A Narrative Study of Patient Encounter Accounts of Physicians, Nurses, and Medical Receptionists after Two Decades of a Paradigm of Patient-Centered Care

Despite recent well-known advancements in patient care in the medical fields, such as patient-centeredness and evidence-based medicine and practice, there is rather less known about their effects on the particulars of clinician-patient encounters. The emphasis in clinical encounters remains mostly on treatment and diagnosis and less on communicative competency or engagement for medical professionals. The purpose of this narrative study was to explore interactive competencies in diagnostic and therapeutic encounters and intake protocols within the context of the physicians’, nurses’, and medical receptionists’ perspectives and experiences. Literature on narrative medicine, phenomenology and medicine, therapeutic relationships, cultural and communication competency, and non-Western perspectives on human communication provided the guiding theoretical frameworks for the study. Three data sets including 13 participant interviews (5 physicians, 4 nurses, and 4 medical receptionists), policy documents (physicians, nurses, and medical receptionists) and a website (Communication and Cultural Competency) were used. The researcher then engaged in triangulated analyses, including N-Vivo, manifest and latent, Mishler’s (1984, 1995) narrative elements and Charon’s (2005, 2006a, 2006b, 2013) narrative themes, in recursive, overlapping, comparative and intersected analysis strategies. A common factor affecting physicians’ relationships with their clients was limitation of time, including limited time (a) to listen, (b) to come up with a proper diagnosis, and (c) to engage in decision making in critical conditions and limited time for patients’ visits. For almost all nurse participants in the study establishing therapeutic relationships meant being compassionate and empathetic. The goals of intake protocols for the medical receptionists were about being empathetic to patients, being an attentive listener, developing rapport, and being conventionally polite to patients. Participants with the least iv amount of training and preparation (medical receptionists) appeared to be more committed to working narratively in connecting with patients and establishing human relationships as well as in listening to patients’ stories and providing support to narrow down the reason for their visit. The diagnostic and intake “success stories” regarding patient clinical encounters for other study participants were focused on a timely securing of patient information, with some acknowledgement of rapport and emapathy. Patient-centeredness emerged as a discourse practice, with ambiguous or nebulous enactment of its premises in most clinical settings.

The effect of a weighted-vest strength and balance training program on obstructed walking in postmenopausal women

SUMMARY Background: Age related declines in lower extremity strength have been associated with impaired mobility and changes in gait patterns, which increase the likelihood of falls. Since community dwelling adults encounter a wide range of locomotor challenges including uneven and obstmcted walking surfaces, we examined the effect of a strength 11 and balance exercise program on obstructed walking in postmenopausal women. Objectives: This study examined the effect of a weighted-vest strength and balance exercise program on adaptations of the stance leg during obstacle walking in postmenopausal women. Methods: Eighteen women aged 44-62 years who had not engaged in regular resistance training for the past year were recruited from the St. Catharines community to participate in this study. Eleven women volunteered for an aerobic (walking), strength, and balance training program 3 times per week for 12 weeks while 7 women volunteered as controls. Measurements included: force platform dynamic balance measure of the center of pressure (COP) and ground reaction forces (GRFs) in the stance leg while going over obstacles of different heights (0,5, 10,25 and 30 cm); and isokinetic strength measures of knee and ankle extension and flexion. Results: Of the 18 women, who began the trial, 16 completed it. The EX group showed a significant increase of 40% in ankle plantar flexion strength (P < 0.05). However, no improvements in measures of COP or GRFs were observed for either group. Failure to detect any changes in measures of dynamic balance may be due to small sample size. Conclusions: Postmenopausal women experience significant improvements in ankle strength with 12 weeks of a weighted-vest balance and strength training program, however, these changes do not seem to be associated with any improvement in measures of dynamic balance.

Explicit/implicit training of cooperative learning with junior elementary students /

This experimental study examined the effects of cooperative learning and expliciUimpliGit instruction on student achievement and attitudes toward working in cooperative groups. Specifically, fourth- and fifth-grade students (n=48) were randomly assigned to two conditions: cooperative learning with explicit instruction and cooperative learning with implicit instruction. All participants were given initial training either explicitly or implicitly in cooperative learning procedures via 10 one-hour sessions. Following the instruction period, all students participated in completing a group project related to a famous artists unit. It was hypothesized that the explicit instruction training would enhance students' scores on the famous artists test and the group projects, as well as improve students' attitudes toward cooperative learning. Although the explicit training group did not achieve significantly higher scores on the famous artists test, significant differences were found in group project results between the explicit and implicit groups. The explicit group also exhibited more favourable and positive attitudes toward cooperative learning. The findings of this study demonstrate that combining cooperative learning with explicit instruction is an effective classroom strategy and a useful practice for presenting and learning new information, as well as working in groups with success.

The implications of being an international medical graduate (IMG) in Canadian society : a qualitative study of foreign-trained physicians' resettlement, sense of identity and health status

This qualitative research study used grounded theory methodology to explore the settlement experiences and changes in professional identity, self esteem and health status of foreign-trained physicians (FTPs) who resettled in Canada and were not able to practice their profession. Seventeen foreign-trained physicians completed a pre-survey and rated their health status, quality of life, self esteem and stress before and after coming to Canada. They also rated changes in their experiences of violence and trauma, inclusion and belonging, and racism and discrimination. Eight FTPs from the survey sample were interviewed in semi-structured qualitative interviews to explore their experiences with the loss of their professional medical identities and attempts to regain them during resettlement. This study found that without their medical license and identity, this group of FTPs could not fully restore their professional, social, and economic status and this affected their self esteem and health status. The core theme of the loss of professional identity and attempts to regain it while being underemployed were connected with the multifaceted challenges of resettlement which created experiences of lowered selfesteem, and increased stress, anxiety and depression. They identified the re-licensing process (cost, time, energy, few residency positions, and low success rate) as the major barrier to a full and successful settlement and re-establishment of their identities. Grounded research was used to develop General Resettlement Process Model and a Physician Re-licensing Model outlining the tasks and steps for the successfiil general resettlement of all newcomers to Canada with additional process steps to be accomplished by foreign-trained physicians. Maslow's Theory of Needs was expanded to include the re-establishment of professional identity for this group to re-establish levels of safety, security, belonging, self-esteem and self-actualization. Foreign-trained physicians had established prior professional medical identities, self-esteem, recognition, social status, purpose and meaning and bring needed human capital and skills to Canada. However, without identifying and addressing the barriers to their full inclusion in Canadian society, the health of this population may deteriorate and the health system of the host country may miss out on their needed contributions.

Athletic injury care training in high school coaches

The purpose of this qualitative study was to understand the client and occupational therapist experiences of a mental health group. A secondary aim was to explore the extent to which this group seemed to have reflected a client-centred approach. The topic emerged from personal and professional issues related to the therapist as teacher and to inconsistencies in practice with the profession's client-centred philosophy. This philosophy, the study's frame of reference, was established in terms of themes related to the client-therapist relationship and to client values. Typical practice was illustrated through an extensive literature review. Structured didacticexperiential methods aiming toward skill development were predominant. The interpretive sciences and, to a lesser extent, the critical sciences directed the methodology. An ongoing support group at a community mental health clinic was selected as the focus of the study; the occupational therapist leader and three members became the key participants. A series of conversational interviews, the . core method of data collection, was supplemented by observation, document review, further interviews, and fieldnotes. Transcriptions of conversations were returned to participants for verification and for further reflection Analysis primarily consisted of coding and organizing data according to emerging themes. The participants' experiences of group, presented as narrative stories within a group session vignette, were also returned to participants. There was a common understanding of the group's structure and the importance of having "air time" within the group; however, differences in perceptions of such things as the importance of the group in members' lives were noted. All members valued the therapeutic aspects of group, the role of group as weekly activity and, to a lesser extent, the learning that came from group. The researcher's perspective provided a critique of the group experience from a client-centred perspective. Some areas of consistency with client-centred practice were noted (e.g., therapist attitudes); however the group seemed to function far from a client-centred ideal. Members held little authority in a -relationship dominated by the leaders, and leader agendas rather than member values controlled the session. Possible reasons for this discrepancy ranging from past health care encounters through to co-leader discord emerged. The actual and potential significance of this study was discussed according to many areas of implications: to OT practice, especially client-centred group practice, to theory development, to further areas of research and methodology considerations, to people involved in the group and to my personal growth and development.

Effectiveness of computer training on attentional skills

This paper presents two studies, both examining the efficacy of a computer programme (Captain's Log) in training attentional skills. The population of interest is the traumatically brain injured. Study #1 is a single-case design that offers recommendations for the second, .larger (N=5) inquiry. Study #2 is an eight-week hierarchical treatment programme with a multi-based testing component. Attention, memory, listening comprehension, locus-of-control, self-esteem, visuo-spatial, and general outcome measures are employed within the testing schedule. Results suggest that any improvement was a result of practice effects. With a few single-case exceptions, the participants showed little improvement in the dependent measures.

Effectiveness of life skills training on the total behaviour of six individuals in a job preparation program

In the first week of a Job preparation Program all twelve female members of the class were invited to be part of a study to determine the effect of Life Skills training on their behaviour over the twelve-week period of the program. Six females volunteered and each was interviewed four times during the Job preparation Program and once after the program ended. The interviews focused on three areas of skill deficiency addressed in Life Skills lessons: their knowledge about themselves and attitude towards themselves; their interpersonal relationships; and their problem-solving ability. The participants' comments over the sixteen-week period of the interviews were used to decide if the total behaviour of the participants, (i.e., what they did, thought, and felt) changed so that each became more effective in satisfying her needs. The study suggested that the total behaviour of three of the six women changed so that they became more effective in satisfying their needs. The fourth female's total behaviour changed in only two of the three areas focused on in the interviews, and the total behaviour of the fifth and sixth females showed no change.

Nurses' attitudes toward computers before and two months after training

This study examined nurses' attitudes toward computers before training and 2 months after training. A quantitative approach and a nonexperimental survey design were used in this study. Stronge and Brodt's (1985) instrument, Nurses' Attitudes Toward Computerization Questionnaire, was used to assess 27 nurses' attitudes prior to and 2 months after computer training. Demographic variables also were collected on the questionnaires. The results of this study showed that, overall, nurses had positive attitudes towards computers in both questionnaires. The results of the first questionnaire were consistent with other studies. There were no studies that involved a follow-up questionnaire using Stronge and Brodt's (1985) instrument. Attitude scores of Questionnaire 2 were higher than attitude scores of Questionnaire 1. More time for nursing tasks, less time for quality patient care, and threat to job security questions were found to be statistically significant. This study found no statistical significance between attitudes and demographic variables. Younger nurses a~d nurses with fewer years of computer experience were most likely to exhibit positive attitudes. Implications for practice and future research were discussed. Some limitations were identified and discussed.

The effect of literacy training on the self-concept of moderately mentally handicapped adults

In this single group, pretest/posttest design study the literacy level and self-concept of nine moderately mentally handicapped adults was assessed. The participants in the study were involved in reading lessons using the Ball-Stick-Bird reading system, a brainbased program. No significant differences were found in either literacy level or reading level after intervention. However, there were changes in reading behaviour. These changes occurred in the subskills ofdirectionality, letter-sound correspondence, wordreading, and use of reading materials.

The effect of social skills training on grade 3 students' self-esteem, moral development and perceptions of classroom environment

Two Grade 3 classes were used to study the effects of a formal social skills training program. Specifically, comparisons were made on self-esteem, classroom environment, and moral development to see whether changes occurred as a direct result of social skills training. One group participated in the social skills program, while the other group did not. It was hypothesized that formal social skills training would improve students' selfesteem, moral development, and the classroom environment. At the end of the program, however, data from class observations, teacher interviews, journal of the social skills training group teacher, and measures of self-esteem, classroom environment and moral development did not support this hypothesis. Although the social skills training group scored significantly higher in class cohesiveness, they did not show marked improvement in the other measures. In fact, in some measures (e.g., friction and competitiveness), they demonstrated greater scores at both pretest and posttests. The social skills training group was, however, able to vocalize and utilize the strategies of several skills which had been a focus of the program, suggesting that formal social skills training is a useful tool for presenting and reinforcing some specific behaviours.

The impact of a training program in phonological awareness on children's early writing

This study examined the effects that a training program in phonological awareness had on the early writing skills of children in a Grade One class in the Lincoln County Separate school system. The intent of the training program was to provide consistent and systematic practice in the manipulation of the phonological structure of language. The games and activities of the training program were related to a framework of developmental phonological skills and practised in a group setting during an unstructured period of the regular classroom schedule. The training program operated three days in a six-day cycle for approximately twenty minutes a day, from November until mid-March. All children were tested at the outset and conclusion of the study to determine level of functioning in letter identification, word recognition, verbal intelligence, phonological awareness and spelling. Results of the pre-tests and post-tests were compared to determine differences between the experimental and control groups over time. In addition, a systematic analysis of the children's writing looked at the development of the spelling of regular and irregular words. The results of this study provided strong support for the hypothesis that the treatment group would progress through the stages of early writing development more quickly than children without such training. On the basis of differences between the groups over time, it was evident that training in phonological awareness had a direct positive effect on the spelling of regular words for children during the early stages of writing. The training program did not have a significant effect on the spelling of irregular words. Test results evaluating phonological awareness indicated a significant difference within each group over time but no significance between the groups during the experimental period. It would appear that the results of these tests reflect maturational changes in the child rather than causal effects of the training program. Nor did the effects of the training program transfer significantly to other aspects of language. Although some of the hypotheses considered were not supported by the study, the results do indicate that children during the early stages of writing development can benefit from a training program in phonological awareness. The theoretical direction for effective programming as a result of this study is discussed. The educational implications of training phonological awareness concurrent to beginning efforts in writing are considered.

Training distribution and the acquisition of maximal isometric elbow flexion strength

Twenty-six sedentary, college-aged females were matched and randomly assigned to one of two groups. The massed group (n=13) completed 15 maximal isometric elbow flexion strength trials in one session, while the distributed group (n=13) performed five such contractions on three successive days. After a two-week and three month rest interval, both groups returned to perfonn another five maximal isometric elbow flexion strength trials to assess retention of any potential strength gains. Elbow flexion torque and surface electromyography (SEMG) of the biceps and triceps were monitored concurrently. There was a significant (P < 0.05) increase in strength in both groups from block one (first five contractions) to block four (first retest) and from block one to block five (second retest). Both groups exhibited a similar linear increasing (P < 0.05) trend in biceps root-mean-square (RMS) SEMG amplitude. A significant (P < 0.05) decrease in triceps RMS SEMG amplitude was found between block one and block four for the distributed group. However, a significant (P < 0.05) increase was then found between block one and five for the massed group, and between blocks four and five for distributed group. These results suggest that there is flexibility in resistive exercise schedules. An increase in neural drive to the agonist muscle continued throughout testing. This was accompanied by a reduction in antagonist co activation that was a short-tenn (two weeks) training effect, dissipated over the longer rest interval (three months).

An assessment of autism knowledge in the medical field

Once thought to be rare, pervasive developmental disorders (PDDs) are now recognized as the most common neurological disorders affecting children and one of the most common developmental disabilities (DD) in Canada (Autism Society of Canada, 2006). Recent reports indicate that PDDs currently affect 1 in 150 children (Centre for Disease Control and Prevention, 2007). The purpose of this research was to provide an understanding of medical resident and practicing physicians' basic knowledge regarding PDDs. With a population of children with PDDs who present with varying symptoms, the ability for medical professionals to provide general information, diagnosis, appropriate referrals, and medical care can be quite complex. A basic knowledge of the disorder is only a first step in providing adequate medical care to individuals with autism and their families. An updated version of Stone's (1987) Autism survey was administered to medical residents at four medical schools in Canada and currently practicing physicians at three medical schools and one community health network. As well, a group of professionals specializing in the field ofPDDs, participating in research and clinical practice, were surveyed as an 'expert' group to act as a control measure. Expert responses were consistent with current research in the field. General findings indicated few differences in overall knowledge between residents and physicians, with misconceptions evident in areas such as the nature of the disorder, qualitative characteristics of autism, and effective interventions. Results were also examined by specialty and, while pediatricians demonstrated additional accurate 11 knowledge regarding the nature of the disorder and select qualitative impairments, both residents and practicing physicians demonstrated misconceptions about PDDs. This preliminary study replicated the findings of Stone (1987) and Heidgerken (2005) concerning several misconceptions of PDDs held by residents and practicing physicians. Future research should focus on additional replications with validated measures as well as the gathering of qualitative information, in order to inform the medical profession of the need for education in PDDs at training and professional levels.

Canadian curling coaches' use of psychological skills training

Hom's (2008) model of coaching effectiveness proposes a series of direct relationships between the beliefs and values of coaches, their behaviours, and the perceptions of their athletes. One specific area of coaching behaviour that is in need of more research is their use of psychological skills training (PSn. The purpose of this study was to examine the relationship between the beliefs and behaviours of curling coaches with respect to PST, and the perceptions of their athletes. In collaboration with the Canadian Curling Association, data was collected from a national sample of 115 curling teams with varying levels of competition and experience. One hundred and fifteen coaches completed PST attitude (SPA-RC-revised) and behaviour (MSQ-revised) measures, while 403 athletes completed two perception measures (CCS and S-CI). Interclass correlation coefficients (ICC) were calculated to ensure intra-team consistency. All ICCs were positive, ranging from r =.39 to .56, and significant at the p < .01 level. A series of multiple regressions were performed. Three of the four regression models were significant, with coaches' PST behaviours accounting for 16% of the variance in athletes' evaluation of their coaches' competencies (GeC). The models for athletes' PhysicalSport Confidence (P-SC) and Cognitive-Sport Confidence (C-SC) accounted for 15% and 36% of the variation, with GCC and coaches' PST behaviours both being significant predictors of the models. After statistically controlling the influence of GCC, coaches' PST behaviours accounted for 3% and 26% of the variation in athletes P-SC and C-SC. These results provide partial support for Hom's (2008) model of coaching effectiveness, and offer new insight into the benefits of coaches' use of sport psychology-related training behaviours.

Examining and describing professional development and continuing education in the personal training and fitness industry : sites and issues of disconnect

The following phenomenologically oriented study examines and describes the relevance and effectiveness of professional development and continuing education programs for real-world situations of personal trainers. The participants were personal trainers, facility managers, and persons involved in the accreditation process. Data collection took place in 3 phases. The first phase consisted of the participants completing the PUMP Questionnaire, followed by focus groups with personal trainers and interviews with managers. The study's 3 data sets required reduction via a content analysis by question, content analysis by existential categories, and further thematic analysis using the lived relation existential dimension. The discussion contains the salient sites and issues of disconnect between clients, personal trainers, and facility managers and how they might affect the personal training experience. The intergenerational disconnect emphasized between Boomers as clients and Millennials as personal trainers requires further exploration and dialogue and underscores the need for different approaches to content and delivery of professional development and continuing education experiences for personal trainers and managers of fitness facilities.