Allan McDougall

Representing complexity well: a story about teamwork, with implications for how we teach collaboration

Medical Education 2012: 46: 869–877

Understanding Palliative Care on the Heart Failure Care Team: An Innovative Research Methodology

CONTEXT There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team. OBJECTIVES To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team. METHODS This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams. RESULTS We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps. CONCLUSION We anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

Adaptive practices in heart failure care teams: implications for patient-centered care in the context of complexity.

Background Heart failure (HF), one of the three leading causes of death, is a chronic, progressive, incurable disease. There is growing support for integration of palliative care’s holistic approach to suffering, but insufficient understanding of how this would happen in the complex team context of HF care. This study examined how HF care teams, as defined by patients, work together to provide care to patients with advanced disease. Methods Team members were identified by each participating patient, generating team sampling units (TSUs) for each patient. Drawn from five study sites in three Canadian provinces, our dataset consists of 209 interviews from 50 TSUs. Drawing on a theoretical framing of HF teams as complex adaptive systems (CAS), interviews were analyzed using the constant comparative method associated with constructivist grounded theory. Results This paper centers on the dominant theme of system practices, how HF care delivery is reported to work organizationally, socially, and practically, and describes two subthemes: “the way things work around here”, which were commonplace, routine ways of doing things, and “the way we make things work around here”, which were more conscious, effortful adaptations to usual practice in response to emergent needs. An adaptive practice, often a small alteration to routine, could have amplified effects beyond those intended by the innovating team member and could extend to other settings. Conclusion Adaptive practices emerged unpredictably and were variably experienced by team members. Our study offers an empirically grounded explanation of how HF care teams self-organize and how adaptive practices emerge from nonlinear interdependencies among diverse agents. We use these insights to reframe the question of palliative care integration, to ask how best to foster palliative care-aligned adaptive practices in HF care. This work has implications for health care’s growing challenge of providing care to those with chronic medical illness in complex, team-based settings.

‘Who is on your health-care team?’ Asking individuals with heart failure about care team membership and roles

Complex, chronically ill patients require interprofessional teams to address their multiple health needs; heart failure (HF) is an iconic example of this growing problem. While patients are the common denominator in interprofessional care teams, patients have not explicitly informed our understanding of team composition and function. Their perspectives are crucial for improving quality, patient‐centred care.

Creating Discursive Order at the End Of Life: The Role of Genres in Palliative Care Settings

This article investigates an emerging practice in palliative care: dignity therapy. Dignity therapy is a psychotherapeutic intervention that its proponents assert has clinically significant positive impacts on dying patients. Dignity therapy consists of a physician asking a patient a set of questions about his or her life and returning to the patient with a transcript of the interview. After describing the origins of dignity therapy, the authors use a rhetorical genre studies framework to explore what the dignity interview is doing, how it shapes patients’ responses, and how patients improvise within the dignity interview’s genre ecology. Based on a discourse analysis of the interview protocol and 12 dignity interview transcripts (legacy documents) gathered in two palliative care settings in Canadian hospitals, the findings suggest that these patients appear to be using the material and genre resources (especially eulogistic strategies) associated with dignity therapy to create discursive order out of their life events. This process of genre negotiation may help to explain the positive psychotherapeutic results of dignity therapy.

Sovereign Survival: Borders as Issues

Abstract Revisiting the relevance of state borders in a changing world, this paper focuses on the complexities of the intersection of the hegemonic character of the state and its manifestations in issues at the border. Three types of border conflict are presented in this case study: trade and the construction of issues across the Canada‐U.S. border, the indirect impact of that state border on social services and social life in the area, and the decreasing significance of statist standards as one approaches its borders. The study uses a typical decision of a quasi judicial agency, the National Transportation Agency, to illustrate the hegemonic practice embedded in the normal practice of statist structures. It concludes with the paradox that the rule of law is crucial to control the exercise of public power and yet the application of legal principles reinforces the ascendancy of hegemonic forces. The border as the hinterland of the state is a liminal zone where these dynamics are especially visible.

Imposing the border: The Detroit River from 1786 to 1807

Abstract In 1783, a border was imposed across the Old Northwest by the newly‐formed United States and Great Britain through the Treaty of Paris. That division down the center of the southern Great Lakes waterway was reconfirmed by the Jay Treaty of 1794. Despite these treaties, control of the borderland region remained in contention. This paper addresses the impact that the imposition of the border had on life in this region as a step on the way to understanding the impact of borders more generally. This historical case study focuses on aspects of social and political transformation in the contested borderlands of the Old Northwest, highlighting both the macrolevel strategy of states, which moved to conclude treaties with the indigenous population in order to control the territory and to deploy settlement, and the microlevel accommodations of settlers, traders, corporations and Native American communities. This paper traces the transformation of the Detroit hinterlands, the specific events around the imposition of the border, and the interdependence of community, commerce and the state. This brief historical overview illustrates immediate outcomes of the creation of a border and outlines some of its social, political, economic and legal consequences in the period.

When I say … gamification

During a recent conversation with a colleague, I described a study I was once involved in that explored communication among members of a liver transplant team. The study observed the simultaneously distinct yet interdependent roles that advanced medical trainees played as part of an interprofessional team. Trainees solved problems, identified allies, searched for resources, played different roles, and, sometimes, combated antagonists from other departments. I remarked to my colleague that all the travelling to different places and requirements to deal with unique challenges had reminded me of a video game. Her reply came in the form of advice: ‘Be careful where you say that. You don’t want to come across as if you are trivialising medical education.’