework contains two core components: a set of guiding principles and a list of 12 overarching questions to help guide, frame and shape the analysis. The guiding principles are intended to ground the key questions, including their supporting sub-questions, to ensure that each is asked and answered in a way that is consistent with an intersectionality-informed analysis. The questions are divided into two main categories—descriptive and transformative—which are designed to provide the necessary components for an effective IBPA. Their combined effect is intended to expand and transform the ways in which policy problems and processes are understood and critically analyzed so as to ensure fine-tuned and accurate policy recommendations and responses.
Session Two: Reconceiving the ‘Problem’ in HIV Prevention: HIV Testing Technologies and the Criminalization of HIV Non-Disclosure
Daniel Grace
University of British Columbia
A new generation of HIV tests allows for a much earlier detection of infection following the transmission event. HIV has an increased risk of transmission during the first 8 weeks after infection due to greater infectivity during this period. What has not been thoroughly examined, however, is the possible relationship between these innovations in laboratory technologies and the increasing use of the criminal law to prosecute alleged cases of HIV non-disclosure in Canada. This paper is informed by formative research with the Canadian Institutes for Health Research (CIHR) team in the Study of Acute HIV infection (AHI) in Gay Men and an intersectionality based policy analysis (IBPA) framework. Considering these two public health issues together using an IBPA framework elucidates key tensions within and across these approaches to HIV/AIDS prevention and governance including the ways in which populations are differentially impacted by these responses. This analysis supports calls for expanding access to new HIV testing technologies in British Columbia in order to increase the detection of AHI, adapt existing prosecutorial guidelines to help eliminate or reduce the application of the criminal law to cases of alleged HIV non-disclosure in the province, and meaningfully invest in HIV prevention efforts which address the structural drivers of the epidemic. While testing is an important albeit insufficient aspect of HIV prevention efforts, the increasing trend towards criminalizing HIV non-disclosure cases in Canada poses significant problems in scaling up an effective national and provincial HIV response.
Session Three: Heterosexism, Medicalization and Sex Panic: Intersectional Perspectives on HIV Prevention Funding For Gay Men
Olivier Ferlatte
Simon Fraser University
For three decades, British Columbia's gay men have remained a key population dramatically impacted by HIV. However, despite this well documented inequity, policies and investments to support prevention activities among this population have fallen short. This paper applies the Intersectionality-Based Policy Analysis (IBPA) framework to identify the complex and intersecting factors that contribute to sustaining inequities in the distribution of resources for HIV prevention. This analysis is informed by semi-structured interviews with six key informants working in HIV policy or community groups. Four main issues were revealed by the IBPA application: 1) Representations of the HIV epidemic in British Columbia are problematic as they exclude gay men and social vulnerabilities; 2) Under funding has created competition among groups where the most vulnerable (including differently positioned gay men) are penalized; 3) The focus on medicalized forms of prevention increases inequities of and among gay men; 4) Funding allocation is tainted by a pattern of systemic discrimination against gay men that is defined at the intersection of heterosexism, medicalization, and sex panic. These findings may be useful to inform the development of new advocacy strategies that include building coalitions with other vulnerable populations. Gay advocates have generally been alone in fighting heterosexist biases in HIV policies. However, this analysis points to additional forms of bias that are also impacting other vulnerable populations. These similarities may help disrupt competition among differently positioned groups and lead to common efforts to see sexual rights respected in the current medicalized prevention context.
Participatory Research Approaches and Social Justice
Alissa Levine
McGill University
Social justice and knowledge translation represent core drivers of participatory approaches to research in health. Indeed, PR's historically grounded ideals of emancipatory learning and action for social change provide sound philosophical foundations for addressing disparities in health.
Concerned with the growing access-to-care gap between privileged and marginalized populations in Québec, McGill University's Oral Health and Society Research Unit has embraced the values and methods of participatory research for producing knowledge and social innovations. This symposium presents three initiatives, documenting process, outcomes, and challenges.
Our first presentation describes the fruitful application of PR in identifying access-to-care issues faced by people with disabilities, and solutions that may be implemented through knowledge translation. The second presentation documents the collaborative production of an ethnodrama-based medium and its application to consciousness-raising regarding poverty and health. Finally, we will present the unique challenges to collective grant writing towards setting up a ‘knowledge crossroads’ project in dentistry.
Session One: Understanding and Reducing the Barriers Faced By People with Physical Disabilities in Accessing Dental Services: a Participatory Approach
Farnaz Rashid-Kandvani
McGill University
Belinda Nicolau
McGill University
Christophe Bedos
McGill University
Participatory research is broadly defined as “systematic inquiry, with the collaboration of those affected by the issue being studied for purposes of education and taking action or effecting change” (Green & George, 1995).
People with physical disabilities constitute a social group that faces difficulties in receiving services that many others take for granted. The objective of my research is to uncover their difficulties in accessing dental services and identify solutions.
My qualitative research is based on a partnership with people with physical disabilities, dental professionals and public health educators. They help us better address the issues faced by disabled people as well as maximise knowledge diffusion among dental professional, the key players in improving the quality of dental services for this group.
Two persons with physical disabilities, one dentist from the Order of dentists and two public health researchers participate on an advisory committee. The members collaborated in this project, individually and through meetings. The committee helped with the development of an interview guide and participant recruitment. Initial interview results have been reviewed and members have discussed participant inclusion criteria and emergent issue of dental professionals' attitudes; they also added questions to the interview guide and discussed possible ways of knowledge translation and their feasibility.
Organizing team meetings with busy members and arranging for universally wheelchair accessible meeting places present two of the challenges faced in my project. My oral presentation aims to describe the collaborative research process and its contribution to the overall research process and outcomes.
Session Two: From Data to Drama: Addressing Social Inequalities in Health through Community Engaged Knowledge Translation in Dentistry
Martine Lévesque
McGill University
Johanne C##x00F4;té
Ordre des hygiénistes dentaires du Québec
Nathalie Morin
Ordre des dentistes du Québec
Isabelle Laurin
Direction de santé publique de l'Agence de la santé publique et des services sociaux de Montréal
Anne Charbonneau
Université de Montréal
Lyse Dore-Rodier
Collectif pour un Québec sans pauvreté
Cynthia Moreau
Collectif pour un Québec sans pauvreté
Sophie Dupéré
Collectif pour un Québec sans pauvreté
Alissa Levine
McGill University
Nancy Wassef
Institut national de santé publique du Québec
Christophe Bedos
McGill University
People benefiting from social assistance are known to underuse their dental coverage partly due to difficulties encountered when interacting with the various members of the dental team. Dentists, for their part, have admitted to negatively interpreting their welfare patients' behaviours and general lifestyle, in response to which discriminatory practices are at times adopted by clinic staff. In 2006, McGill University, University of Montreal, the Quebec Antipoverty Coalition, the Quebec Order of Dentists, the Quebec Order of Dental Hygienists and the Direction de la santé publique-Montréal founded a collaboration based on mutual concern for addressing this issue.
One of our partnership's goals is to innovate, implement and evaluate oral health professional educational strategies for improving knowledge, attitudes and skills for effective response to patients dealing with poverty issues and challenges. Member organizations' representatives (approximately 10) collaborate through semester-based workshops marked by consensual decision-making, trust, and shared learning. Experiential and practical knowledge of professionals and underprivileged people inform pedagogical content and format, alongside empirical data and theory.
From 2009–2011, in collaboration with social intervention theatre professionals, our group produced a short film depicting the life of a single mother living on welfare, and her interactions with a Montreal-based dental clinic. Strongly inspired by the ethnodramatic approach to knowledge translation, this production aims to raise awareness, elicit critical reflection in learners and provide public voice knowledge production forums. This oral presentation will describe the collaborative development of the film, and present preliminary results of its current uses in various health professional educational settings.
Session Three: Participatory Approaches in Health Research: Preparing a Grant Application with Community Partners; the Perspective of Academic Researchers
Christophe Bedos
McGill University
Martine Lévesque
McGill University
Sophie Dupéré
Collectif pour un Québec sans pauvreté
Oral diseases are highly prevalent among people living on social assistance and represent a tremendous burden for both them and society. Despite their great need for treatment and the existence of public dental insurance programs in Canada, people on social assistance rarely consult dentists. To better understand this situation, our research team conducted several qualitative studies in Montreal over the last years. Our research shows that, one the one hand, people on social assistance report negative experiences at the dental office and often feel blamed by professionals. On the other hand, our studies reveal that dentists experience frustrations with people on social assistance and express critical views toward them.
In order to improve mutual understanding and rapport between these two groups, we have developed a participatory-action research project with partners representing dental professionals, people living in poverty, and academic researchers. Together, we wrote a proposal that was recently submitted to the Canadian Institutes of Health Research. If financed, our project will rely on a highly original methodological approach: we will invite 12 people on social assistance and 12 dental professionals to repeatedly “cross perspectives”; together, they will identify “conflictual” situations in dental clinics, understand the logics behind these situations, and develop solutions to solve or prevent them.
In our presentation, we will provide a brief overview of this project and describe how we collaboratively developed our grant proposal. In particular, we will expose the strengths of working within partnerships as well as the difficulties and challenges that we have faced.
Qualitative Oral Health Research with Marginalized Populations
Basem Danish
McGill University
Increasingly, researchers are demonstrating how oral health is a critical component of overall health. As a result, oral health care is becoming more integrated into health care services and community health programs. Despite these changes, widespread oral health disparities still exist in Canada. In 2012, the Canadian Dental Working Group called for further oral health research to tackle inequities affecting vulnerable and marginalized populations. Currently, oral health researchers are increasingly using qualitative methodologies to help address these inequities, exploring people's everyday experiences of both clinical practice and the ramifications of health and social policies. The goal of this symposium is to discuss some recent qualitative research on the oral health of marginalized populations, focusing on both urban and rural communities. Using methodologies ranging from descriptive to ethnographic, our presentations seek to illuminate challenges to oral health care as well as recommendations for improvement.
Session One: Expectations for Oral Health Services in Northern Quebec Aboriginal Communities
Felix Girard
McGill University
Christophe Bedos
McGill University
The James Bay Cree have endured significant changes in their way of living. Dental caries is now a major public health concern, and data shows that Cree people tend to use dental services in emergency situations rather than in a preventive way. It is thus important to know if Cree people are satisfied with the public dental services that are provided and what their needs are. This project aims to respond to the following two questions: What are people's expectations for dental services? Do current dental services meet people's expectations? We conducted qualitative descriptive research based on individual semi-structured interviews (n = 13). The interviews were audio-recorded and transcribed. We then performed an inductive-deductive thematic analysis. The results revealed that participants had a wide range of expectations, but that these expectations were rarely met. First, they wanted to be able to quickly access services when they felt a need to consult, for instance when having a toothache. Participants also wanted to deal with caring and experienced dental professionals, which was not always the case according to them. They wished that large families and the elderly could access dental hygiene counseling and support in their homes and gathering places. In conclusion, we would like to make three key recommendations: to improve access to dental services, especially in emergency situations; to train dental professionals in patient-centered approaches and to know more about the Cree culture; and to dialogue with Cree people in developing, implementing and evaluating oral health services.
Session Two: Oral Health in Montreal's Urban Aboriginal Community
Gabrielle Lemay
McGill University
Mary Ellen Macdonald
McGill University
Urban Aboriginal populations are often underrepresented in health research, despite the fact that over half of Aboriginal Canadians live in urban centers. There is especially little research concerning the oral health needs of this population. Our previous research suggested that in a prominent Montreal Aboriginal community organization, upwards of 60% of clients are missing teeth and 30% have urgent oral health needs. The purpose of this current project was to better understand these survey results. Using an ethnographic frame, we conducted semi-structured interview with 10 clients, seeking to understand their oral health care needs and experiences. Interviews were audio-recorded and transcribed, and then analysed using a broad deductive frame (drawing on our prior research with this community) followed by inductive thematic analysis. Participants were generally well informed about oral health, hygiene and care, and also knew about their rights, resources and how to access care. And yet, dental hygiene (brushing, flossing) was rarely routine, dental care rarely sought, and feelings of shame and stigma regarding appearance were common. Challenges finding food and shelter, as well as negative past experiences of discrimination prevented clients from preventative oral hygiene and care.
Our next steps are to work together with this community organization and the dental community to find viable solutions to better meet urban Aboriginal people's needs.
Session Three: A Rural Oral Health Research Study
Elham Emami
McGill University - Universite de Montreal
Christophe Bedos
McGill University
Paul Allison
McGill University
Little is known about how rural residents in Canada perceive and experience their oral health. This study used qualitative descriptive research to explore how rural environment can have an impact on oral health. A purposeful maximum variation sampling technique was used to recruit study participants from rural Quebec. Audio-recorded, 60–90 minutes, face-to face interviews with semi-structured, open-ended questions were conducted by a trained interviewer, and were continued until saturation was reached (n=15). Interview questions were based on the conceptual framework of Health Belief Model and the McGill Illness Narrative Interview. Thematic analyses included interview debriefing, transcript coding, data display and interpretation. Five main themes emerged from the interviews: rural idyll, perceived oral health, access to oral health care, access to dental information and cues to action. The participants were mostly satisfied with rural lifestyle, but they were concerned about the impact of limited access to dental services and dental education on their oral health. These issues became more problematic when rural residents were elderly, young children with special care needs, and when they had lower socioeconomic status. A few rural residents, who were dissatisfied with the provided dental care, considered legal action however resisted due to their link to the small community and possible stigmatization. The dental care professionals were not selected as the main cues to action. These results could assist health care professionals and policy makers in the provision of appropriate oral health care to rural residents and in the development of future rural oral health research activities.
Qualitative Research in Ambulance Services: the Reality of Practice
Julia Williams
Queensland University of Technology and the University of Hertfordshire
This symposium seeks to explore the role of qualitative research in ambulance services drawing on primary work from Australia and the UK. Research within ambulance services is gaining momentum both from within the paramedic profession and, also, from other professions interested in prehospital and/or urgent, unscheduled emergency care.
The presenters want to explore some of the myths associated with the paramedic profession in terms of their primary roles and examine the culture(s) within the profession that may serve to perpetuate some of these misconceptions. Discussion will include investigation of a variety of aspects of paramedic practice from management of people with non urgent health and social care needs (the majority of ambulance staff's work), through to managing people experiencing time critical, life threatening emergencies.
All sessions will address how qualitative research can impact on practice, education and/or policy within ambulance services.
Session One: A Paramedic's Work is All Lights and Sirens: Reality or Desire?
Scott Devenish
Queensland University of Technology
The media, television shows and just generally seeing ambulances travelling at speed to sick and/or injured patients leads the general public to view paramedic work as all ‘lights and sirens’, life and death type of work. In fact, this type of work makes up only a small proportion of the overall cases paramedics in Australia and the United Kingdom actually attend. Culturally, paramedics reflect on this component of paramedic practice as their reason for being, often choosing not to portray, or sometimes even belittling, the routine and low acuity side of paramedic work to the general public and newcomers to the profession. This session within the symposium will explore the important role of qualitative research in highlighting to those in paramedic management, educator and preceptor positions, as well as to the newcomers to the profession, the reality shock this cultural stance often creates for new employees when faced with the reality of paramedic practice.
In addition, lack of recognition of the non time critical, non urgent patients can influence the type of research that is being generated from within (and outside) the ambulance service. It is important to address these misconceptions to ensure that ambulance services' research examines the wide spectrum of patients' needs that it encounters on a daily basis. It is hoped that this presentation will stimulate debate around how qualitative research can contribute to improved understanding of the paramedic profession and its contribution to healthcare services.
Session Two: Making a difference: Queensland Ambulance Service's Vulnerable Clients Program Initiative
Jo Stephens
Queensland University of Technology
Undergraduate paramedic students are often attracted to a paramedic career because it is viewed as an exciting ‘trauma related’ and ‘high energy’ occupation. However, the undergraduate programs in universities and also in the vocational setting may not prepare students for the reality of the role as a large majority of their work is actually managing patients with low acuity illness. Paramedics provide a 24/7 out of hospital service, which can include caring for the needs of people with complex acute and chronic health concerns as well as unmet social needs. These vulnerable client groups face many challenges, including access to services and social stigma. Paramedics can be a valuable resource to connect the person to appropriate health and social service agencies. Qualitative research opportunities are useful to examine the issues of vulnerable clients in out of hospital environments.
This session focuses on qualitative data which has informed paramedic practice and curriculum design within the Queensland Ambulance Service during a pilot program ‘The Vulnerable Clients Program Initiative’. This initiative set out to enhance the knowledge, skills and abilities of operational ambulance staff when providing care to vulnerable people including, for example, people experiencing homelessness, mental health issues, bereavement, or elder abuse.
Session Three: Qualitative Research in Trauma: is it a Case of ‘Nice but not Necessary’?
Julia Williams
Queensland University of Technology and the University of Hertfordshire
It will be clear from this symposium that much work within ambulance services in the UK and Australia does not involve acutely ill or injured people (patients). However it would be a considerable omission within this symposium if we did not examine the role of qualitative research in high acuity illness and/or trauma. In the UK about 7% of ambulance service work is related to trauma and/or high acuity illness and this session explores published qualitative research which focuses on the acute end of the continuum of ambulance staff's work.
It is interesting to note that much work in trauma and acute illness within prehospital settings appears to be quantitative and this presentation will consider possible reasons for this. At the same time, the discussion will explore exactly what qualitative research can offer to the understanding of time critical, acute, out of hospital healthcare from the practitioners' as well as the patients' perspectives.
Qualitative research can adopt different positions of centrality within a study from being the sole approach, through to being an adjunct to a predominantly quantitative investigation; this is no different in time critical, acute situations. What is important is that qualitative research is seen to make a valuable and a valued contribution to any investigation. Within paramedic practice and education there is abundant scope to engage with qualitative research and yet there is still some way to go before its value is fully recognised.
In line with this year's QHR Conference's core theme of demonstrating that qualitative research should be used to inform education, policy and practice, this session serves to illustrate how this has been undertaken within the Queensland Ambulance Service.
Restorying Northern Issues from Northern Perspectives
Nancy Gibson
Canadian Institute for Energy Training
The symposium includes research from four articles published in a special edition of Pimatisiwin entitled, Emerging and Converging Research: Restorying Northern Issues from Northern Perspectives.
Session One: Relational Flow Frames: A Model for Nonindigenous Researchers Working With Indigenous Populations
Susan Hopkins
GNWT-Early Childhood & School Services
The Relational Flow Frames have four components and are built on the relational accountability work of Shaun Wilson: relational emergence, relational flow, relational convergence, and relational continuity. Relational Flow Frames emerged through a study of the lived experiences of high school graduates from the Tlicho community of Behchoko, Northwest Territories. An initial plan for purposive sampling evolved into a form of snowball sampling better described as relational sampling. Four relational research principles were defined and then later refined through phenomenological research documenting a model of the Tlicho Community Action Research Team. The Relational Flow Frames may be useful to other nonIndigenous researchers working in Northern communities.
Session Two: Speaking Of Research: Aligning Expectations for Funders and Community Researchers
Nancy Gibson
Canadian Institute for Energy Training
Carrielynn Lund
Canadian Institute for Energy Training
Over the past two decades the various Canadian sources of research funding have moved from an academic, science-based focus to a more inclusive model, encouraging applications that support research partnerships with community organisations. This transition is creating challenges for some funders, as well as academic and community applicants in terms of definitions and expectations. With the advent of community-based participatory research new perspectives on respectful, ethical research partnerships are appearing. The paper reviews some of the challenges and strategies for community partners, academics and funders in terms of research approach and practice.
Session Three: Telling it like it is ‘Anyways’: Capturing Tlicho Pregnancy Experiences through Photovoice
Pertice Moffitt
Aurora College
Pregnancy can be a time of emotional upheaval, including joy and despair, as well as cultural affirmations from home, family, and community. Fourteen expectant mothers from a Tlicho community in the Northwest Territories shared their individual and collective stories about health beliefs and health promotion practices during their pregnancies and births of their babies. The photovoice method was embedded in a focused ethnographic study as a means of supporting an exchange of ideas between the participants and engaging in meaningful dialogue from local women's perspectives. This type of methodology grounded the study in local conceptions of pregnancy and birthing whereby the women themselves highlight the circumstances and priorities. The purpose of this paper is to share the power and voice from within that was expressed by Tlicho women as they used cameras and words to describe what they do to stay healthy during their pregnancies. The contexts of daily life and living in a remote community predicate their words. The stories that emerged in this research are shared to demonstrate the reality and diversity that exists. From these stories, health professionals and decision makers can realize a greater understanding of the influences and experiences of women living in remote northern communities. In addition, these narratives demonstrate the importance of working with women to create health promotion programs that better meet their needs and support their beliefs and lifeways.
Session Four: D##x00F4; Edàezhe: Building Resiliency among Aboriginal Youth
Dianne Lafferty
Yellowknife Catholic Schools
“D##x00F4; Edàezhe” is a Dogrib expression describing a person who is capable, skillful and knowledgeable: a person who has the skills needed to survive in the world in the traditional Dene sense. In 2009, Yellowknife Catholic Schools received a grant to develop and implement a crime prevention program (called D##x00F4; Edàezhe), which included community liaison support, mentorship and leadership and resiliency development. Part of this project is based on a model program, the Leadership and Resiliency Program, which Yellowknife Catholic Schools adapted to suit the unique needs of Northern Aboriginal youth. Further adaptations have included developing and implementing programming for elementary aged students and incorporating community liaison support and mentorship components for all identified students. Eighty percent of the students in D##x00F4; Edàezhe are Aboriginal. The objective of D##x00F4; Edàezhe is to enhance the capacities of identified youth to decrease risk factors and increase protective factors related to crime and victimization. Midway through the project, preliminary findings for students in D##x00F4; Edàezhe show an increase in attendance and school grades and a decrease in school disciplinary actions. More important, are the anecdotal stories of the students as they become more confident in their abilities to be “D##x00F4; Edàezhe” as they navigate their current environment.
The Use of Qualitative Research in Understanding Practice, Program and Policy-Level Interventions with Complex Populations: The Case of Children with Medical Complexity
Ashley Lacombe-Duncan
Hospital for Sick Children
Children with medical complexity (CMC) are a growing population characterized by serious chronic conditions, functional limitations, multiple family-identified needs, and high resource utilization, requiring services from a variety of providers across numerous settings. The incorporation of diverse perspectives in qualitative health research examining this population is necessary to understand their care needs and to inform decision-making regarding family-centered service delivery that is both practical at a clinical and policy level.
The papers presented in this symposium applied qualitative methods to develop a rich understanding of barriers and facilitators to care of CMC at the practice, program, and policy level, through semi-structured interviews/focus groups with families, providers, managers and policy makers. This research will facilitate family-centered improvements in both clinical service delivery and health systems structure. The richness that diverse perspectives contributed to the understanding of the topic of care for this vulnerable population will be explored.
Session One (Practice Level): The Usefulness of Care Plans for Children with Medical Complexity
Sherri Adams
Hospital for Sick Children
Sanjay Mahant
Hospital for Sick Children
Jeremy Friedman
Hospital for Sick Children
Radha MacCulloch
McGill University
David Nicholas
University of Calgary
A care plan is a written document created by the health care provider (HCP) in partnership with the family that outlines the major medical issues and care needs for their child. A qualitative study utilizing grounded theory methodology was undertaken to explore how parents and HCPs of children with medical complexity (CMC) perceive the usefulness of a care plan. Semi-structured interviews with 15 parents and focus groups with 15 HCPs were conducted. The data was analyzed iteratively for themes and emerging theory.
Both HCPs and parents identified the care plan as an important tool in the care of CMC. Analysis of the data revealed key themes that were unique to either parents or HCPs, from which emerged a theory of why and how care plans are useful. For parents, themes related to patient-centeredness and timeliness of care were dominant. Parents felt the care plan increased their credibility in interactions with the health care team by clarifying the child's needs and utilizing medical terminology from a perceived authoritative source. For HCPs, themes related to efficiency and safety were dominant. HCPs described the care plan as a ‘roadmap’ that directed care and facilitated focused assessments and frank discussions with the family.
While the views of parents and HCPs overlapped in some areas, the specific usefulness and benefits of the care plan were distinct between groups. Findings informed a comprehensive care plan template as well as a model of why and how to best utilize care plans within family-centered models of care.
Session Two (Program Level): Applied Use of a Theoretical Model to Understand a Complex Intervention: Evaluation of the Integrated Complex Care Model
Ashley Lacombe-Duncan
Hospital for Sick Children
Shauna Kingsnorth
Bloorview Research Institute
Krista Keilty
Hospital for Sick Children
Cindy Bruce-Barrett
Hospital for Sick Children
Eyal Cohen
Hospital for Sick Children
Children with medical complexity (CMC) form a vulnerable group characterized by multiple and prolonged hospitalizations, frequent medical errors and poor care coordination. Organizational integration is essential to improving outcomes for CMC. To this aim, an Integrated Complex Care Model (ICCM) was developed through partnership between an acute care hospital, a children's rehabilitation hospital, and a community home health organization. Qualitative methods contributed to an in-depth exploration of processes and outcomes of this pilot initiative.
Semi-structured interviews and focus groups were conducted with 33 ICCM stakeholders and key documents were reviewed. Codes were determined a posteriori, drawing from an existing theoretical framework for integration and care coordination, facilitating examination of the model at a system, organizational and family level.
Enablers to model implementation included protected clinical time, clarity in staff roles and responsibilities, and communication and engagement strategies targeted towards key stakeholders involved in care of CMC. Barriers to model implementation included real and perceived policy barriers, such as policies related to inter-organizational patient information sharing. Families identified the perceived usefulness of care coordination through the ICCM and an electronic care plan that reflects both the medical and psychosocial aspects of their child's care. Continued challenges experienced by families included times of transition (hospital-to-home) and the need for expanded partnerships beyond the three organizations involved.
Results of this evaluation informed both implementation and sustainable growth of the ICCM, as well as the beginning development of integrated health systems for CMC and their families beyond the initial scope of the project.
Session Three (Policy Level): Information Sharing for Children with Medical Complexity Within and Across Health Care Organizations
Laura Quigley
University of Toronto
Ashley Lacombe-Duncan
Hospital for Sick Children
Sherri Adams
Hospital for Sick Children
Charlotte Moore
Hospital for Sick Children
Eyal Cohen
Hospital for Sick Children
Children with medical complexity (CMC) require special medications and/or technologies, as well as the services of a variety of health care providers across a number of settings. CMC comprise 0.5% of all children; however they consume approximately 1/6 of paediatric health care resources. Information sharing both within and across organizations is essential to providing integrated care for this population, but has been reported to be extremely challenging. The purpose of this qualitative study was to identify the barriers to and facilitators of information sharing across providers and families of CMC.
Secondary review of semi-structured interviews and focus groups (n=52), semi-structured interview with key stakeholders (n=4) and document review were used to examine the experiences of key stakeholders in multiple sectors regarding the sharing of information for CMC. Emerging themes were identified to produce a theoretical model.
Both barriers to and facilitators of information sharing were related to one of three major themes: lack of consistent policies and standards across organizations further confounded by differences in interpretation of policies at the organizational and provider level; the current health system focus on episodic care rather than the continuum of care; and the lack of an integrated, accessible, secure platform on which summated health care information is stored.
Families, providers, and policy makers all recognize the multitude of obstacles to information sharing for CMC. Findings informed a model of how barriers to information sharing interact to prevent optimal information sharing both within and across organizations. Key facilitators illustrate potential solutions to improve communication.
Interdisciplinary Conversations, Collaboration, and Research on the Cancer Care Experience
Dr. Richard Hovey
McGill University
Advancements in health care have decreased the cancer mortality rate and thereby increased cancer survivorship. Therefore, improving the patient experience through the trajectory of their treatment is a key priority in cancer care. A transformative shift from a predominately biomedical perspective to the ontology of cancer brought three researchers from Dentistry, Nursing and Education together through conversation to learn with, from and about each other's research findings and extend our understanding of patients' experiences of cancer. Furthermore, we explore how patient engagement in our research can contribute to improve patient-centred care. Paper 1 presents head and neck cancer patients' experiences about the information they received at the hospital. Paper 2 presents the development and dissemination of a meaning-making intervention to optimize existential awareness and psychological adjustment among patients with breast, colorectal, or ovarian cancer. Paper 3 demonstrates how distress influenced the decision-making process for men newly diagnosed with prostate cancer.
Session One: Information Provision in Head and Neck Cancer Care – a Qualitative Study
Violet D'Souza
McGill University
Erin Watson
McGill University
Elizabeth Blouin
McGill University Hospital Center
Anthony Zeitouni
McGill University Hospital Center
Paul J. Allison
McGill University
Patient information is considered both as a resource and a means of empowerment. Studies conducted with cancer patients show that good quality information can improve patient outcomes such as adherence to treatments, lower levels of anxiety and satisfaction with care. However, very little research has been done with Head and Neck (H&N) cancer patients. Our aim was to describe and compare the experiences of H&N cancer patients receiving information concerning their cancer and treatment at two hospitals with different approaches to information delivery. A total of 11 H&N cancer patients and 2 Nurse Coordinators (NC) participated in this study that used qualitative methods. One hospital provided the Multimode Comprehensive Tailored Information Package (MCTIP), whereas the other hospital used a normal care approach for information provision. Data were gathered by semi-structured interviews with subjects and by observing information provision at both centers. Interviews and information deliveries were audio taped. Our study findings show that the subjects who received the MCTIP perceived the information that they received was timely, understandable, contained the details they needed, and helped them in preparing them for the treatment. And the subjects who did not receive the MCTIP expressed that they proceeded towards the treatment with no clear idea about various steps in cancer care and they felt confused and lost. The results suggest that subjects who received the information through MCTIP had better information provision experience, while peers receiving a normal care approach expressed dissatisfaction with elements of their information provision experience.
Session Two: The Influence of Distress on Knowledge Transfer for Men Newly Diagnosed with Prostate Cancer
Dr. Richard Hovey
McGill University
Karen E. Cuthbertson
University of Calgary
Katherine A. Birnie
Dalhousie University
John W. Robinson
Tom Baker Cancer Centre and University of Calgary
Bejoy C. Thomas
Tom Baker Cancer Centre
Helen F. Massfeller
University of Calgary
J. Dean Ruether
Tom Baker Cancer Centre
Cheryl Scott
Tom Baker Cancer Centre
The purpose of this inquiry was to evaluate the efficacy of prostate cancer education sessions. Implementation of 3-h patient educational sessions was intended to provide men newly diagnosed with localized prostate cancer, who face difficult and complex decisions, information about potential treatment options. Fifty-seven men completed the distress thermometer assessment before the education session to assess baseline levels of distress. Seven of the men were interviewed post-educational session to determine the degree of knowledge transfer from the session. This study explored the efficacy of the patients' learning experience using an interpretive phenomenological research approach. Resulting data revealed that these patients, as adult learners, were distressed and that, despite the availability of pertinent medical content, the subject material was not learned as intended or readily understood. The conclusion drawn from this preliminary applied educational research study was that the education model used was less than efficacious at ensuring that sufficient knowledge transfer was achieved for medical treatment decision-making processes. These findings suggest a need for future research to explore the application of adult learning theories and approaches that may offer enhanced knowledge translation and transfer for prostate cancer education programs.
Session Three: Patient Interviews in the Diffusion of Innovation in Cancer Care
Virginia Lee
McGill University Hospital Center
The patient experience of living with cancer is a high priority domain in cancer care. To a certain extent, patient care depends on how well we understand the human experience of cancer. This third paper will describe a sequence of studies that incorporated the patient perspective along various phases of a novel intervention being developed to enhance psychological adjustment during the cancer experience. Individuals newly diagnosed with breast, colorectal or ovarian cancer and within the first 6 months of beginning chemotherapy treatment were recruited to participate in three clinical studies, including one randomized controlled trial. In each study, the study participants completed interviews or submitted written narratives about what they perceived as pivotal events that marked their cancer journey. The data were analysed using an interpretive description approach to document how individuals newly diagnosed with cancer ‘made sense’ of a new reality that was profoundly affected by the need for optimism and an acute awareness of existential vulnerability. This presentation will discuss how the qualitative findings in each study were critical to steer the next steps in the diffusion of this novel intervention. Specifically, the qualitative findings were instrumental to help define the intervention, to identify important patient reported outcomes for measurement, to contextualize the quantitative findings derived from self-report questionnaires, and to illuminate clinically meaningful areas to consider when transferring the intervention into practice.
Hermeneutical Research: a Question of Method
Angela Morck
This panel will present emerging ideas in qualitative inquiry, focusing on the merits of hermeneutically-oriented methodologies for health research. The first paper will examine the meaning of research method from a Gadamerian philosophical stance in which hermeneutical inquiry is considered as un-method. The second paper will describe an empirical framework for conducting hermeneutical research, adapting the philosophical work of Charles Taylor on human sciences, interpretation, and social imaginaries. The third paper will explore the process of interpretation based on multiple interviews of participants who shared their life stories. By delving into stories that are modified in some way, either through elaboration or progressive revelations, we will consider how to interpret evolving or changing versions. This symposium invites three researchers into a conversation about hermeneutic research within the health and social sciences. The intention is to demonstrate how hermeneutics can be interpreted into multiple contexts while being mindful of their philosophical ancestries.
Session One: Philosophical Hermeneutic Recklessness: Understanding the Un-Method for Social and Health Science Research
Richard Hovey
McGill University
Philosophical hermeneutics may be somewhat misunderstood and misinterpreted as a research approach due to its apparent lack of a repeatable structured method vis-à-vis the scientific method. I will provide an overview of philosophical hermeneutics and articulate why it should remain as the un-method among other research methods. The dominant discourse of method as scientific will be discussed. Philosophical hermeneutics as an alternate method evolved through time and commitment to the underlying philosophy will be explored. In this context, philosophical hermeneutics becomes an un-colonized means to gain an understanding of complex social-relational, cultural, and historical human experiences of health for applied research. The presentation will incorporate applied philosophical hermeneutic research findings as examples from projects that span topics such as patient safety, osteoporosis, diabetes within an Aboriginal context, and patient / health professional / medical education.
Session Two: Charles Taylor, Hermeneutics and Social Imaginaries: a Framework for Ethics Research
Franco Carnevale
McGill University
Hermeneutics, also referred to as interpretive phenomenology, has led to important contributions to health research. The philosophy of Charles Taylor has been a major source in the development of contemporary hermeneutics, through his ontological and epistemological articulations of the human sciences. The aim of this paper is to demonstrate that Taylor's ideas can further enrich hermeneutic inquiry in health research, particularly for investigations of ethical concerns. The paper begins with a brief outline of Taylor's hermeneutical framework, followed by a review of his key ideas relevant for ethics research. The paper ends with a discussion of my own empirical research with critically ill children in Canada and France in relation to Taylor's ideas, chiefly Social Imaginaries. I argue that Taylor's hermeneutics provides a substantive moral framework as well as a methodology for examining ethical concerns.
Session Three: Unfolding Lives: Gradual Disclosure of Sensitive Information in Qualitative Interviews
Alissa Levine
McGill University
We examine two forms of gradual disclosure that emerge from our in-depth narrative interviews. The first we refer to as elaborative disclosure and the second as oppositional disclosure. Elaborative disclosure proceeds by a series of additions, filling in the story, revealing sensitive elements over time and in an expected order (less sensitive and more normative information coming first, followed by more delicate revelations). Oppositional disclosure is slightly more problematic because it involves claims that are modified and even reversed over the course of the interviews. The same pattern occurs across participants, however; similar issues are presented and revisited to unfold in set ways, with participants eventually explaining discrepancies. These patterns of disclosure strengthen our understanding of how, over time, non-normative behavior and sensitive issues can be revealed through a process consistently characterized by ever deepening revelations. Our findings have important methodological implications concerning specific qualitative techniques required for interviewing on sensitive and normatively-bound issues, including repeated in-depth interviews and progressive, though not confrontational, probing. These findings also suggest that interpretation involves recognizing the forms of disclosure and their development into ultimately complete or plausible versions.