Incidental Opportunities Research Articles

The Patient Pathway Review for Atrial Fibrillation.

The care pathway for patients with atrial fibrillation (AF) is variable and this variability is explored in a patient pathway review. This review describes events that may take place for a patient with AF considering the "ideal" and the "real-world" pathway and attempts to rationalize them by considering the patient, clinician, health service, and societal perspective. In the "ideal" pathway, AF in a patient is either identify before or after stroke. The "real-world" pathway introduces the concepts that symptoms may influence patient decision-making to seek help, AF may be identified incidentally, and healthcare professionals may fail to identify AF. The management of AF includes no treatment or treatment such as stroke prevention, rate or rhythm control, and comorbidity management. The overall outcomes for patient depend on the presence of symptoms and response to therapies. The two major priorities for patients are symptomatic relief and avoidance of stroke. While most clinicians will find that initial AF management is not challenging but there may be incidental opportunities for earlier identification. From the healthcare service perspective, noncardiologists and cardiologists care for patients with AF, which results in much heterogeneity management. From the societal perspective, the burden of AF is significant resulting in substantial cost from hospitalizations and treatments. People with AF can take on different paths, which depend on factors related to the patient's decision-making, clinical decision-making, and patient's response to the treatment. A streamlined approach to a holistic and integrated care pathway approach to AF management is needed.

Effects of Surprises During Quality Improvement Projects: A Longitudinal Study on Method-Driven Learning in Behavioral Healthcare

Quality improvement teams engage in multiple learning opportunities during an improvement project. These learning opportunities consist of both induced opportunities, such as formal training efforts, and incidental opportunities due to surprises (i.e., events that violate expectations) encountered during problem solving activities. In this paper, we propose that these two types of team learning opportunities can result in method-driven learning (MDL) at the team level. Our data are collected using a unique longitudinal survey design spanning 31 weeks that involved 33 participants in five design for Six Sigma projects conducted in different behavioral healthcare organizations, yielding a total of 562 weekly survey responses. We examine two modes of surprises. Those occurring spontaneously (measured based on self-rated and coder-rated variables) and reflective surprises (measured as externally-induced treatments). Our results show that: 1) the proportion of surprises occurring spontaneously during problem solving activities is positively correlated with team learning (i.e., MDL); and 2) collective reflections on surprises also facilitate team learning. Furthermore, we find evidence that surprises occurring spontaneously can negatively moderate the effect of induced learning opportunities (measured as efforts expended on training) on team learning. However, we find no evidence of such a negative moderation effect for surprises from reflection. Overall, our paper develops a nuanced understanding about the direct and moderating effects of surprises on team learning in the behavioral healthcare context, thereby contributing not only to the quality management literature but also quality improvement practices in behavioral healthcare.

From school improvement to student cases: teacher collaborative work as a context for professional development

ABSTRACT Research has extensively linked teacher collaborative work with opportunities for both explicit and implicit professional development. However, while teachers work together more often than before, little is known about how workplace collaborative contexts are structured in terms of who and how frames the problems of practice. Drawing on an ethnographically inspired case study, this article examines three common collaborative contexts and discusses how and why different ways of structuring them through problem framing mattered for professional development. The findings reveal that the context intended for school improvement offered only incidental opportunities for teachers to engage in problem framing. The ‘work works’ question was central in structuring the contexts intended for professional development and often acted as a limiting frame. In contrast, teachers’ work with student cases involved broader opportunities for explorative problem framing. The analysis emphasises the role of framing questions in structuring teacher collaborative work.

Working Harder at Working Together: Building Collaboration between Public Health and Health Care Delivery.

Working Harder at Working Together: Building Collaboration between Public Health and Health Care Delivery.

Clinical supervision and learning opportunities during simulated acute care scenarios.

Closer clinical supervision has been increasingly promoted to improve patient care. However, the continuous bedside presence of supervisors may threaten the model of progressive independence traditionally associated with effective clinical training. Studies have shown favourable effects of closer supervision on trainees' learning, but have not paid specific attention to the learning processes involved. We conducted a simulation-based study to explore the learning opportunities created during simulated resuscitation scenarios under different levels of supervision. Fifty-three residents completed a supervised scenario. Residents were randomised to one of three levels of supervision: telephone (distant); in-person after telephone consultation (immediately available), and in-person from the beginning of the simulation (direct). These interactions were converted into 234 pages of transcripts for analysis. We performed an inductive thematic analysis followed by a deductive analysis using situated learning theory as a theoretical framework. Learning opportunities created during simulated scenarios were identified as belonging to either of two categories, incidental and engineered opportunities. The themes resulting from this framework contributed to our understanding of trainees' contributions to patient care, supervisors' influences on patient care, and trainee-supervisor interactions. All forms of supervision offered trainees incidental opportunities for practice, although the nature of these contributions could be affected by the bedside presence of supervisors. Supervisors' involvement in patient care by telephone and in person was associated with a shift of responsibility for patient care, but represented, respectively, engineered and incidental opportunities for observation. In-person supervisor-trainee interactions added value to observation and created additional opportunities for incidental feedback and engineered practice. The shift of responsibility for patient care occurred during both direct and distant supervision, and did not necessarily translate into a lack of opportunities for trainee participation and practice.

‘If and when?’: the beliefs and experiences of community living staff in supporting older people with intellectual disability to know about dying

The aim of this study was to explore the way in which community living staff engaged with people with intellectual disability (ID) about dying and death. Guided by grounded theory methodology, focus groups and individual interviews were conducted with staff who had either no experience with client death, experience of a client sudden death, or a client death experience which was pre-dated by a period of end-of-life care. While in principle, staff unanimously supported the belief that people with ID should know about dying, there was limited in-practice engagement with clients about the topic. Engagement varied according to staff experience, client capacity to understand and the nature of the 'opportunity' to engage. Four 'opportunities' were identified: 'when family die', 'incidental opportunities', 'when clients live with someone who is dying' and 'when a client is dying'. Despite limited engagement by staff, people with ID are regularly exposed to dying and death. People with ID have a fundamental right to know about dying and death. Sophisticated staff skills are required to ensure that people with ID can meaningfully engage with end-of-life issues as opportunities arise.

<i>Cebus paraguayanus</i> in zoos: the spontaneous expression of species-specific behaviors

Captive Cebus paraguayanus were observed to express spontaneously a wide variety of species-specific behaviors in different zoos from Argentina. The monkeys were kept in old-style wire mesh cages with cement floors, as well as island enclosures. We collected qualitative data on nine species-specific behaviors, and all the sex-age classes analyzed expressed some of these behaviors. The results indicated that in spite of living under predictable captive conditions without environmental enrichment, Cebus paraguayanus were able to react to the incidental opportunities that were presented in these environments.

Introduction to Volume 4.2 of the Journal of Early and Intensive Behavioral Intervention.

This issue offers seven reports of experiments, two reviews of the literature, and a book review. The lead article by Dunst et al. provides our readers with two analyses of the of response contingent child learning for profoundly disabled participants and their parents. This is interesting and important work that places both children and their parents at the center of the stage. The research also suggests potential behavioral developmental analyses that might be done with typically developing children. Most of all the paper identifies what can and should be done with individuals with profound disabilities, but often is not done. Three of the research reports address contemporary topics in verbal behavior analysis. Each of these analyses incorporates the listener role and the intercept of the speaker and listener. The papers provide protocols that lead the induction of new verbal developmental capabilities, or cusps, that have been identified in recent research in verbal behavior (Greer & Ross, 2007). The intensive tact procedure (Pereira-Delgado and Oblak) replicates and extends findings of the effectiveness of this procedure in expanding non-instructional social verbal interactions by preschoolers with language delays and shows how to induce social verbal behavior without having to wait for incidental opportunities. Specifically, the protocol shows how to provide the prerequisites that allow children to be affected by contact with verbal opportunities when they could not be affected by those opportunities before the intervention. The intensive tact procedure builds generalized reinforcement effect for the emission of tacts. Tacts are the critical foundation for the unfolding of more advanced verbal capabilities and socialization (e.g., naming and conversational units). Until children have the naming capability and are fluent readers the only way that they can acquire tacts is through direct instruction. Once they have naming they can acquire tacts indirectly and that is the capability that Speckman-Collins, Park, and Greer address in the test of the effect of acquiring auditory matching on the listener component of naming. The auditory matching protocol described by Speckman-Collins et al. expands prior work where auditory matching led to either first instances of echoics or exact echoics. In their study, the authors found that the auditory matching protocol resulted in the listener half of naming in children with limited speaker repertoires. Naming was also found to be a collateral outcome of systematic training in observational learning in the Rothstein and Gautreaux paper. Helou, Lai, and Sterkin report new data on the effect of writer immersion on functional writing, particularly the editing aspect of functional writing. Editing is an expanded listener capability. Their work adds to the growing evidence of the utility of the findings from verbal behavior analysis for curriculum objective to reach effective writing to children and youth with and without disabilities. Three of the research reports involve the induction or expansion of observational learning repertories and the manner in which tutoring taps the benefits of observational learning for tutors. Observational contact with contingencies is a critical repertoire. It is a repertoire that is often deficit or missing in some students; however recent work shows how it can be induced or expanded. Research in behavior analysis is currently addressing observational learning with renewed vigor and the result of this work is both surprising and promising (Greer, Singer-Dudek, & Gautreaux, 2006). One of the more promising efforts is the treatment of observational learning as a dependent variable rather that the traditional treatment of it as an independent variable. For too long we have ignored the importance of analyses of how we learn from indirect contact with contingencies of instruction or social interaction and the relation of higher order classes to certain types of observational learning that is key to social behavior. …

Forced Copulation in Waterfowl

Abstract 1. Although almost all waterfowl (ducks, geese and swans comprizing the family Anatidae) have basically monogamous mating systems, males of 39 species have been observed to perform or attempt forced copulation (FC) (previously called "rape"). 2. Suggestions that FC is an artifact of crowding in urban mallards, an outlet for thwarted male sex drive, a component of territory defence, or an alternative reproductive strategy of unpaired males are not supported by available evidence. 3. In the case of the mallard, HEINROTH'S (1911) interpretation of FC as a secondary insemination method whereby paired males increase their reproductive success by fertilizing some of the eggs laid by females other than their mate is supported by evidence of various kinds. FCs are performed by paired males; they occur during periods in the breeding season when eggs are being fertilized; they are directed mainly at females in prelaying and laying condition; paired males usually defend their mates against males attempting FC (suggesting defence of genetic paternity); paired males have been seen to copulate forcibly with their own mates after the latter have been subjected to FC (suggesting an antidote insemination strategy). 4. Experiments on captive mallards have shown that eggs can be fertilized by sperm delivered during FC and, since females can store viable sperm for up to 17 days, sperm competition must be taking place. Artificial insemination experiments have shown that (a) the second of 2 competing inseminations 6 hours apart overlays the former insemination and is 70% more potent, (b) there is an insemination "window" within 1 hour of oviposition when the next egg in the clutch is fertilized. The extent to which males time their copulations (FCs, pair copulations, forced pair copulations) to take advantage of these patterns of sperm competition is not known. 5. Studies of the lesser snow goose, northern pintail and lesser scaup indicate that FC is a secondary reproductive strategy of paired males in these species also. Observations on 13 species of dabbling duck provide additional evidence for the selection of fertile females as FC targets and the development of male tactics for achieving and combatting FC. 6. It is difficult to rule out the possibility that females could derive certain benefits from FC inseminations (e.g. genetic diversity of offspring) but the costs and risks of being involved in FC assaults can be high and the females apparently try to avoid FC. Female dabbling ducks can be damaged, or even killed, during assaults and female escape behaviour (high flights, diving, hiding in cover) entails energetic costs and wastage of time that are presumably detrimental to females during the period when they are producing eggs. 7. As HEINROTH suggested, FC probably does not occur in swans, most geese and shelducks because it is incompatible with the major roles that paired males play in defence of breeding territories, mates, nest-sites and broods in these groups. The occurrence of FC in snow and Ross goose may be facilitated by colonial nesting.. 8. Among dabbling ducks, male territoriality is associated with strong mate-guarding and these characteristics appear to conflict with male FC activities. Involvement of paired males in extrapair courtship, polygyny and brood-care may produce additional conflicts with FC behaviour in certain species. 9. In at least 4 species of waterfowl (mallard, northern pintail, lesser snow goose, lesser scaup) behavioural evidence indicates that FC is part of a mixed male reproductive strategy of the type postulated by TRIVERS (1972). Rigorous testing of the hypothesis will require studies to (a) assess the incidence of multiple paternity in wild clutches, (b) distinguish species (or populations within a species) in which paired males actively pursue FC tactics from those in which they merely capitalize on incidental opportunities for FC.