How is knowledge mobilized when we can’t agree on what knowledge is? Reconciling “ practice relevance ” and “ the public interest ” across boundaries of research-practice & medicine- social science Peter Nugus Australian Institute of Health Innovation, Macquarie University 6 th April, 2019
Co-investigators Peter Nugus, Maud Mazaniello-Chezol, Nadjib Mokraoui, Anna Horton, Josianne Lamothe, Gillian Bartlett, Emille Boillot, Paula Bush, Annabelle Levesque-Chouinard, Jamieson Clark, Valérie Dory, Marion Dove, Roland Grad, Matthew Hacker Teper, Vania Jimenez, Audrey Juras, Kendall Kolne, Neb Kovacina, Lucie Lambert, Serge Medetongnon, Pierre Pluye, Ellen Rosenberg, Leora Simon, Myriam St-Pierre, Isabelle Vedel, Laura Rojas-Rozo, Jeannie Haggerty
Outline • Knowledge mobilization across boundaries • Methodology: multiple case study and mixed methods • Case 1: Medical student ethnographic project • Case 2: Promoting practitioner-led research (PBRN) • Case 3: Designing a new PhD in Health Sciences Education • Discussion / conclusion: Reconciling cultural differences across knowledge boundaries
Knowledge mobilization across boundaries • Movement towards greater research engagement by practitioners (Borkowski, 2016; Harding, et al. 2017; Kuyare et al., 2016) • Evolving relationship between knowledge use and production • Neo-liberalism: It ’ s good for “ the people ” is research is “ practical ” (Giroux, 2007, 2008) • Despite the complexity / specialization of modern societies. • Generalized calls for accessible knowledge to benefit users ( “ democratizing ” ) (Alison et al ., 2017; Heard 2017; Matus et al ., 2018)
Knowledge mobilization across boundaries • Less research on how characteristics of different knowledge communities influence knowledge mobilization efforts (Borkowski 2016; Harvey, et al., 2016; Hanlon et al., 2018; Matus et al ., 2018) • In order to inform / effect structural changes, we need clarity over the cultural differences between different stakeholders/communities Objective: To understand the influence and implications of power differences, priorities, cultures and perspectives among different knowledge communities for sustainable knowledge mobilization.
Methodology • Multiple qualitative case study: • Case 1: Medical student ethnographic project • Case 2: Promoting practitioner-led research (PBRN) • Case 3: Designing a new PhD in Health Sciences Education
Methodology • Mixed methods (within a qualitative framework): • Semi-structured interviews for three cases • Field interviews for three cases • Field / journal notes for three cases • Document analysis for two cases • Observations for one case • Pre-post surveys for one case
Methodology • Data analysis: • Qualitative content analysis for three cases • Exploratory factor analysis & repeated measures ANOVA for one case • Human research ethics: • Secured separately for the three cases
Case 1: Medical students ’ mandatory ethnographic project • Context: • 2015-2018 – In new curriculum • Mandatory, 2 nd year (Jan-June), 180 students per year • Only such mandatory course anywhere
Case 1: Medical students ’ mandatory ethnographic project • Context: • Activity: An activity ( Observing Healthcare in Action - OHA ) in which students combine direct / “live” observations of clinical care with broad understandings of the meaning of that care – through focus on a particular theme (e.g. patient safety, interprofessional relations etc.): • 2 lectures (including Socrative) & 2 workshops • Supporting documents (e.g. Guide) and articles • 3 x 3 hour observations in a primary care clinic • Analysis in written assignment / oral presentation • Wine & cheese with clinical sites & the 4 best presentations
Case 1: Medical students ’ mandatory ethnographic project • Organizational context : • In Transition to Clinical Practice • Housed in Department of Family Medicine (DFM) • McGill accepts undergraduate medical students • Insufficient family medicine residents • In Accreditation, faculty had performed poorly in student responsiveness, and received negative publicity • “ Medical dominance ” or the medicalization of society is grounded in medicine ’ s unique ( “ esoteric ” ) knowledge and language (Abbott, 1988; Freidson, 1970; Willis, 1989) • Writing / reflective activities tend to play down evidence.
Case 1: Medical students ’ mandatory ethnographic project • Objective : For students to understand that medical decisions (such as about diagnosis and treatment) are influenced by contextual factors and perspectives on clinical care (beyond bio-medicine) (e.g. technology, inter-professional relations, staffing levels etc.)
Assignment / presentation topics Interactions/Communication (15%) Space/waiting room (13%) Inter-profession relations/roles (12%) Organizational/work culture/processes (11%) Technology (9%) Patient culture/needs (8%) Reception (7%) Policy-practice (7%) Professionalism/ethics (6%) Governance/structure (4%) Infection control (3%) External relations (3%) Other (2%)
Case 1: Medical students ’ mandatory ethnographic project • Findings: • The students learned: - 490 pre-post surveys by 197 students (2015-2017) - Significant increase (p<0.02) for the perceptions of understanding how healthcare is organized. “ I understand… ” • How health organizations work • The role of primary care clinics in the health system • The structure of health care in this province • The structure of primary health care in this province • The roles of health care staff in roles other than medicine
Case 1: Medical students ’ mandatory ethnographic project • (R)evolution: • Name – from ethnography to OHA • Aims – from ethnography to institutions/organizations • Activity / Delivery methods – fewer workshops, shorter lectures, from 3 to 2 observations • Assessment requirements – from written to oral • Variable support – a strong “ determinant ” • Negotiation – continual and intense / needed insider/s
Case 1: Medical students ’ mandatory ethnographic project Student perspectives, behaviours and outcomes: • Questionable relevance to “ real medicine ” • “ Real ” (foundational) medicine first • Organized resistance (lobbying, student representatives) • Students perceive that they already do a lot of writing • Ultimately succeeded in having the exercise removed.
Case 1: Medical students ’ mandatory ethnographic project "In particular, my observations of the interprofessional team, with an emphasis on the role of the nurse and of the psychotherapists, as well as my discussions with these professionals, have made me realize that even though the work that a physician does is crucial, there are several essential aspects of patient care that the allied health professionals are much more qualified to address. Going forward in clerkship and beyond, this realization will likely encourage me to give much more weight to their point of view when establishing a plan for the care of my patient, and to try and consider things from their point of view. ” (OHA student, 2017)
Case 1: Medical students ’ mandatory ethnographic project "Up until now, we have received a universally optimistic view of medicine. This course was one of the first opportunities where we were invited to think critically about the care patients receive and to make recommendations to improve care. I believe the constant positive framing of medicine is problematic because it becomes harder for us to receive criticism from our patients or our colleagues since we believe there ’ s nothing wrong with the way medicine is practiced." (OHA student, 2016)
Case 1: Medical students ’ mandatory ethnographic project “ … It would be nice to have time to just focus on studying medicine and not having to do projects that are unrelated ” . (Medical student) “ There are many other more pressing issues to deal with at the point we are at in our career, and this seems like a waste of time. … (It ’ s) not very relevant for us. ” (Medical student)
Case 1: Medical students ’ mandatory ethnographic project • Social science lecturer / coordinator perspectives, behaviours & outcomes: • Extensive consultation (8 physician-social scientists in 4 countries, 15 students past and present, TLS etc) and amendments • Intense lobbying • Strong response to internal review • Considerable learning by students • Exceptionally high quality of written assignments • Unsuccessful in retaining the exercise in TCP, but given opportunity to re-approach Undergraduate Curriculum Committee with an alternative proposal.
Case 1: Medical students ’ mandatory ethnographic project • Structure of lecture 1: 1. Socrative exercise 2. Youtube intro to ethnography: The Hidden Obvious 3. 2 cases: Hoarding and hand-washing 4. What are the objectives? 5. Why do I need to do this exercise? 6. How will I do it?
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