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In 2007 the Cancer Care Ontario Hepatobiliary-Pancreatic (HPB) Community of Practice was formed during the wake of provincial regionalization of HPB services in Ontario, Canada. Despite being conceptualized within the literature as an educational intervention, communities of practice (CoP) are increasingly being adopted in healthcare as quality improvement initiatives. A qualitative case study approach using in-depth interviews and document analysis was employed to gain insight into the perceptions and attitudes of the HPB surgeons in the CoP. This study demonstrates how an engineered formal or idealized structure of a CoP was created in tension with the natural CoPs that HPB surgeons identified with during and after their training. This tension contributed to the inactive and/or marginal participation by some of the surgeons in the CoP. The findings of this study represent a cautionary tale for such future engineering attempts in two distinct ways: (1) a CoP in surgery cannot simply be created by regulatory agencies, rather they need to be supported in a way to evolve naturally, and (2) when the concept of CoPs is co-opted by governing bodies, it does not necessarily capture the power and potential of situated learning. To ensure CoP sustainability and effectiveness, we suggest that both core and peripheral members need to be more directly involved at the inception of the COP in terms of design, organization, implementation and ongoing management. [ABSTRACT FROM AUTHOR]

Introduction Making substantial changes to the form and delivery of medical education is challenging. One reason for this may be misalignment between existing conceptualizations of curricula and curriculum reform in medical education, with the former perceived as 'complex' yet the latter as linear. Reframing curriculum reform as a process-driven, complex entity may enhance the possibility of change. To explore the utility of this approach, we carried out an exploratory case study of curriculum reform in a real-life context. Methods We used a qualitative case study approach. Data were collected from 17 interviews with senior faculty involved in curriculum reform in one medical school plus document analysis of approximately 50 documents and files, to provide background, context, and aid triangulation. Results Data coding and analysis was initially inductive, using thematic analysis. After themes were identified, we applied the 'wicked problem' framework to highlight aspects of the data. This paper focuses on two main analytic themes. First, that multiple players hold different views and values in relation to curriculum reform, resulting in various influences on the process and outcomes of reform. Second, 'solutions' generate consequences which go beyond the anticipated advantages of curriculum reform. Discussion This is the first empirical study of curriculum reform in medical education which uses the wicked problem framework to conceptually illuminate the complex processes which occur in relation to reform. Those involved in reform must be reflective and attentive to the possibility that persistent and emerging challenges may be a result of wicked problems. [ABSTRACT FROM AUTHOR]

Background: Interprofessional collaboration is an important aspect of patient discharge from a general internal medicine (GIM) unit. However, there has been minimal empirical or theoretical research that has examined interactions that occur between medical residents and other healthcare professionals in the discharge process. This study provides insight into the social processes that shape and characterize such interactions.Objective: To explore factors that shape interactions between medical residents and other healthcare professionals in relation to patient discharge, and to examine the opportunities for negotiations about discharge between these professional groups.Design: A qualitative ethnographic approach using observations, interviews and documentary analysis.Participants and Setting: Healthcare professionals working in a GIM unit in Canada.Approach: Sixty-five hours of observations were undertaken in a range of settings (e.g. interprofessional rounds, medical and nursing rounds, nursing station) in the unit over a 17-month period. A maximum variation sampling approach was used to identify healthcare professionals working in the unit. Twenty-three interviews were completed, recorded and transcribed verbatim. A directed content approach using theories of medical dominance and negotiated order was used to analyze the data.Key Results: The organization of clinical work in combination with clinical teaching influenced interprofessional interactions and the quality of discharge in this GIM unit. While organizational activities (orientation and rounds) and individual activities (e.g. role modeling, teaching) supported negotiations between medical residents and other healthcare professionals around discharge, participants had varied perspectives about their effectiveness.Conclusions: This study illuminates social factors and processes that require attention in order to address challenges with interprofessional collaboration and discharge in GIM. These findings have implications for medical education, workplace learning, patient safety and quality improvement. [ABSTRACT FROM AUTHOR]

Understanding the immigrant experience accessing healthcare is essential to improving their health. This qualitative study reports on experiences seeking healthcare for three groups of immigrants in Toronto, Canada: permanent residents, refugee claimants and undocumented immigrants. Undocumented immigrants who are on the Canadian Border Services Agency deportation list are understudied in Canada due to their precarious status. This study will examine the vulnerabilities of this particular subcategory of immigrant and contrast their experiences seeking healthcare with refugee claimants and permanent residents. Twenty-one semi-structured, one-on-one qualitative interviews were conducted with immigrants to identify barriers and facilitators to accessing healthcare. The open structure of the interviews enabled the participants to share their experiences seeking healthcare and other factors that were an integral part of their health. This study utilized a community-based participatory research framework. The study identifies seven sections of results. Among them, immigration status was the single most important factor affecting both an individual's ability to seek out healthcare and her experiences when trying to access healthcare. The healthcare seeking behaviour of undocumented immigrants was radically distinct from refugee claimants or immigrants with permanent resident status, with undocumented immigrants being at a greater disadvantage than permanent residents and refugee claimants. Language barriers are also noted as an impediment to healthcare access. An individual's immigration status further complicates their ability to establish relationships with family doctors, access prescriptions and medications and seek out emergency room care. Fear of authorities and the complications caused by the above factors can lead to the most disadvantaged to seek out informal or black market sources of healthcare. This study reaffirmed previous findings that fear of deportation forestalls undocumented immigrants from seeking out healthcare through standard means. The findings bring to light issues not discussed in great depth in the current literature on immigrant health access, the foremost being the immigration status of an individual is a major factor affecting that person's ability to seek, and experience of, healthcare services. Further, that undocumented immigrants have difficulty gaining access to pharmaceuticals and so may employ unregulated means to obtain medication, often with the assistance of a doctor. Also, there exists two streams of healthcare access for undocumented immigrants-from conventional healthcare facilities but also from informal systems delivered mainly through community-based organizations. Finally, within the umbrella term 'immigrant' there appears to be drastically different healthcare utilization patterns and attitudes toward seeking out healthcare between the three subgroups of immigrants addressed by this study. [ABSTRACT FROM AUTHOR]

Background: Despite the significant improvements in surgical care in developed countries, the adoption of laparoscopy in lower-middle-income countries (LMICs) has been sporadic and minimal. Although the most quoted explanation for this has been an apparent lack of resources and training, recent studies have demonstrated that these constraints may not be the only significant barrier. The overall aim of this study was to analyze barriers to the adoption of laparoscopic surgery at a hospital in an LMIC. Methods: Using an exploratory case study design, this investigation identified barriers to the adoption of laparoscopic surgery in an LMIC. More than 600 hours of participant observation as well as 13 in-depth interviews and document analyses were collected over a 12-week period. Results: Three overarching barriers emerged from the data: (1) the organizational structure for funding laparoscopic procedures, (2) the hierarchical nature of the local surgical culture, and (3) the expertise and skills associated with a change in practice. The description of the first barrier shows how the ongoing funding structure, rather than upfront costs, of the laparoscopic program limited the number of laparoscopic cases. The description of the second barrier highlights the importance of understanding the local surgical culture in attempts to adopt new technology. The description of the third barrier emphasizes the fact that due to the generalist nature of surgical practice, surgeons were less willing to practice more technically complicated and time-consuming procedures. Conclusion: This exploratory case study examining the barriers hindering the adoption of laparoscopy in an LMIC represents a novel approach to addressing issues that have plagued surgeons across LMICs for many years. These findings not only further understanding of how to improve the adoption of laparoscopy in LMICs but also challenge the economic-centric notions of the problems that affect the transfer of innovation across social, economic, and geographic boundaries. [ABSTRACT FROM AUTHOR]

Public and professional concern about health care quality, safety and efficiency is growing. Continuing education, knowledge translation, patient safety and quality improvement have made concerted efforts to address these issues. However, a coordinated and integrated effort across these domains is lacking. This article explores and discusses the similarities and differences amongst the four domains in relation to their missions, stakeholders, methods, and limitations. This paper highlights the potential for a more integrated and collaborative partnership to promote networking and information sharing amongst the four domains. This potential rests on the premise that an integrated approach may result in the development and implementation of more holistic and effective interdisciplinary interventions. In conclusion, an outline of current research that is informed by the preliminary findings in this paper is also briefly discussed. The research concerns a comprehensive mapping of the relationships between the domains to gain an understanding of potential dissonances between how the domains represent themselves, their work and the work of their 'partner' domains. [ABSTRACT FROM AUTHOR]

Over the last 15 years there has been an increasingly energetic search for theories and definitions in the burgeoning area of knowledge translation (KT) in the health care context. The focus has been on the design and evaluation of KT activities with little attention to developing a considered KT theoretical/methodological approach that takes a more distanced critical inquiry to the studying of KT interventions. As such, what has been overlooked in the health professions KT literature to date is a suitably complex conceptualisation of translation that encompasses the multiplicity of KT interventions, the dynamic environments in which they are occurring, and the production of new knowledge which arises from their interactions. Attending to these epistemological issues; i.e. issues of the type of knowledge and how it is produced, is crucial to developing a relational understanding of the production and emergence of context-specific clinical knowledge and practice in KT processes. Such an approach is compared to the traditional KT evaluations by KT practitioners themselves of the compliance or non-compliance of individual and organisational behaviour change. A Sociology of KT (SKT) is proposed to complement the applied and evaluative research practice of implementing planned action KT activities. The purpose of a SKT basic research agenda is to understand both the context-specific nature of KT interventions and the epistemological premises of the activities of KT implementers themselves, in order to advance the science of KT and inform, complement and add to the success of applied and evaluative KT research in the future. [ABSTRACT FROM AUTHOR]