Foundations of Interprofessional Health Education: An Ecological Theory 3031334132, 9783031334139

Table of contents :
Preface
Contents
About the Author
List of Figures
List of Tables
List of Examples
Contents
Chapter 1: Introduction
Part I: The Natural Domain
1.1 IP Problem: Premature Closure
Chapter 2: Affordances
References
Chapter 3: The Classical Model
References
Chapter 4: Critical Realism
References
Chapter 5: Realist Affordances
References
Part II: The Mental Domain
1.1 IP Problem: Hidden Affordances
Chapter 6: The Lifeworld
Intrinsic Expansion
Mediated Expansion
References
Chapter 7: Sense of Being
The “Self”
Identity
References
Chapter 8: Emotion
References
Chapter 9: “Knowing” the World
References
Chapter 10: Intrinsic Expansion of the Lifeworld
References
Chapter 11: Mediated Expansion of the Lifeworld
References
Chapter 12: Inner Wisdom
Depth Psychology
Mindfulness Meditation
Native American Spirituality
Summary
References
Part III: The Social Domain
1.1 IP Problem: Tacit Social Affordances
Chapter 13: Behavioral Settings
References
Chapter 14: Language: Ritual and Stories
Rituals
Stories
References
Chapter 15: Semiotics
Wiley’s Combination of Peirce and Mead
Biosemiotics
References
Chapter 16: Revisiting Identity
Role Identity
Social Identity
Person Identity
References
Chapter 17: Boundaries and Bridges
Boundaries
Bridges
References
Part IV: Nonlinearity
1.1 IP Problem: “Either/Or” Thinking
Chapter 18: Complex Adaptive Systems
Self-Creation
Emergence
Stratification
References
Chapter 19: Complementarity
References
Chapter 20: Dynamics
Coordination Dynamics
Adaptive Cycle Theory
References
Part V: Application
Chapter 21: Design/Implementation
References
Chapter 22: Maintenance
General Concepts
Teams
Task Forces
Crews
References
Chapter 23: Evaluation
Planning the Evaluation
Choosing the Level of Interest
Choosing the Method
Choosing the Purpose
Carrying Out an Evaluation Program
Descriptive Studies
Exploratory Studies
Performative Studies
Predictive Studies
Planning an Integrated Multi-study Program
Summary
References
Chapter 24: Conclusions
References
Glossary
Index

Citation preview

Foundations of Interprofessional Health Education An Ecological Theory C. Scott Smith

123

Foundations of Interprofessional Health Education

C. Scott Smith

Foundations of Interprofessional Health Education An Ecological Theory

C. Scott Smith Division of General Internal Medicine University of Washington, School of Medicine Seattle, WA, USA

ISBN 978-3-031-33413-9    ISBN 978-3-031-33414-6 (eBook) https://doi.org/10.1007/978-3-031-33414-6 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

This book is about something new—a theoretical organizational structure for healthcare education much broader than that which is typically assumed. In addition to the “macro-state” of static elements, linear interactions, and predictable effects from individual causes, we add the ecological “micro-states” of dynamic relationships, mutual nonlinear influences, and unpredictable emergence. Each view is valid in certain contexts. Neither is sufficient in and of itself. This is a theory that I have come to after 40 years of medical practice and clinical teaching in healthcare. As I gained more experience and knowledge, I felt that health education, especially interprofessional health education, lacked a comprehensive theory to guide design, implementation, and evaluation. Many theories were attractive, each matching or explaining some authentic aspects of teaching and learning. These include experiential learning theory (the literal application of the old adage “see one–do one–teach one”) and cognitive learning theories such as the hypothetico-deductive model (putting forward a few hypotheses to explain the patient’s complaints and then analytically narrowing them down to “the diagnosis”), dual processing theory (hypothesizing a balance between analysis and intuition), and script concordance theory (evaluating new story elements in an ill-defined or uncertain presentation), which appealed to my ordered, structural tendencies. Where these theories seemed to be weak was the powerful influence of context, emotion, and other people in the clinical situation. Here, I found activity theory (an explanation of how rules, mediating artifacts, and division of labor affect action) and situated learning (the ubiquity and power of apprentice-like learning) to be helpful. Trying to incorporate all these ideas, variables, and interactions into a usable model led me to the field of complex adaptive systems. This relatively new field emphasized fuzzy rather than rigid boundaries and how a collection of autonomous individuals following simple rules can lead to emergent behaviors at the level of the whole. I finally came across the theories of ecological psychology. This set of theories seemed to capture well the difficulties I had been having applying the earlier theories to design, implementation, and evaluation of interprofessional health education. It is this comprehensive ecological theory of interprofessional education that I attempt to convey in this book. v

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Preface

A book like this is never really written by a single individual. During the development of this theory, I had significant engagement, reflection, and feedback from the Coordinating Center of the Department of Veterans Affairs, Centers of Excellence in Primary Care Education—an experiment in team-based interprofessional education (Stuart Gilman, Judy Bowen, Kathy Rugen, Nancy Harada, Laural Traylor, and Deborah Ludke)—from our local Center of Excellence (Amber Fisher, India King, Bill Weppner, Janet Willis, Elena Speroff, Melanie Nash, and Winslow Gerrish), and from my educational research team (Chris Francovich, William Hill, Janet Gieselman, Magdalena Morris, Tim Gordon, and Rick Tivis). I am especially indebted to two colleagues who did a deep read of the manuscript and provided excellent feedback that made this a substantially better book: Mamta K. Singh, MD, MS, and Deborah Smith, DNP, FNP-BC. Seattle, USA  C. Scott Smith

Contents

1

Introduction����������������������������������������������������������������������������������������������    1

Part I The Natural Domain 2

Affordances����������������������������������������������������������������������������������������������    9 References��������������������������������������������������������������������������������������������������   13

3

The Classical Model��������������������������������������������������������������������������������   15 References��������������������������������������������������������������������������������������������������   18

4

Critical Realism����������������������������������������������������������������������������������������   19 References��������������������������������������������������������������������������������������������������   23

5

Realist Affordances����������������������������������������������������������������������������������   25 References��������������������������������������������������������������������������������������������������   27

Part II The Mental Domain 6

The Lifeworld ������������������������������������������������������������������������������������������   31 Intrinsic Expansion������������������������������������������������������������������������������������   32 Mediated Expansion����������������������������������������������������������������������������������   32 References��������������������������������������������������������������������������������������������������   33

7

Sense of Being������������������������������������������������������������������������������������������   35 The “Self”��������������������������������������������������������������������������������������������������   35 Identity ������������������������������������������������������������������������������������������������������   36 References��������������������������������������������������������������������������������������������������   37

8

Emotion����������������������������������������������������������������������������������������������������   39 References��������������������������������������������������������������������������������������������������   40

9

“Knowing” the World������������������������������������������������������������������������������   41 References��������������������������������������������������������������������������������������������������   43

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Contents

10 Intrinsic  Expansion of the Lifeworld ����������������������������������������������������   45 References��������������������������������������������������������������������������������������������������   47 11 Mediated  Expansion of the Lifeworld����������������������������������������������������   49 References��������������������������������������������������������������������������������������������������   51 12 Inner Wisdom ������������������������������������������������������������������������������������������   53 Depth Psychology��������������������������������������������������������������������������������������   53 Mindfulness Meditation ����������������������������������������������������������������������������   55 Native American Spirituality ��������������������������������������������������������������������   56 Summary����������������������������������������������������������������������������������������������������   58 References��������������������������������������������������������������������������������������������������   59 Part III The Social Domain 13 Behavioral Settings����������������������������������������������������������������������������������   63 References��������������������������������������������������������������������������������������������������   65 14 Language:  Ritual and Stories ����������������������������������������������������������������   67 Rituals��������������������������������������������������������������������������������������������������������   68 Stories��������������������������������������������������������������������������������������������������������   69 References��������������������������������������������������������������������������������������������������   70 15 Semiotics ��������������������������������������������������������������������������������������������������   71 Wiley’s Combination of Peirce and Mead ������������������������������������������������   73 Biosemiotics����������������������������������������������������������������������������������������������   73 References��������������������������������������������������������������������������������������������������   74 16 Revisiting Identity������������������������������������������������������������������������������������   77 Role Identity����������������������������������������������������������������������������������������������   78 Social Identity��������������������������������������������������������������������������������������������   78 Person Identity ������������������������������������������������������������������������������������������   79 References��������������������������������������������������������������������������������������������������   79 17 Boundaries and Bridges��������������������������������������������������������������������������   81 Boundaries ����������������������������������������������������������������������������������������������    81 Bridges ����������������������������������������������������������������������������������������������������    83 References������������������������������������������������������������������������������������������������    84 Part IV Nonlinearity 18 Complex Adaptive Systems ��������������������������������������������������������������������   89 Self-Creation����������������������������������������������������������������������������������������������   89 Emergence��������������������������������������������������������������������������������������������������   91 Stratification����������������������������������������������������������������������������������������������   93 References��������������������������������������������������������������������������������������������������   97 19 Complementarity ������������������������������������������������������������������������������������   99 References��������������������������������������������������������������������������������������������������  102

Contents

ix

20 Dynamics������������������������������������������������������������������������������������������������   105 Coordination Dynamics ��������������������������������������������������������������������������   105 Adaptive Cycle Theory����������������������������������������������������������������������������   108 References������������������������������������������������������������������������������������������������   110 Part V Application 21 Design/Implementation��������������������������������������������������������������������������   115 References������������������������������������������������������������������������������������������������   119 22 Maintenance ������������������������������������������������������������������������������������������   121 General Concepts ������������������������������������������������������������������������������������   121 Teams ������������������������������������������������������������������������������������������������������   123 Task Forces����������������������������������������������������������������������������������������������   124 Crews ������������������������������������������������������������������������������������������������������   125 References������������������������������������������������������������������������������������������������   127 23 Evaluation����������������������������������������������������������������������������������������������   129 Planning the Evaluation ��������������������������������������������������������������������������   129 Choosing the Level of Interest ������������������������������������������������������������   129 Choosing the Method��������������������������������������������������������������������������   130 Choosing the Purpose��������������������������������������������������������������������������   131 Carrying Out an Evaluation Program������������������������������������������������������   132 Descriptive Studies������������������������������������������������������������������������������   132 Exploratory Studies������������������������������������������������������������������������������   133 Performative Studies����������������������������������������������������������������������������   136 Predictive Studies��������������������������������������������������������������������������������   137 Planning an Integrated Multi-study Program��������������������������������������   138 Summary��������������������������������������������������������������������������������������������������   139 References������������������������������������������������������������������������������������������������   140 24 Conclusions��������������������������������������������������������������������������������������������   143 References������������������������������������������������������������������������������������������������   145 Glossary����������������������������������������������������������������������������������������������������������   147 Index����������������������������������������������������������������������������������������������������������������   149

About the Author

C.  Scott  Smith, MD  received his Mechanical Engineering degree from the MIT, his MD from the University of Washington School of Medicine, and his clinical teaching certificate from the Stanford Faculty Development Program. He practiced and taught healthcare trainees for 39 years and retired as a Professor of Internal Medicine, Emeritus with the University of Washington School of Medicine in 2019. Along the way, Dr. Smith did research in helping learners with difficulties, improving the production of rural primary care doctors, development of competencies and milestones, and use of social science outcome measures (e.g., cultural consensus analysis, social network analysis) to assess health education programs. In 2011, he became the co-director of the new Center of Excellence in Primary Care Education at the Boise, Idaho, V.A. Medical Center, one of five in the nation. He lives in Boise, Idaho, with his wife Cathy Sandstrom (a retired pediatrician) and currently works with immigrant and refugee physicians to help them pass the “National Boards,” get into residency training, and get licensed to practice in Idaho.

xi

List of Figures

Fig. 2.1 Fig. 2.2 Fig. 15.1 Fig. 15.2 Fig. 17.1 Fig. 1 (Part IV) Fig. 20.1 Fig. 20.2 Fig. 1 (Part V)

The visual array ��������������������������������������������������������������������   10 Nametag holder ��������������������������������������������������������������������   12 Semiotics ������������������������������������������������������������������������������   72 An example of semiotic chaining������������������������������������������   72 Conceptual models����������������������������������������������������������������   82 Learner trajectory������������������������������������������������������������������   88 Interactions between levels����������������������������������������������������  106 Attractor basins����������������������������������������������������������������������  107 Overview of key elements of the theory��������������������������������  111

xiii

List of Tables

Table 21.1 Team, task force, and crews����������������������������������������������������������  116

xv

List of Examples

Example 1.1 Example 1.2 Example 1.3 Example 1.4 Example 1.5 Example 1.6 Example 1.7 Example 1.8 Example 1.9 Example 2.1 Example 2.2 Example 2.3 Example 2.4 Example 3.1 Example 3.2 Example 3.3 Example 3.4 Example 4.1 Example 4.2 Example 4.3 Example 4.4 Example 4.5 Example 4.6 Example 4.7 Example 4.8 Example 4.9 Example 4.8 Example 5.1 Example 5.2 Example 5.3 Example 5.4

Seating arrangement������������������������������������������������������������������   6 Night sweats������������������������������������������������������������������������������  11 Abscess #1��������������������������������������������������������������������������������  12 Gamification������������������������������������������������������������������������������  13 Abscess #2��������������������������������������������������������������������������������  18 Spouse Abuse����������������������������������������������������������������������������  21 Abscess #3��������������������������������������������������������������������������������  22 Perception-of-care map ������������������������������������������������������������  22 Abscess #4��������������������������������������������������������������������������������  27 Flip chart exercise ��������������������������������������������������������������������  30 Developmental diagnostic ability����������������������������������������������  46 Ethnographic study�������������������������������������������������������������������  50 Meditation ��������������������������������������������������������������������������������  58 Organizational culture model����������������������������������������������������  62 Selecting primary care��������������������������������������������������������������  65 PCM identifying operational problems������������������������������������  68 Organizational cultures as barriers��������������������������������������������  83 Nonlinear diagnostic development��������������������������������������������  88 Huddles ������������������������������������������������������������������������������������  93 Another study group example ��������������������������������������������������  94 Fire and rust������������������������������������������������������������������������������  96 Digital and analog codes ���������������������������������������������������������� 100 Electromagnetism���������������������������������������������������������������������� 101 Meet your colleagues���������������������������������������������������������������� 102 Two truths and a lie ������������������������������������������������������������������ 102 Startup �������������������������������������������������������������������������������������� 106 Social network analysis������������������������������������������������������������ 109 Smoking cessation intervention������������������������������������������������ 112 Polypharmacy clinic������������������������������������������������������������������ 117 Original RFP ���������������������������������������������������������������������������� 118 Feedback loops�������������������������������������������������������������������������� 122 xvii

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List of Examples

Example 5.5 Low-Acuity ED Visits �������������������������������������������������������������� 125 Example 5.6 Social determinants of health���������������������������������������������������� 126 Example 5.7 Resident learning in clinic (descriptive)������������������������������������ 132 Example 5.8 Organizational culture model (exploratory)������������������������������ 133 Example 5.9 Testing CCA’s Ability to detect operational problems (exploratory) ���������������������������������������������������������������������������� 134 Example 5.10 QCA of Australian competencies (exploratory) ���������������������� 135 Example 5.11 Ambulatory firm system (performative)������������������������������������ 136 Example 5.12 LISREL analysis of patient trust, satisfaction, and loyalty (performative)���������������������������������������������������������������������������� 136 Example 5.13 Pilot study of SNA to detect structural changes ���������������������� 137 Example 5.14 Developing a PCMH implementation index (predictive)���������� 137 Example 5.15 Realist Evaluation of an IPE program for medical students (predictive)������������������������������������������������������������������ 138 Example 5.16 A Series of studies of a specific intervention���������������������������� 138

List of Sidebars

Sidebar 2.1 Sidebar 2.1 Sidebar 1.3 Sidebar 2.1 Sidebar 2.2 Sidebar 2.3 Sidebar 2.4 Sidebar 2.5 Sidebar 2.6 Sidebar 2.7 Sidebar 3.1 Sidebar 3.2 Sidebar 3.3 Sidebar 3.4 Sidebar 3.5 Sidebar 3.6 Sidebar 3.7 Sidebar 4.1 Sidebar 4.2 Sidebar 4.3 Sidebar 5.1 Sidebar 5.2 Sidebar 5.3

Affordances ��������������������������������������������������������������������������������  13 Critical realism����������������������������������������������������������������������������  22 Realist affordances����������������������������������������������������������������������  26 The lifeworld ������������������������������������������������������������������������������  33 Identity����������������������������������������������������������������������������������������  36 Emotional response ��������������������������������������������������������������������  40 Intuition and analysis������������������������������������������������������������������  42 Intrinsic expansion����������������������������������������������������������������������  47 Mediated expansion��������������������������������������������������������������������  50 Inner wisdom������������������������������������������������������������������������������  58 Behavioral settings����������������������������������������������������������������������  64 Rituals ����������������������������������������������������������������������������������������  69 Stories������������������������������������������������������������������������������������������  70 Biosemiotics��������������������������������������������������������������������������������  74 Identity����������������������������������������������������������������������������������������  79 Boundaries����������������������������������������������������������������������������������  83 Bridges����������������������������������������������������������������������������������������  84 Self-creation��������������������������������������������������������������������������������  91 Emergence����������������������������������������������������������������������������������  92 Stratification��������������������������������������������������������������������������������  95 Design checklist�������������������������������������������������������������������������� 119 Maintenance checklist���������������������������������������������������������������� 126 Evaluation checklist�������������������������������������������������������������������� 140

xix

Chapter 1

Introduction

I was struggling to identify a foundational theory for health education, especially interprofessional health education, that could inform design, implementation, and evaluation. Ecological theory seemed to be the overarching theory I was looking for, incorporating other attractive theories like experiential learning theory, cognitive learning theories, activity theory, situated learning theory, and chaos/complexity theory as partial, focused special cases. First, ecological theory hypothesized a stratification, a hierarchical structure: empirical events (direct sensory experience), actual events (these plus possible events), and the real (underlying mechanisms, not directly accessible). Then, it assumed that all layers were dynamic and changing, not fixed. Finally, it incorporated many of the elements of complex adaptive systems I had found useful: structural coupling between the entity and its environment, new emergent properties at higher organizational levels, and the fact that behavior was recurrently drawn to “attractors.” Ecological theory emphasizes relationships between elements as more important than properties of elements. In the following chapters, I will outline the important aspects of the set of ecological theories as I understand and apply them. Throughout the book, I use several structuring tools. Sidebars are bullet point summaries of a section, set aside in a small box near the end. These are numbered sequentially within each part. Examples are also numbered sequentially within each part and are set aside in the italicized text by lines. These may be general conceptual examples but are often examples of specific studies or curriculum elements that illuminate the point of a section. Figures are numbered sequentially throughout the entire book. Each part ends with a set of “Implications for Interprofessional Education” or a “Checklist.” The book is organized into five parts: The Natural Domain, The Mental Domain, The Social Domain, Nonlinearity, and Applications. The first four parts address common problems in interprofessional education (IP problem) as follows: Natural Domain: IP problem: Premature Closure. Trainees want to reduce the messiness and complexity of the world to fixed “rules” and algorithms that guide © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_1

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1 Introduction

correct action. This leads them to stop too early in their characterization of the medical problem, or of each other. This has to do partly with how reality is actually laid out and accessible to the learner (the subject of Part I) and also how our minds work (the subject of Part II). When a novice watches (or is taught by) an expert, following an algorithm is what it appears like the teacher is doing. Also, language is a self-referential, imprecise system. Both the tendency to oversimplify the world (including each other) and the limits of language can lead to premature closure and make it more difficult to teach the skills necessary to prepare learners for a practice that is uncertain and dynamically changes. This section will explain our propensity for causally coherent stories consisting of concrete entities and singular cause → effect relationships. It will introduce the first key concept in ecological psychology, affordances. Affordances are reciprocal relationships between resources in the world and the organism. These resources must be noticed and utilized to be effective. I will cover pedagogical techniques that can help learners to differentiate between a triggering affordance (merely make us think of an entity but do not seriously change likelihood) and a distinguishing affordance (truly make the likelihood of an entity much more or less likely). By the end of this section, we will come to see two worlds: a macro-state of observable entities and their interactions and a micro-state of tacit relationships and exchanges. Mental Domain: IP Problem: Hidden Affordances. Many important elements in healthcare decision-making are subliminal, not obvious or concrete. Learning involves noticing and properly appropriating a wider array of features in the world. Problem-solving involves emotion, experience, intuition, and rational thought. Trainees eventually must learn to appropriate and properly utilize a broad array of important, useful features in the world (affordances). This section will introduce the second key concept in ecological psychology model, the lifeworld. The lifeworld is the set of meaningful features (affordances) that a trainee is able to attend to and appropriately respond to. Increasing the lifeworld is the main function of clinical education. This section will explain the principles of intrinsic (experiential) and extrinsic (mediated) expansion of the lifeworld. Intrinsic expansion may still have important pedagogical implications, such as designing exposure to novel situations or “coaching” about often unrecognized affordances, such as emotions. Extrinsic expansion works best when conveying “enabling constraints”—not rules about what to do but, rather, what states to avoid. Specific interactions are dictated by the developmental level of the learner(s). Expanding from section one, this approach hypothesizes two types of affordances: (1) a natural world connected through macro-states to an individual’s mental domain and (2) an internal world of micro-states that connect rational analysis and intuition. Social Domain: IP Problem: Many Social Affordances Are Tacit. Training clinics have “rules” that regulate role, power, identity, and behavior. We are mostly trained in professional silos but must become aware of and challenge these rules where appropriate in order to learn to function as interprofessional teams.

1 Introduction

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To become a high-functioning team, much of the expansion in interprofessional trainees’ lifeworlds must occur in the realm of social affordances. We have biases and stereotypes that can decrease the cognitive load of dealing with each other but can also act as barriers to effective teamwork. Each of us has been deeply conditioned into our own professional culture. Becoming aware of this and “flattening the hierarchy” require creative educational exercises and telegraphing permission for these difficult discussions. Here, I introduce the third key concept in ecological psychology, behavioral settings. This human-made, social level of affordances creates permissive, supportive, or restrictive influences on behavior. These affect each learner’s identity: their role identity (competence), social identity (worthiness), and their person identity (authenticity). Much of the power of behavioral settings comes from the language, rituals, and stories we chose to propagate. After becoming aware of this level of affordances, it can be extremely useful to walk through your training clinic with the “eyes of a beginner” to see what norms and messages are transmitted. Nonlinearity: IP Problem: Failing to Recognize Complementarity. Our minds tend to gravitate toward an “either-or” mode of categorization, when in reality the whole is often difficult to see and is “both-and.” Interprofessional group members often make rapid categorical judgements of each other—"he/she is an expert and should be attended to” versus “he/she assumes entitlement and should be ignored.” Some of our thorniest conceptual problems contain two conflicting points of view; you cannot employ them simultaneously, and yet they both have some validity. These are resolved by moving to a higher level of organization and incorporating both viewpoints, as special case perspectives, into a broader holistic model. For instance, is light a wave or a particle—neither it is a “wavicle.” This is the fundamental message of my final key concept in ecological psychology, complementarity. This section explores how seemingly contradictory features can be used to trigger a search at a higher organizational level for complementary affordances and holistic understanding. This section begins with a basic understanding of complex adaptive systems theory, with its critical concepts of interdependent hierarchies, attractor basins, and emergent behavior. Then the concept of coordination dynamics, the resonance or damping between elements and levels over time within a hierarchy, can indicate where to look for a holistic model. These are learnable skills and critical for the success of interprofessional education. The fifth section, Applications, presents the theory in its entirety and is a summary of earlier chapters—using affordances, lifeworlds, behavioral settings, and complementarity to address the common interprofessional education problems— with recommendations and examples for designing, maintaining, and/or measuring interprofessional education programs.

Part I

The Natural Domain

1.1  IP Problem: Premature Closure Vignette: A medical resident had an international rotation in Kenya in November. He is now doing a primary care rotation in Kansas in January. He sees a patient who seems moderately ill with a rapid onset of fever, myalgias, headache, and dry cough. The patient states that several of their friends have a similar illness. He has not had any vaccines in the past 10 years. The resident presents the patient to the preceptor with a working diagnosis of “malaria.” This is premature closure, by selection of a categorical answer before full consideration of all possibilities. It is an example of what Kahneman et al. (2021) call a “fundamental attribution error,”1 and it is similar to what Whitehead (1978) calls “misplaced concreteness.”2 In the example above, it might be diagrammed like this: ϭ͘ DĂůĂƌŝĂ Ϯ͘ /ŶŇƵĞŶnjĂ ;ĐŽŶĐƌĞƚĞĐĂƵƐĞƐͿ

ŐĞŶĞƌĂůŝnjĞĚƐLJƐƚĞŵŝĐ ŝŵŵƵŶĞƌĞĂĐƟŽŶ ;ĂďƐƚƌĂĐƚƌĞƐƵůƚͿ

Premature closure is very common in interprofessional education and can occur as errors in the categorization of diagnoses, perceptual facts, or even each other. It has several causes. First, a recent experience, as in our case above, can introduce conceptual bias. Second, perception itself can be erroneous (mistaking a tree limb for a snake in the dark). Also subtly, and the point of the first part of this book, there is a bias favoring the concrete and stable over the abstract and changing. The

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 Assigning credit or blame to an agent that is better explained by luck, objective circumstances, or a better answer. 2  Mistaking an abstraction for a concrete reality. 1

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The Natural Domain

concrete and abstract features of the world are connected by metaphor—images, language, stories, and ritual. Humans have a tendency to simplify explanations into causally coherent stories (e.g., “all doctors are …) using simple cause-effect linear models rather than more realistic (albeit harder to conceptualize) abstract, interdependent models that result in dynamics and uncertainty. We rarely think of the effects of the physical environment on interprofessional training, but it is the source of most of our resources, many of our constraints, and much of the substrate for our beliefs, values, theories, and actions. When we do consider the physical environment, we tend to focus either on a pragmatic understanding (the sun rotates around the earth because that is how it appears each day) or on reductionist scientific theories (the earth rotates around the sun because gravity best explains all observed planetary motions). In our approach to healthcare, we count on the natural world to be lawlike, stable, and predictable. There are lots of rules, but if you learn them and apply them properly, you provide good healthcare. While our goal is concreteness and predictability, our lived experience is completely different. In practice, especially in primary care, healthcare often seems uncertain, dynamic, and even bordering on the chaotic. Patient complaints can come from a bewildering mix of physical, mental, social, economic, or other causes, alone or in combination. The natural world contributes much to our “sense of place,” our embeddedness in the world from which we are able to act. As we began our journey as a Center of Excellence in Primary Care Education (a title that suddenly seemed pretentious), we cast about for concepts, theories, and practices that could weave this together and provide solid ground. Yet, making sense of the patient’s “dis-ease” from this complex perspective seemed difficult. Working seamlessly as in interprofessional team, with diversity in skills and experience, also seemed challenging. Teaching how to do this seemed out of the question. Part one is a survey of some of the more important ideas that helped us frame a material structure for our approach. It also provided pedagogical techniques to help avoid premature closure.

Example 1.1 (Seating Arrangement) A colleague and I created a series of ambulatory medicine seminars for internal medicine residents.3 These were offered in the dining room of a historic building with a large oval table. This was ideal, in that it was a comfortable surrounding and there was no obvious position of authority at the “head” of a table. We conducted the first couple classes with open seating. Soon, a tacit seating arrangement was established. Before the next class, my co-teacher and I sat in completely different chairs, forcing a different division of the 3

 Smith CS, Kilfoyle MJ (editors). We co-created this syllabus in 1990 and co-edited it yearly for the next 11 years. It functioned as the core of an integrated curriculum for internal medicine residents in a primary care track. Accepted by the Educational Clearinghouse for Internal Medicine 2nd Edition (1993). Over 60 copies requested nationwide. 3

References

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group. As they entered and checked in, we were able to talk about the disorientation they felt, and how quickly the concrete physical and abstract psychological/social environments interacted to establish tacit seating rules and hierarchies. This, and many other exercises like this, began the long important journey of reflection, articulation, and dialogue about our interprofessional relationships.

References Kahneman DL, Sibony O, Sunstein CR. Noise. A flaw in human judgement. New York: Little, Brown, Spark; 2021: 218. Whitehead AN. Process and reality. New York: The Free Press (Macmillan); 1978: 18. Smith CS, Kilfoyle MJ, editors. Primary care seminars. In: Association of Program Directors in Internal Medicine and Society of General Internal Medicine (editors). Educational clearinghouse for internal medicine, 2nd ed.; 1993.

Chapter 2

Affordances

Ecological psychology is the view that the organism and the environment have mutual, reciprocal relationships. The unique, and frankly counterintuitive, assumption is that perception is direct and not mediated.1 This means, for vision, that we directly perceive light reflected off multiple surfaces, not separate conceptual entities (like tables) in the environment, and these direct perceptions change perspective as we move.2 This direct perception is not confined to sight alone. We also experience kinesthetic (felt subjective quality of our movement) and kinetic (observed effects of our movement such as intensity, direction, and range) as we carry out animated movement (Sheets-Johnstone 2016). We track sound with directional cues because we have two ears separated by a distance. We use all these direct perceptions to guide proper action. We do not require linguistic propositions, mental representations (pictures or maps), or emotions to act, although we may use any of those modalities later to modulate and/or explain our actions. The environment and the organism interact through affordances, features that afford the opportunity to be recognized and utilized as a resource by a capable organism. The organism recognizes the affordance and appropriates it, and in the process changes the environment. Think about the first animal to walk across a meadow. Little rocks, flat soil, and puddles of water (all affordances supporting/ inhibiting being walk-on-able) determine the route that they take. However, the next animal has a visual path of flattened meadow grass to follow. Soon there is a

 This concept is key. An organism perceives the ground AND walks on the ground. Perception (being direct) is about the ongoing walk-on-ability of the ground (the action). There is no intermediary between perception and action, such as a verbal or visual representation (Gibson 2015). 2  “From any vantage point, the structure of [reflected] light is intrinsically informative about the source of its structure (Turvey 2019). See especially Fig. 23.6. 1

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_2

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well-worn trail. Affordances are a reciprocal relationship between the abilities of the organism and the features in the environment.3 Both will be changed. Gibson, a pioneer in the ecological psychology of visual perception in animals, defines affordances as follows: “Affordances [are] the perceived functional significance of an object, event, or place that establishes the possibility and sets limits on action.” (Gibson 2015: 123) “Stimulus information, at any given instant, is obtained as a result of self-produced actions, it is not forced on individuals.” (ibid: 139) “Perceiving and acting collaborate in the detection of invariances.” (ibid: 193)4

Once again, our perception of what activity an object affords is not mediated by a mental representation; rather, it is directly perceived and embedded in the energy array (or differentiable manifold) ((Turvey 2019): 162). Movement of our sensors is critical to identifying stable features of the environment that may be affordances, “invariances” that stand out. For instance, moving our head gives us a different visual perspective, with some objects being visually occluded and others coming into the field of vision. This may reveal an affordance, such as a previously hidden blueberry (eat-able). The affordance provides direct information about the environment. For instance, birds use the optic array and energy flow pattern as they fly to make a soft landing on a branch (Hershenson 2000). This is depicted in Fig. 2.1. a

b

Fig. 2.1  The visual array. The visual array provides two types of information to a flying bird. In (a), we see the object in the visual field becoming larger and the visual angle subtended becoming narrower as the branch is approached. (b) depicts how the phenomenon of motion changes when the object is stationary (left) and the optical distortion that occurs due to forward motion (right). The bird uses these data to keep the rate of optical expansion (how quickly the object is “growing” in the visual field) constant. This is not a calculation that the bird makes; rather, it is an innate or learned adjustment of action (flight speed) coupled to specific optical information  Affordances are a relationship between subjective (my abilities) and objective (features of the world) perspectives. They are not inherent only in the individual subject or the features of the world (Chemero 2003). 4  Affordances are invariant relationships and are detected by movement (i.e., what stays the same as we vary our perspective). 3

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Time to contact (Ʈ) is, then, an affordance detected by the bird’s flight movement that allows it to alight gently on the branch (as optical expansion reaches zero). This is also how a baseball player runs to the correct location to catch a fly ball, by making the rate of optical expansion of the ball constant as he/she runs (Fink et al. 2009): Perception for all organisms is … understood in terms of lawful regularities and symmetry principles defined at the ecological scale ((Turvey 2019): 382, footnote 2)

Affordances may be signs or symbols. Signs are direct (blueberry) or substitute (smell of blueberries) tokens that reveal an actual, available resource that could be manipulated, transformed, or exchanged. They do not require social agreement to have meaning. Symbols are abstract tokens, such as the word “blueberry,” that require social agreement to have meaning. They are useful for planning, regulating, coordinating, or storing information. However, symbols can be either trigger affordances (make us think of a category but do not actually change the likelihood of that category) or distinguishing affordances (truly make the likelihood of a category significantly higher or lower) (Smith and Paauw 2000). Trigger affordances can be another cause of premature closure (see Example 1.2 below). Example 1.2 (Night Sweats) Remember the first category that pops into your head when I mention the following feature (affordance)—night sweats. You may have thought of tuberculosis, lymphoma, or HIV.  Night sweats are a trigger affordance for these diseases. It makes us think of them but is not particularly accurate as a diagnostic criterion. Much more common causes of night sweats are menopause, a viral illness, or SSRI antidepressant side effects.

Together, as we will see in later sections, access to affordances and knowledge of their use regulate social structures. This is demonstrated in Fig. 2.2. Affordances are a biological process embedded directly in perception and experienced at a pre-reflective level. They offer the possibility for action inherent in the organism-ecosystem relationship.5 They consist of the material nature of the environmental resource (a branch—physics), the perceptual sensations that are generated within the energy field (narrowing optical angle with approach—a dynamic perception), and the relationship between these (Ʈ, time to contact). They are neither psychological constructs nor cognitive concepts—indeed, they are not changed by neural or psychological factors. They are nonlocal, and they are made “real” through our recognition of them and our actions toward them. Affordances are selective enablers/constraints for behavior. The same physical object may provide different affordances depending on the ecological organism-environment scale. For example,  Affordances are pre-reflective, prior to abstractions (categories). We act immediately on “functionally meaningful objects and events.” Abstractions come later and may be useful for elaborating, remembering, or describing our actions ((Heft 2003): 151). 5

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Fig. 2.2  The name tag holder in our teaching clinic. The labels (signs, direct affordances) help to find a name tag quickly. What are the symbolic meanings? How would a psychology or pharmacy trainee (lumped under miscellaneous) interpret the symbolic meaning of this affordance?

the same large rock in a garden may afford the possibility of being jump-on-able by a deer, step-on-able by a human, and climb-on-able by an ant. In the same environmental feature, different behaviors are afforded. This is why the same physical environment offers different ecological niches for different organisms.

Example 1.3 (Abscess—1) A medical example of an affordance might occur with a large, red, warm, indurated skin lesion. The affordance of fluctuance, fluidity, and compressibility may be observed when the lesion (in the environment) is palpated by the clinician (movement, tactile perception) and indicates specific action (time for incision and drainage). Fluctuance cannot be described completely in words alone (although words may help to frame it for novices); it is not simply a cognitive concept. It must be experienced directly to be learned and its meaning understood.

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Affordances are ubiquitous and important in the interprofessional training environment. Example 1.4 is an example where a tacit symbolic affordance was made visible for discussion. Example 1.4 (Gamification) We created our own version of the interprofessional education game (iPEG) (Joseph and Diack 2014). While using this game in a seminar with internal medicine residents, pharmacy residents, psychology interns, and nurse practitioner residents, a pharmacy resident drew an action card that read “without using words, pantomime an action that allows the group to recognize a physician.” He pantomimed taking a stethoscope off from around his neck, putting the earpieces in the ears, and listening to an imaginary chest. “Physician,” the rest of the class exclaimed within a second. I said, “That’s interesting. You answered that almost instantly, suggesting a strong subconscious model.” I went around the room and asked each class member if they knew how to use a stethoscope. To a person, they did. “So why was that a physician?” The ensuing discussion allowed us to explore social markers of each profession and their validity. In this case, carrying the stethoscope around the neck was identified as a uniquely “physician” thing to do.

But what exactly are these affordances? In the classic model of physics, affordances seem to be material, existing in an inert material world with specific “X,” “Y,” and “Z” coordinates, while organisms act as independent, inert observers. However, as we shall see, this formulation is too simple. Side Bar 2.1 Affordances Affordances are the relationship between features of the environment and dispositions of the organism. They are imbedded directly in perception. They imply potential possibilities and consequences of action relative to a particular perceiver. Symbolic affordances can be trigger OR distinguishing affordances.

References Chemero A. An outline of a theory of affordances. Ecol Psychol. 2003;15(2):181–95. Fink PW, Foo PS, Warren WH. Catching fly balls in virtual reality: a critical test of the outfielder problem. J Vision. 2009;9(14):1–8. Gibson JJ. The ecological approach to visual perception. New York: Psychology Press; 1979/2015, pp. 109. Heft H.  Affordances, dynamic experience, and the challenge of reification. Ecol Psychol. 2003;15(2):149–80.

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Hershenson M. Visual space perception. A primer. Cambridge, MA: MIT Press; 2000. Joseph S, Diack L.  Playing interprofessional games: reflections on using the Interprofessional Education Game (iPEG). J Interprof Care. 2014; https://doi.org/10.3109/1356182 0.2014.942839. Sheets-Johnstone M.  Insides and outsides. Interdisciplinary perspectives on animate nature. Exeter: Imprint Academic; 2016. p. 35–8. Smith CS, Paauw DP. When you hear hoof betas: four principles for separating zebras from horses. J Am B Fam Pract. 2000;13(6):424–9. Turvey MT. Lectures in perception. An ecological perspective, vol. 351. New York: Routledge; 2019.

Chapter 3

The Classical Model

The scientific revolution (roughly 1550–1750) replaced superstition and mythical explanations of the natural world with the classical model of physics and the scientific method. In the classical model, observers are separate and independent of the objects they observe (objectivity). Changes are caused by linear relationships between forces and objects (predictability). Causal relationships between entities require proximity in space and time (contiguity). And large complicated systems can be broken into smaller parts, observed, and the results summed together to understand them (reductionism). Newton’s formulation, F = mA, provided a new understanding for the behavior of physical objects, from thrown pebbles to rockets going to the moon. Over time, this approach evolved into a successful structure for science consisting of reductionism, mechanistic models, linear mathematical descriptions, and universal laws: “… science [became] an impersonal way of looking at the world, a reading of the language of the universe in a new and absolute symbolism. This is the mathematical mystery of nature which had inspired Copernicus, Kepler, and Galileo  …” (Bronowski and Mazlish 1993)

However, anomalies began building up with the classical model. In the early twentieth century, a new chapter in physics was born with quantum mechanics. It represented a radical break from classical physics that is still being debated. Capra (1999)1, in his exploration of the parallels between modern physics and Eastern mysticism, states: “The exploration of the atomic and subatomic world in the twentieth century has revealed an unsuspected limitation of classical ideas, and has necessitated a radical revision of many of our basic concepts”

 This book explores the deep connections and unity between all things that are revealed in both quantum mechanics and Buddhism. Also, how things that appear as opposites (e.g., wave–particle or yin–yang) are seen to be two perspectives of a higher order thing. 1

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As Caroll (2019) states: “… quantum mechanics represents a violent break from the way we have always thought about physics before, shifting from a view where the world exists objectively and independently of how we perceive it, to one where the act of observation is somehow fundamental the nature of reality.”

Quantum mechanics challenges two fundamental assumptions of the classical model: objectivity and contiguity. As the above quotes attest, the idea that a neutral, independent witness can observe objective phenomena without affecting them was shattered by quantum mechanics. One way it is explained (in the “Copenhagen interpretation”) is that the act of observation collapses the probability waveforms from multiple probabilities to a single actuality. Subjective awareness seems to influence objective reality! In classical physics, contiguity (constant conjunction) in space or time is critical to establishing causation. “Causes” cannot create “effects” without direct, adjacent influence. The cue ball must strike another billiard ball to cause it to careen off. However, due to quantum entanglement, if two quantum objects interact and their quantum events become correlated, then measuring one (collapsing its wave function) determines the qualities of the other and causes it to have complementary properties, even if it is many miles away. This is not due to a force or flowing energy; it is due to a relationship between energy states that is not changed with spatial distance (Schrödinger, 1935, p  555). If this were due to communication between the two at the time of measurement, as understood in classical physics, it would require processes that exceed the speed of light, a violation of relativity! Again, Carroll states (2019:18)2: “What we see when we look at the world seems to be fundamentally different from what actually is.”

While the classical model works well for explaining and predicting stable, linear systems such as the trajectory of a rocket, it does not do well for more complex dynamical systems, such as predicting weather. Eugene Wigner (1964), in his Nobel acceptance speech, states: “Physics does not endeavor to explain nature. In fact, the great success of physics is due to restriction of its objectives: it endeavors to explain the regularities in the behavior of objects. This renunciation of the broader aim, and the specification of the domain for which an explanation can be sought, now appears to be an obvious necessity.” 3

Complex systems appear to violate the second law of thermodynamics that all systems increase in disorder (entropy) over time. While this is true of closed systems, complex systems create/sustain their order by establishing a boundary, importing energy and matter, and exporting their disorder (entropy, waste) into their

 “Classical mechanics offers a clear and unambiguous relationship between what we see and what the theory describes. Quantum mechanics, for all its success, offers no such thing.” 3  This point, that physics is successful because it limits its own scope and does not endeavor to explain all of nature, is unfamiliar to most lay people. 2

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surroundings. They have multiple positive and negative feedback loops that are interwoven and stratified. They are self-organizing, critically sensitive to initial conditions, and exhibit emergent (novel) structures and behaviors. Waldrop (Waldrop 1992: 17) states: “Somehow, the old categories of science were beginning to dissolve. Somehow, a new unified science was out there waiting to be born. It would be a rigorous science … grounded in natural law. But instead of being a quest for the ultimate particle, it would be about flux, change, and the forming and dissolving of patterns. Instead of ignoring everything that wasn’t uniform and predictable, it would have a place for individuality and accidents of history. Instead of being about simplicity, it would be about—well, complexity.”

However, it may be that complex systems do not violate entropy laws. Instead, they may be adding essentially a fourth law of thermodynamics that better dissipators of order are favored to self-organize, creating more order internally, but exporting an even greater amount of disorder to the environment, thus creating a net increase in entropy that is not in violation of the third law. This occurs not in the isolated complex system, but in the open system plus the environment (Siegel 2018). The complex adaptive system perspective challenges two more things about the classical model: predictability (determinism) and reductionism. Complex system behavior is not entirely predictable. This is due to emergent behavior caused by recursion, nonlinearity, and self-referential feedback (more on this later). A collection of parts, through these processes, can organize a novel behavior that only emerges at the level of the whole, and this is not foreseeable ahead of time. However, any one system is likely to operate with boundary limits on how far astray the variables can wander (more on this later also). The old saw about “the whole is equal to the sum of its parts,” which is the basis for a reductionist approach, is also not true in complex systems, and for the same reason—emergence. These problems grow even more prominent with biological (Jablonka and Lamb 2005: 1), sociocultural (Wheeler 2006: 12), and ecological systems (Scheffer 2009: 23). A whole new behavior, at the level of the system as a whole, is not predictable from its parts. Complex, adaptive, open systems are self-organizing, create emergent behaviors, and develop hierarchical states. As Holland (2014) writes: “Hierarchical organization is  …  closely tied to emergence. Each level of a hierarchy typically is governed by its own set of laws … The laws of a new level must not violate the laws of earlier levels—That is, the laws at lower levels constrain the laws at higher levels.”

We seem to live in two worlds simultaneously, a macro-state of large energy and information aggregates (such as baseballs) and a micro-state of individual interactions (such as light). The classical model works well for understanding the macro-­ states. It does not work well for understanding the micro-states. There seems to be a balance and cycling of aggregating tendencies (e.g., emergence) and disaggregating tendencies (e.g., entropy). Current thinking is that the classical model of physics—macro-state (things, forces between them, causation, unidirectional time)—is a special case, for aggregates, of a broader relational model of micro-state reality (relationships, probabilities, interaction across space, no direction to time). We have made great strides in understanding and improving our daily lives by applying the

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classical model in appropriate domains. However, solutions to many of the world’s most pressing problems—overpopulation, the environment, gun violence, inequalities, and racial injustice—have not been well served by this model. As we see above, quantum mechanics, systems thinking, bio/ecological systems, and sociocultural systems challenge the objectivity, materialism, reductionism, linearity, predictability, and even the concept of causation found in the standard scientific model. The new model is less about things and more about relationships. So where does that leave us? Nobel-winning physicist Robert Laughlin (Laughlin 2005) stated: “Much as I dislike the idea of ages, I think a good case can be made that science has now moved from an Age of Reductionism to an Age of Emergence, a time when the search for ultimate causes of things shifts from the behavior of parts to the behavior of the collective. It is difficult to identify a specific moment when this transition occurred because it was gradual and somewhat obscured by the persistence of myths, but there can be no doubt that the dominant paradigm is now organizational.”

Example 1.5 (Abscess—2) To understand the influence of the classical model, let us return to our patient with an abscess from Chap. 1, and let us suppose that he suffers from diabetes. His glucose levels are likely to be elevated, but why? The classic model encourages simple, linear, causative rules such as “Infection causes an increase in stress hormones, especially cortisol and adrenaline. These hormones cause insulin resistance by lowering the rate of non-oxidative glucose disposal to nearly zero” (Yki-Järvinen et al. 1989).

These reductionist explanations are the type of explanation that almost all health professionals are exposed to during their training.

References Bronowski J, Mazlish B. The western intellectual tradition. New York: Barnes & Noble; 1993. Capra F. The Tao of Physics. Boston: Shambhala. 1999. Caroll S. Something deeply hidden. New York: Dutton; 2019. p. 3–4. Holland JH. Complexity. A very short introduction. Oxford, UK: Oxford University Press; 2014. Jablonka E, Lamb MJ. Evolution in four dimensions: genetic, epigenetic, behavioral, and symbolic variation in the history of life. Cambridge, MA: MIT Press; 2005. Laughlin RB. A different universe. Reinventing physics from the bottom down. New York: Basic Books; 2005. Scheffer M.  Critical transitions in nature and society. Princeton, NJ: Princeton University Press; 2009. Schrödinger E. Die gegenwärtige situation in der quantenmechanik (The present situation in quantum mechanics). Naturwissenschaften. 1935;23(48):807–12 Siegel DJ. Aware. New York: TarcherPerigee; 2018. Waldrop MM. Complexity. New York: Simon & Schuster; 1992. Wheeler W. The whole creature. London: Lawrence & Wishart; 2006. Yki-Järvinen H, Sammalkorpi K, Koivisto VA, Nikkilä EA. Severity, duration and mechanisms of insulin resistance during acute infection. J Clin Endocrinol Metab. 1989;69(2):317–23.

Chapter 4

Critical Realism

Critical realism is a commitment to naturalism (mind-independent reality), but not to the foundational position of particles or substances. Most of us believe that the world is “real” because we can see it, touch it, taste it, smell it, and hear it. This leads us to assume that reality is unidimensional, coming from a single, privileged level of stratification, the physical world, that can be objectively described. Critical realism is a philosophical position that incorporates but extends beyond this viewpoint. It is located somewhere between traditional positivism (the world is real and apprehended directly by observation) and constructivism—our understanding of the world is filtered through human senses and concepts; therefore, we cannot know it directly and we construct it through social agreement (Wong, et al., 2012). In 1978, Roy Bhaskar first published his theory of critical realism. While this theory is very extensive, the main points are these: Like positivism, realism makes a commitment to a mind-independent reality. In other words, the world exists autonomously. It does not require human minds or co-­creation (as in idealist and constructivist models) to exist. Unlike positivism, it assumes that we cannot directly perceive the real mechanisms of causation, the natural laws. Like constructivism, this theory recognizes the fact that our experiences are not directly of natural laws but, rather, are limited by the capacities of sensory systems and filtered by preconceived, socially influenced conceptual structures. Bhaskar (2008, 2017) hypothesized the following hierarchy: • Empirical events: The field of direct sensory experience • Actual events: All events, experienced and potential (possible, but maybe not realized) • Real: The underlying mechanisms that generate events In the early decades of the last century, Mach, James, and Russell developed the concept of neutral monism. Basically, this concept assumed that there were fundamental elements that could lead to both psychological features (mind) and material features (body). What you observed, like in quantum mechanics, depended on how © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_4

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you observed (Banks, 2014). This was a direct response to Cartesian mind/body dualism. Bhaskar extended neutral monism (mind/body) to a multifaceted reality, with several domains, none of which are independently foundational. These include not just material and mental, as in neutral monism, but social, cultural, economic, and others. Anything that has a causal effect is “real” and occurs in a laminated dynamical system (Bhaskar, 2017). Putting these together, reality is structured, differentiated, and dynamic. One reason is because of emergence. Emergent properties are why the whole is greater than the sum of the parts, and why reality is continuously changing. But it is not magic. Nothing new is added to create the emergent entity. There is simply a new organization of subordinate elements. As Bhaskar (2018: 60) points out: “While the higher level is unilaterally dependent on the more basic one, it is nevertheless taxonomically irreducible to it. The higher level of being also … has the capacity to act back on the more basic level.”

Furthermore, not just any reorganization of the parts will result in an emergent whole. The parts and the whole must mutually reinforce (sustain/constrain) each other. Perhaps, an example will help. Do societies emerge from the action of individuals, or do they exist independently and constrain individuals? Bhaskar would say that neither is strictly true by itself (Bhaskar, 1978). An assemblage of individuals, organized in the correct way, can emerge to create a society. Individuals experience engagement that reproduces/transforms society through a combination of material causes (e.g., products of labor) and immaterial causes (e.g., idealism, patriotism). This feels like normal part-whole materialism. However, society also enables and/or constrains the behavior of individuals through immaterial causative agents such as norms, shame, guilt, and pride. Both levels act to sustain/constrain each other and the individual-society system. Emergence only exists if the resultant emergent entity has a consistent inter-causal impact that maintains the collaborative arrangement (Elder-Vass, 2004). Reexamining our bird-landing-on-a-branch example from chapter one, affordances, from the perspective of critical realism, then should link (reveal?) information from the environment which is based on invariant lawful mechanisms (unknowable to us directly) that offer ecologically specific actions to the organism. At one level, we can speak of “organism” and “environment” separately. At the higher level, an organism-environment coupled system emerges. Critical realist philosophy has spawned the field of realist evaluation. This is a species of theory-driven evaluation that simultaneously covers formative (prospective), summative (concurrent), and synthetic (retrospective) program evaluation. As Pawson and Tilley (2004: 2) state: “Programmes (sic) are theories incarnate. They begin in the heads of policy architects, pass into the hands of practitioners and, sometimes, into the hearts and minds of programme subjects. These conjectures originate with an understanding of what gives rise to inappro-

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priate behavior, or to discriminatory events, or to inequalities of social condition and then move to speculate on how changes may be made to these patterns.”

Where positivism assumes that causation is identified by constant conjunction, realism is a search for hidden mechanisms that cause regularities. However, the mechanisms are not directly accessible, and the lawful regularities may be at a physical or temporal separation. Constant conjunction is neither necessary nor sufficient for causation in open systems and critical realism. Realist evaluation specifies this search for hidden mechanisms within context-mechanism-outcome configurations: CMOCs (Pawson & Tilley, 2004: 8; Wong, et al., 2012: 91). These are essentially theories about how hypothesized mechanisms might lead to the outcomes of concern. Example 1.6 (Spouse Abuse) One example of the need for realist (theory-based) evaluation is represented by a series of studies of domestic violence (Sherman 1992; Tilley 2000). The first was done in Minneapolis. The intervention of arrest (with publicly revealing the fact in the newspaper) decreased recidivism by ~50% compared with those given advice or released. This method was rapidly adopted nationwide. It worked in several cities, and yet increased recidivism rates in several others. A realist evaluation showed that, in communities where the perpetrator was embarrassed by public notification, the recidivism rate went down. In communities where they were angered by public notification, the recidivism rate went up.

One consequence of critical realism is that causative forces in interprofessional practice come from many domains simultaneously, especially the physical and social domains. According to the doctrine of cultural realism (Archer, 2000), the most important influences for interprofessional education occur from at least three levels: the natural order, where our immediate well-being is involved, signaled by emotions of pain/pleasure; the practical order, where performative achievement (skills) are involved, signaled by emotions of failure/achievement; and the social order, where discourse is involved, signaled by emotions of shame/pride. In interprofessional education, two important levels are the individual situation and the system. The individual situation is where affordances are directly controlled—patterns, flow transformations, and exchanges—to stabilize a particular identity in the moment (more on this in later sections). The system, at a different level, regulates affordances over extended time and across situations to control the identity stabilization process (Burke & Stets, 2009: 109). There is some overlap, but each has its own causative power. From the situational perspective, how would each individual utilize the name tags in Figure  2? From the system perspective, what deep assumptions led the designers to come up with this particular solution?

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Sidebar 2.1 Critical Realism There is a mind-independent real world of generative mechanisms and causes. It is multifaceted, dynamical, and not directly accessible. Our experience of the world is filtered by the limits of our sensory systems and our sociocultural expectations. This means that “facts” and “theories” are fallible and contingent. In summary, critical realism assumes a stratified, multimodal, dynamical world in which underlying causal mechanisms are not directly observable but must be inferred by agreement with a theory used to make a description or support an action. It involves competition between a set of theories as explanations, not a prediction. The intransitive (non-changing) portion connects deep causal relationships with actual (potential) events. The transitive (contingent, fallible) portion connects these events to perceived empirical events. Example 1.7 (Abscess—3) Let us reexamine our patient from Chaps. 2 and 3 with an abscess, and let us again assume that he has diabetes. However, let us now go beyond the simple “Infection raises glucose → treat the infection and the glucose will return to normal” to incorporate critical realism. A 2-week slice of his monitoring diary is likely to show wide variations, much more chaotic than a simple continuous function (rising when infected and dropping when the infection is treated). The glucose level is determined by multiple interacting systems (insulin dosing, exercise, diet, inflammation, mood, routine vs. novel situations, etc.) each operating on its own timescale. Furthermore, the dynamics of each system’s effect on glucose level tends to change over different time periods from hours to weeks (Wilson & Holt, 2001). Critical realism provides a framework for approaching this complexity.

By the late 1990s, my research team was examining contingent, group-specific perspectives of healthcare and their effect on team function.

Example 1.8 (Perception-of-Care Map) This study of differences between group perspectives involved recursive analysis and modeling of data from a large multi-site, multi-method study of recurring operational problems in ambulatory teaching clinic (Smith, et al., 2006). We discovered that a pentagram-shaped “perception-of-care” map of structural care (accessible knowledge about the patient, established clinic routines), educational care (graduated supervision and responsibility),

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relationship-­based care (concern for patient as a person, treat patient as an individual), algorithmic care (valid algorithms that guide provision and measurement of care), and efficient care (clinic visit is timely and productive) explained the data well. Further, the importance of each perspective varies considerably between faculty, learners, patients, and administrators, and this could be seen as coming from different realist domains (material, social, economic, etc.). As far as our patient with an abscess and diabetes goes, these studies suggest that different actors would focus on different perspectives (affordances): Can we easily obtain historic measures of the patient’s diabetes control? What lesson should be learned from this “case”? How is the patient handling this disruption? What does “science” say to do next to control the glucose? How quickly can a care plan be established, including shifting some of the care burden to other team members?

It is likely that each profession views clinical care from a different (sometimes competing) perspective, and we now have some of the skills for detecting these differences. One thing this means for interprofessional education is that “rules of thumb”—about clinical care and each other—are approximate, contingent, and should be expected to change. This can be leveraged to point out that each profession’s understanding of a clinical situation is dynamic and likely only one part of the picture.

References Archer MS. Being human. The problem of agency. Cambridge, UK: Cambridge Univ Press; 2000. Banks EC.  The realist empiricism of Mach, James, and Russell. Neutral Monism reconceived. Cambridge, UK: Cambridge University Press; 2014. Bhaskar R. On the possibility of social scientific knowledge and the limits of naturalism. J Theory Soc Behavior. 1978;8:1–28. Bhaskar R. A realist theory of science. London: Verso: Routledge; 2008. Bhaskar R. The order of natural necessity. Self-published; 2017. Bhaskar R. Interdisciplinarity and wellbeing. London: Routledge; 2018. Burke PJ, Stets JE. Identity theory. New York: Oxford University Press; 2009. Elder-Vass D. Re-examining Bhaskar’s three ontological domains: the lessons from emergence. Presented at IACR conference, Cambridge, UK; 2004. Pawson R, Tilley N. Realist evaluation. London: Cabinet Office; 2004. Sherman L. Policing Domestic Violence. New York: Free Press. 1992. Smith CS, Morris M, Hill W, Francovich C, Christiano J. Developing and validating a conceptual model of recurring problems in teaching clinic. Adv Health Sci Educ. 2006;11:279–88. Tilley N. Realistic evaluation: An overview. Research Gate. 2000. https://www.researchgate.net/ publication/252160435_Realistic_Evaluation_An_Overview. Accessed 6/25/21. Wilson T, Holt T. Complexity and clinical care. Brit Med J. 2001;323:685–8. Wong G, Greenhalgh T, Westhorp G, Pawson R. Realist methods in medical education research: what are they and what can they contribute? Med Educ. 2012;46:89–96.

Chapter 5

Realist Affordances

Many traditions speak of a field of potential, the ground of being, and a field of actualization, the real world. Bohm called these the implicate order and the explicate order.1 He envisioned the implicate order as folded in upon itself at unimaginably small, unperceivable dimensions on a continuum of subtlety. It exists outside of time and space. The explicate order was when this was unfolded and became perceivable. He hypothesized a holomovement, a continual flow of energy and information back and forth along this continuum of subtlety and back again. Given the “new physics,” we can expect that affordances are not a “thing” but, in fact, involve potential and relationship. Furthermore, this relationship has causative power. Heras-Escribano (2019) states: “… when we explore the environment we do not just perceive physical objects: rather, we perceive what we can do with them: We perceive the graspability of a cup, the climability of a step, or the kickability of a ball … [there is] continuity between perception and action, a situated embodied idea of meaning or value that [is] not semantic or representational.”2

Not representational—not dependent on manipulation of mental images or cognitive models of the affordance. Not semantic—not dependent on language or propositions about the affordance. Not psychological, nor cognitive. Instead,

 Other traditions that speak of a ground of being from which reality is derived: Taoism (infinitely mysterious Oneness), Hindu (Brahman—pure consciousness), Judaism (Shekinah—utterly unknowable), Sufi Islamic (intimate and mysterious), Christian mystics (love in action) (Bohm, 2002: 186–196; see also Higginbotham and Paganism, 2020: 145–150 for further details). 2  This incorporates the idea that affordances point both ways (environment/individual) or are simultaneously subjective and objective. There is something in the environment that has features. There is something in my disposition, my capabilities and current goals, that could find these features useful. An affordance has to do with the match or the relationship between these points of view, and it influences behavior. 1

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5  Realist Affordances “…  there is a world of pure experience, a dynamic and changing world in which we experience those relations immediately and pre-reflectively” (Heft, 2001)

Affordances then have a dynamic, relational history with each individual: “[Affordances] can only be analyzed if we consider the organism as embedded in the environment, creating a mutual history of interactions extended over time.”3

Heras-Escribano (2019: 71) proposes a dispositional view of affordances: “Dispositions are tendencies and, like all tendencies, they do not need to manifest all the time but, when they do, some special circumstances are needed.”

An affordance then is a feature of the environment that is complemented by a reciprocal disposition (causal tendency) of the organism. “Reality can only be known from the contingent points of views that organisms establish” (Turvey, 1992). These change with time and experience. Novices rely on broad, nonspecific affordances, often trusting to the facts and concepts that experts identify after ex post facto reflection. Experts rely on fine-grained, highly context-specific variables used in the moment (Heras-Escribano, 2019). The novice is using “rules”, socially constructed, culturally specific procedures that are framed in language, goal-­ oriented and intentional. Experts are searching after value that implies “laws”; real, natural, universal, causal, and pre-consciousness (Hodges and Baron 1992). Rules and laws come from different strata of reality in the construct of critical realism. Thus, the interprofessional educational task is to move trainees to adopt a broader set of strata, to encourage fine-tuning of our dispositions by eliciting greater differentiation and specificity of affordances. We will look closer at these dispositions to utilize affordances from the individual and group perspective in future chapters.

Sidebar 1.3 Realist Affordances Affordances are not cognitive representations or linguistic propositions about features in the natural world. Instead, they are dispositions, tendencies, or propensities to act in a certain way based on a mutual historical relationship between the organism and the available environmental features.

 For instance, a certain log across a stream has been “walk-across-able” for me when hiking. However, as I have gotten older and my balance has declined, I quit crossing the log. Same environmental feature, changed disposition toward it, different behaviors elaborated. Affordances are specific to the individual (Heras-Escribano, 2019). 3

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Example 1.9 (Abscess—4) Consider again our patient with an abscess and diabetes. Many learners will use rules that they have learned for managing this combination at face value. Only experts will have keyed into the broader more subtle affordances (family dynamic, economics, patient demeanor, own “gut” sense) that would suggest causes such as physical abuse, acquired immunodeficiency syndromes, insulin antibodies, poor injection hygiene, or Munchausen syndrome. Developing this expanded sensitivity requires ongoing relationships between learner and environment/context, time for reflection, and sensitive coaching. Classical concepts such as length, width, and height pertain to objects as though they were concrete elements in the environment. The alternative concepts of “inside” and “outside” are more relational and more fundamental.4

One particular area to consider with regard to realist affordances in interprofessional education is how the structure of affordances plays out among and between professions. We will discuss this further in Chap. 16.

References Bohm D. Wholeness and the implicate order. London: Routledge; 2002. Heft H. Ecological psychology in context: James Gibson, Roger Barker, and the legacy of William James's radical empiricism. Mahwah, NJ: Lawrence Erlbaum; 2001. p. 26. Heras-Escribano M. The philosophy of affordances. Cham, SZ: Palgrave MacMillan; 2019. p. 63. Higginbotham J, Paganism R.  An introduction to earth-centered religions. Woodbury, MN: Llewellyn Publications; 2020. Hodges BH, Baron RM. Values as constraints on affordances: Perceiving and acting properly. J Theory of Social Behavior. 1992;22(3):263–94. Sheets-Johnstone M.  Insides and outsides. Interdisciplinary perspectives on animate nature. Exeter, UK: Imprint Academic; 2016. Turvey M.  Affordances and prospective control: an outline of the ontology. Ecol Psychol. 1992;4(3):178.

 Kinesthetic (inside) sensations reveal the first-hand qualitative experience of movement, the spatiotemporal energetic dynamics (pg. 35). Kinetic (outside) sensation, seeing our body as a quasi-­object, reveals the quantitative effects of our movement, its intensity, direction, and range (pg. 38). Together, these dual senses, kinesthetic and kinetic, provide the synergies of meaningful movement that ground our “phenomenological trinity” (pg. 44)—I MOVE (kinesthetic/kinetic), I DO (agency), and I CAN (reflexive possibility), according to constructive phenomenology, are the foundations of habits, emotions, and agency (Sheets-Johnstone, 2016). 4

Part II

The Mental Domain

1.1  IP Problem: Hidden Affordances Vignette: I was seeing a young ER trauma patient with a novice nurse practitioner (NP) resident. Our initial evaluation seemed like the patient was stable, but I insisted we remain vigilant because I was concerned. Within several minutes, his vital signs deteriorated and he was “crashing.” After a successful resuscitation, he was on his way to the operating room to remove a ruptured spleen. The NP resident was quite shaken. Afterward, we sat down to discuss the case. “How did you know he was going to crash?” she questioned. I said, “Before I answer that, how did you feel when you first entered the room. What emotion did you have?” “I was scared!” she said. I replied, “So was I. That is important information. You may be picking up on something you aren’t consciously aware of, and your fear may be a sign of his acuity. Whenever you feel it you should be extra cautious.” Certainly, the mental state of learners is a co-determinant in interprofessional educational outcomes. Elements such as fear, shame, interest, or motivation may modulate engagement. Innate cognitive bias can filter expectations and attention. Acquired stereotypes can seriously affect cooperation and performance. Teasing these out, or even helping learners to accept that they exist, must be a core part of interprofessional curriculum. While this section does not provide a comprehensive list of all important mental domains, it does cover those that I have found most important for interprofessional training. Mind-body dualism, the assumption that mental elements and material elements are different types of substances, has been a prominent influence on psychology, neurology, and neurobiology since Descartes. More recently, a cybernetic operating model and computer metaphor have further influenced our assumptions about how the mind operates. Like the classical model of physics, these have been helpful metaphors that have led to advances. However, we will see again in this section the limits of this thinking and the need to expand our understanding of the “mental.”

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Example 2.1 (Flip Chart Exercise) One of our sister interprofessional institutions (Cleveland) taught us this valuable teaching exercise. Early on, we facilitate discussion of stereotypes with a flip chart exercise (King et al. 2017). We divide the class by professions and have them gather at their profession-specific flip chart, which is led by a faculty member from that same profession. The leader tells them, “In a moment, I am going to say one word. I want you to speak out the first things that come to mind when you hear it.” The leader then speaks the name of their own profession (e.g., “doctor” for physicians) and records the brainstormed impressions from the group on the flip chart. The sheet is flipped over. All professions then rotate to the next flip chart and repeat the exercise for a different profession (e.g., “nurse,” “pharmacist,” “psychologist”) with a faculty member from that profession. After rotating through all professions and back to their home station, each profession reviews what was said about them by all the other participants. Finally, they reconvene in the large group and reflect on what they expected, what was surprising, and what they learned.

Reference King IC, Fisher AK, Wersland JL. Addressing and exploring professional stereotypes. workshop A6, track 2. Collaborative Family Health Association, Annual Meeting, Houston TX. 2017. https://cdn.ymaws.com/www.cfha.net/resource/resmgr/2017/Conference/Resources/A6_ King_PPT.pdf. Accessed 14 March 2021.

Chapter 6

The Lifeworld

It is useful to view affordances from the organism’s perspective, not just from the environmental perspective of the relationship. Every organism has a lifeworld of features that they attend to, what the “environment” contains for them, creating unique organism-environment relationships. The lifeworld was first described by Jakob von a Uexküll (1957), a German biologist, as the umwelt. In ecological psychology, as affordances, they are basically the important elements in the environment that afford the opportunity for relationship, interaction, and value for a particular organism. They must be noticed and then utilized. So, for instance, the lifeworld of an earthworm may include humidity, temperature, and chemical triggers for which it contains receptors. Affordances in the environment provide opportunities for activity in the worm that correspond to this lifeworld. The result is that the worm digs a hole and plugs it with leaves in cold, dry weather but does not plug it in warm, moist weather (Darwin 1881). In the same ecosystem, the lifeworld of a bird may consist of wind velocity and direction, time to contact with a target, and memories of an earthworm as satisfying food. As mentioned in Chap. 2, affordances can be signs or symbols. As signs, they are analog (physical objects), aimed at the current physical affordances in the niche, and they trigger action (behaviors). As symbols, they are digital (language), indicating potential resources, and they are generalizable. As stated earlier, one way to look at interprofessional education is as successive fine-tuning of our dispositions toward affordances by eliciting detection of a greater number and differentiation in greater specificity. Functional-cognitive psychologists define learning as “change in behavior  …  as a consequence of regularities in the environment,” which can be intrinsic or mediated (DeHouwer and Hughes 2020: 4).

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Intrinsic Expansion Every organism exhibits exploratory behavior, trying to obtain the affordances they need to thrive, called “effort after meaning” (Reed 1996: 104). Detection of information (affordances) is intrinsically motivating and leads to improvement in perception and learning (Gibson 1979). This occurs without either reinforcement or explicit teaching (Reed 1996: 105). Thus, it is important for interprofessional education that appropriate exposure to authentic affordances will, in and of itself, improve perception and discrimination of key affordances.

Mediated Expansion Expansion of the lifeworld may also be mediated. In many organisms, spatiotemporal regularities (the red button in a particular apparatus) function as an intermediate contextual cue pointing toward concrete affordances (push that button, get some food), which results in classical or operant conditioning. However, in verbally capable humans, words and direct observation can function as intermediate contextual cues for abstract meaning transferred using language, symbols, or mimicry (DeHouwer and Hughes 2020: 192–3). Only humans can act on abstract relationships and then generalize accordingly. As an example, when relationships between abstract symbols are shown during a training phase, generalizations can be based on these logical abstract relationships and not on button position. This is true for humans but not for nonhuman primates (DeHouwer and Hughes 2020: 160). The ability to generalize certain abstract symbolic relationships is critical to obtaining the correct balance between discrimination (specificity) and generalizability (transferability) for key affordances, teasing out which abstract features of an affordance are most important. Language allows humans to use alternative avenues for knowing. They can use the immediate, first-order, nonanalytical awareness of direct perception of affordances. They can also use reflective, second-order, analytical awareness of affordances, particularly if guided by more expert members (Heft 2003). Expert guidance should help novices focus their attention on which are critical affordances and how to discern them in more detail. J.J. Gibson, the founder of ecological psychology, stated, “I have been moving toward a psychology of values instead of a psychology of stimulus” (quoted in Reed 1988). As we mentioned in section one, rules and laws seem to come from different realist strata. Rules are forward looking, and rule-following is a social phenomenon that can be broken or breached. Natural laws are backward-looking, oriented toward origins and ultimate natural causes, and they are inviolable. And yet, we see from critical realism that laws and causative mechanisms are not directly perceivable. They are constrained by the limits of our senses and by the sociocultural filters of expectation. For humans, “only a rather complex blend of the biological causal

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model with the social rule-following model will give us an adequate [explanation of their behaviors]” (Harré and Secord 1972). Values function in the ecological niche to coordinate rules and laws. “[Values] are more forgiving than laws and less forgiving than rules [and] provide the elasticity sufficient for maintaining the creative tension between and among rules and laws” (Hodges and Baron 1992). So, appropriation of affordances is a quest after values. Over time and recurrent use, both individual (first-order) and collective (second-order) perception and utilization of affordances will evolve, adapting and coming closer and closer to representing real natural laws. Sidebar 2.1 The Lifeworld The lifeworld is the field of affordances that the organism is attuned to. It can be expanded intrinsically through recurrent experience. It can be expanded extrinsically, mediated by guidance from experts.

References Darwin C. The formation of vegetable mold through the action of worms with observations on their habits. London: John Murray; 1881. DeHouwer J, Hughes S. The psychology of learning. Cambridge, MA: MIT Press; 2020. Gibson JJ. The ecological approach to visual perception, New York: Psychology Press; 1979/2015. Harré R, Secord PF. The explanation of social behavior. Oxford: Basil-Blackwell; 1972. Heft H.  Affordances, dynamic experience, and the challenge of reification. Ecol Psychol. 2003;15(2):149–80. Hodges BH, Baron RM. Values as constraints on affordances: perceiving and acting properly. J Theory of Social Behavior. 1992;22(3):263–94. Reed ES. Adaptation and the development of behavior. Dev Psychol. 1988;21(2):203–6. Reed ES. Encountering the world. New York: Oxford University Press; 1996. von Uexküll J. A stroll through the worlds of animals and men: a picture book of invisible worlds. In: Schiller CH, editor. Instinctive behavior: the development of a modern concept. New York: International Universities Press; 1957. p. 5–81.

Chapter 7

Sense of Being

The “Self” We are not born with a sense of “self” (Siegel 2018; Flanagan 1994). How the “ME,” the “I,” and the “SELF” develop is not settled. Hypotheses put forth by psychologists, philosophers, neuroscientists, and others include accrual of experience (James 1892/1966), binding of “somatic markers” (body states) to an autobiographical narrative (Damasio 1994, 1999, 2010), developmental interactive social processes—especially language (Mead 1967), and binding and emergence due to recurrent feedback loops with personal reference (Flanagan 1994; Hofstadter 2007) among many more. What is largely agreed upon is that there is an objective sense of self, “ME,” which is the protagonist for our life story. This is likely accurate and the result of increased brain complexity due to evolution and individual development (Hofstadter 1999). This provides a critical substrate for learning from experience. The “ME” can be conceptualized as the individual side of the self-as-affordance. The subjective sense of self, “I,” self-as-knower with choice and agency guiding action, is inaccurate (Wegner 2002: 186). It seems that our reasoning is in control. It seems that action-based self-invariants give us self-agency, self-coherence, self-­ affectivity, and self-history (Stern 1985). It is this sense of self that has been challenged by empirical data (Wegner 2002: 57). Things that are actually separated in time, and not in the order we consciously distinguish, are bound together in the brain. For example, choices such as which word to use in a given sentence, when reading, or typing, seem to be under rational control. However, studies demonstrate automatic actions/reactions that occur before we report conscious awareness of word choice (Wegner 2002: 57). Not realizing that the motor process has already been triggered, the protagonist experiences the idea to act, and then action occurs, giving them the sense of free will. Apparently, an automatic system presents the idea of a voluntary action to consciousness and simultaneously triggers the action. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_7

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The “SELF” is a useful construct that maintains our identity as an ideal conscious agent. It binds our intentions, conscious will, and action together and when one of these elements is missing, we supply it through confabulation (Wegner 2002: 57). When one has a “SELF,” one has a self-identity and self-reflection. Both are important in interprofessional education.

Identity One definition of identity is: An identity is the set of meanings that define who one is when one is the occupant of a particular role in society, a member of a particular group, or claim particular characteristics that identify him or her as a unique person (Burke and Stets 2009: 3).

While “self” is a locus or perspective from within our own person, identity has more to do with the perception, ours and others, of our place in the social order. People possess multiple identities because they occupy multiple roles simultaneously (e.g., nurse, ambulatory clinic, teacher, mother, wife). We will simply mention here some basic concepts. Individual identity drives behavior, which creates social structure. However, social structure feeds back to influence identity. All three (identity, behavior, social structure) are linked through a common system of meaning (Burke and Stets 2009: 49). We act to stabilize our most important identities by influencing perceptions, our own and those of others: Disturb a perception that is being controlled, and the identity will act to compensate or counteract the disturbance. Disturb a perception that is not being controlled, and the identity will act in disregard of the “disturbance” (Burke and Stets 2009: 73).

Three of the most important identities for our discussion at this stage are social identity (worthiness), role identity (competence), and personal identity (authenticity) (Burke and Stets 2009: 112–126). As we and others in the situation work to stabilize these (and other) identities, it leads to an incredibly complex interrelated social structure. Sidebar 2.2 Identity Individual identity, social structure, and behavior are linked through a common system of meanings. Three important identities are: –– Social (worthiness) –– Role (competence) –– Personal (authenticity)

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References Burke PJ, Stets JE. Identity theory. New York: Oxford University Press; 2009. Damasio A. Descartes Error. New York: Avon Books. 1994. Damasio A. The Feeling of What Happens. New York: Harcourt Brace. 1999. Damasio A. Self Comes to Mind. New York: Vintage. 2010. Flanagan O. Consciousness reconsidered. Cambridge, MA: MIT Press; 1994. p. 177. Hofstadter DR. Godel, Escher, Bach: An eternal golden braid. New York: Basic Books; 1999. p. 709. Hofstadter DR. I am a strange loop. New York: Basic Books; 2007. p. 95. James W.  Psychology: the briefer course. In: Alport G, editor. New  York: Harper and Row; 1892/1961 Mead, GH. Mind, self, and society. Chicago: University of Chicago Press. 1967. Siegel DJ. Aware. the science and practice of presence. New York: TarcherPerigee; 2018. p. 229. Stern DN. The interpersonal world of the infant. The view from psychoanalysis and developmental psychology. New York: Basic Books; 1985. p. 46. Wegner DM. The illusion of conscious will, vol. 2002. Cambridge, MA: MIT Press; 2002. p. 18.

Chapter 8

Emotion

Emotion is archeologically the oldest brain function, beginning at least with nonmammalian vertebrates and becoming well developed across mammalian species (Panksepp and Biven 2012). The “triune brain” (MacLean 1990), while not exactly accurate, provides a useful heuristic for understanding emotions. The deep, ancient brain stem region, the “reptilian” brain, produces, among other core functions, instinctual behavior such as approach/avoid and fight/flight. This is accomplished by primary emotions that drive these instinctual behaviors. Primary emotions cross species and include fear, anger, sadness, and happiness (Ekman and Friesen 1975; Panksepp and Biven 2012). Some would add nuances of positive affect including play, nurturance, and lust (Panksepp and Biven 2012: 2). The limbic system, or “cat” brain (old mammalian), in humans is wrapped around and integrated with the brain stem. The limbic system’s nonconscious conditional control over the reptile brain is the source of classical and operant conditioning (Hampden-Turner 1989). It is also the source of unconditioned (no external rewards or punishments) learned behaviors, where within-brain processes serve as “rewards” and “punishments” directly in unconditioned learning tasks (Panksepp and Biven 2012: 24). Nonconscious learned emotional behaviors include dominance/submission, defending territory, hunting, bonding, and nesting (Hampden-­ Turner 1989). Overlying both the brain stem and limbic system, and also integrating with these, the neocortex, “primate” brain, is responsible for higher thought such as abstraction, language, reflection, and planning. The combination of primary emotions (brain stem), conditional control (limbic system), and neocortical function (attitudes) leads to complex social emotions such as envy, guilt, jealousy, shame, pride, and awe. These lead to behaviors focused more on the past (memories) or future (plans, worries). They can also lead to distorted self-images (Panksepp and Biven 2012: 19/20). The problem for interprofessional learners is when emotional responses are not fully integrated and reactions are automatic. As an example of how this might be © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_8

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used, when a patient is aggressive or threatening, the learner may withdraw (primarily reptilian), lash out (primarily limbic), or feel shame in their inability to manage the situation (primarily cortical). Discussing that these undifferentiated behaviors require different responses—face your fear, suppress your automatic reaction, or accept your limits—and exploring how ideally the initial emotion is recognized and then, through reflection and control, integrated into a balanced response. Sidebar 2.3 Emotional Response It can be useful to think of our responses as instinctive (brain stem), emotions (limbic), and rational/social emotions (cortical). We cannot control feeling the response, but with practice—recognition, integration, and deliberation—we gain the freedom and ability to choose the reaction.

References Ekman P, Friesen WV. Unmasking the Face. Englewood Cliffs, NJ: Prentice-Hall. 1975. Hampden-Turner C. Maps of the mind, vol. 80. London: Collier; 1989. MacLean PD. The triune brain in evolution: role in paleocerebral functions. New York: Plenum Press; 1990. Panksepp J, Biven L. The archeology of mind. New York: Norton; 2012.

Chapter 9

“Knowing” the World

Several academic traditions point to two ways to “know” the world. While these methods of experiencing the world are very different, as we will see, they are complementary. One of the most well-known theories comes from behavioral psychology and is known as “Thinking Fast and Slow” (Kahneman 2011). System 1 is automatic, fast, and intuitive (subconscious). System 2 is deliberate, slow, and analytic, with a limited capacity of 7 +/− 2 “chunks” for information processing (Miller 1956). These systems work in tandem. System 1 intuition quickly offers up a target concept. This can be arrived at through skill (experiential coherence) or heuristics (learned general rules of thumb). The latter, while often very useful, are also the source of many of our cognitive errors in decision-making (Croskerry 2003). System 2 then analyzes the adequacy of the concept provided by system 1 through deliberative adjustment but may stop at a “good enough” rather than an optimized solution. This may allow influence from cognitive biases. Psychoanalytic theory offers a different perspective. Primary process is “unconscious mental activity in which there is free, uninhibited flow of psychic energy from one idea to another. This mental process operates without regard for logic or reality.” Secondary process is “rational mental activity under the control of the ego and the reality principle. This mental process, which includes problem-solving, judgment, planning, and systematic thinking, enables individuals to meet both the external demands of the environment and the internal demands of their instincts in rational, effective ways” (APA 2020). Heft states: “The distinction between immediate, first-order, nonanalytic awareness and reflective, second-order, analytical awareness is important because it identifies two alternative avenues for knowing” (Heft 2003). A third related theory is the dynamic theory of perception, explaining creativity, especially for visual arts and music, by integration of a deep, undifferentiated (free-­ floating attention) level and the surface differentiated (structured, logical) level (Ehrenzweig 1995: 88). The deep level is preconscious and holistic and appears chaotic. It is driven by core instincts and drives and allows transient connections © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_9

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between even conflicting thoughts, temporal and spatial ambiguities, and subliminal images. The surface level is where gestalts (ordered, coherent, namable) are formed as “figures” and separated from the irrelevant “ground.” There is “open conflict between the surface and depth sensibilities, between intellect and intuition” (Ibid: 64) that leads to anxiety, between the apparent disorder of the undifferentiated level and the requirement for order in the differentiated gestalts. However, if one develops “depth perception” and “unconscious scanning,” one can “abandon the conscious need for logic, order, and sequence” (Ibid: 65) and sense a different coherence inherent in the deep level. There is a powerful drive, both within the individual and society, to reduce this coherence to words, defined concepts, and rules of thumb, which concretizes the dynamic process into a gestalt and destroys the creativity. These theories share the perspective of two levels, which I would call intuition and analysis. Intuition is unbounded, combinatorial, and global. It can temporarily violate logical rules, leading to novel inputs and connections. Analysis is limited, resource intensive, and focused, transforming the intuitive experience for export and into words, logic, and rules of thumb. Ideally, these are balanced, but analysis and gestalts tend to override intuition in our current culture. Sidebar 2.4 Intuition and Analysis Intuition and analysis are two complementary ways of experiencing the world. Intuition is open, unbounded, and creative. Analysis is closed, linear, and exportable.

Upon entering health training, most learners have “folk” concepts of illness based on media portrayals, their early experiences, and family understanding of health events. Training often has them reorganize this understanding into scientific, “medicalized,” organ-based “dis-eases and treatments”: for instance, from “fluid buildup,” which is how the family explained grandpa’s heart failure, to “diastolic heart failure with a decompensation event.” In early training, it can be helpful to compare and contrast these concepts to make explicit the new connections and integration, but also to maintain an understanding of early concepts. This can begin grounding the balance between intuitive wisdom and rational thinking and can help facilitate communication with some patients (by retaining early wording) in the future. Later in training, facilitating “fuzzy categories” by identification of central prototypes and expected ranges helps learners to accept the variability and uncertainty of clinical practice. Advanced trainees benefit from learning to “test” their rapid intuitive assessment using mental simulations, running actions forward. This can reinforce that all theories and facts are contingent.

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References American Psychological Association (APA) Dictionary. 2020. https://dictionary.apa.org/primary-­ process and https://dictionary.apa.org/secondary-­process. Accessed 20 Dec 2020. Croskerry P.  The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775–80. Ehrenzweig A. The hidden order of art. Berkeley, CA: Univ. of California Press; 1995. Heft H.  Affordances, dynamic experience, and the challenge of reification. Ecol Psychol. 2003;15(2):152. Kahneman DL. Thinking fast and slow. New York: Farrar, Straus and Giroux; 2011. Miller GA. The magical number seven, plus or minus two: some limits on our capacity for processing information. Psychol Rev. 1956;63(2):81–97.

Chapter 10

Intrinsic Expansion of the Lifeworld

As stated above, for humans, time-on-task improves our powers of discrimination for affordances even without instruction or direct feedback. This apparently requires conscious access: “Conscious access is deceptively trivial … behind our perceptual awareness, however, lies an intricate avalanche of brain activity that involves billions of visual neurons and that may take nearly half a second to complete before consciousness kicks in” (Dehaene 2014: 10).

But if affordances are embedded directly in perception, why do we need conscious awareness of them to improve performance? Although nonconscious processing can be extensive, “conscious access adds an additional layer of functionality. The broadcasting function of consciousness allows us to perform … thought experiments, purely mental operations that can be detached from the external world” (Ibid: 14).

Beginning meditators know that our minds frequently disrupt awareness, wandering off toward memories—regrets and successes from the past—or plans for the future. This lack of order in mental activity threatens achievement of our goals via “psychic entropy” (Csikszentmihalyi 1990:36). However, when thoughts, perceptions, actions, and goals are in perfect harmony in flow, this effortless state is intrinsically rewarding and self-perpetuating (Ibid: 39–40). Consciousness is not required to act on affordances, but it does bring additional functionality; it allows us to “run mental simulations,” to reflect, to communicate our insights to others, and to solve novel and complex problems. This can further reinforce learning. The vignette at the beginning of Part II (page XX, “How did you feel”) is a good example of facilitated intrinsic expansion of the lifeworld where the affordance (fear) is brought into consciousness for discussion and deliberation. Problem-solving in healthcare is a complex mix of emotion, intuition, experience, and rational thought, but what is the correct mix and order? A broad array of studies from neurology, behavioral psychology, first-person accounts, and interspecies comparisons have demonstrated that emotion comes first. It is rapid and holistic and © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_10

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frames a general response (e.g., “approach”/“avoid”). The feeling may well be tied to an emotion-laden memory or prior experience (e.g., “friend”). Then, rational analysis fine-tunes the response (Damasio 1994; Haidt 2012; Klein, Klein 1999; Minsky 2006; Panksepp and Biven 2012). Think about meeting a long-ago acquaintance on the street. You probably remember how you felt about that person before you remembered their name. I like the way that Jonathan Haidt frames this (Haidt 2012: 1). He states: “The mind is divided, like a rider on an elephant, and the rider’s job is to serve the elephant.” The emotional elephant is a powerful force and is difficult to steer, and the rational rider feels that they are in charge but in reality they are at best offering subtle guidance and suggestions. Example 2.2 (Developmental Diagnostic Ability) Problem-solving goes through developmental stages. In our study of possible diagnoses of shortness of breath (distinguishing pneumonia, heart failure, or asthma), physician novices used propositions and rules acquired from outside sources (explicit semantic memory) to cautiously propose solutions. They were also subject to the “apprentice effect,” anxiety, and embarrassment that lead to emotional distress, cognitive overload, and mistrust of their common ideas (because their folk concepts had previously been found to be wrong). As they became intermediates, compiling medical experiences and discussions into personal episodic memories, they reached the limits of working memory. They began converting personal episodic memories into more efficient concrete rules, and they used proportionally more rules, arranged in complex rule hierarchies, than any other group. Finally, experts compiled groups of rules into prototypes with central examples and a range of possibilities. They unintentionally focus on key affordances that seem to be stored and retrieved through stories. Diagnosis becomes a search through competing prototypes and stories, guided more by history, with disconfirming cues or absence of expected cues from the environment, than in earlier stages (Smith et al. 2014).

This movement from abstract facts and rules toward direct perception and conscious simulation is reflected in recognition-primed decision-making (Klein 1999). Klein studied several expert actions in time-pressured novel situations. The experts could not initially describe why they did what they did. What he discovered was a three-step process that exhibits an optimal functional blend of instinct, analysis, and efficiency. 1. Pattern matching: An intuitive metaphorical connection to prior experiences is made. The narrative of the prior experience is used to identify an aberrant element, either an extra or missing affordance, which makes the situation novel. 2. Mental simulation: A promising solution, suggested by the aberrant element, is simulated by imagining how it will play out.

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3. Satisficing: This singular (versus comparative) evaluation approach is more efficient. It may not identify the optimal solution, but it will rapidly identify a workable solution to the novel problem (Klein 1999:20). Finally, joint appropriation of affordances in the environment is critical to interprofessional group learning. A triadic relationship (me-affordance-you) that interpenetrates “my” environment with that of other people is manifested by movement. Coordinated movement becomes a critical sharing of the affordances of the environment (Heras-Escribano 2019). Sidebar 2.5 Intrinsic Expansion Exposure to novel situations drives expert intrinsic refinement in three steps: –– Pattern matching –– Mental simulation –– Satisficing

References Csikszentmihalyi M.  Flow. The psychology of optimal performance. New  York: Harper Perennial; 1990. Damasio A. Descartes error. New York: Avon Books; 1994. Dehaene S. Consciousness and the brain. New York: Penguin Books; 2014. Haidt J. The righteous mind. New York: Vintage Books; 2012. Heras-Escribano M. The philosophy of affordances. Cham, SZ: Palgrave MacMillan. 2019. Klein G. Sources of power. how people make decisions. Cambridge, MA: MIT Press; 1999. Minsky M. The emotion machine. New York: Simon & Schuster; 2006. Panksepp J, Biven L. The archeology of mind. New York: Norton; 2012. Smith CS, Hill W, Francovich C, Morris M, Robbins B, Robins L, Turner A. Diagnostic reasoning across the medical education continuum. Healthcare. 2014;2:253–71.

Chapter 11

Mediated Expansion of the Lifeworld

Keys to designing interprofessional curriculum are shared team identity, clear roles/ tasks/goals, interdependence, integration, and shared responsibility (Reeves et al. 2010). What type of instructional and curricular structure can best foster these elements and learner’s interaction with, and expansion of, their lifeworld? There is no single best answer. Novices may benefit from simple framing of unrecognized affordances. For instance, as above, asking “What emotion did you feel as you approached that E.R. patient?” can promote a discussion of how their fear (an affordance) may be a sign of patient acuity. Intermediate trainees benefit most from gently eliciting and then perturbing their rule structures. Advanced trainees benefit from learning to “test” their rapid intuitive assessment (step one in recognition-­ primed decision-making above) using mental simulations, running actions forward. One useful technique is prospective hindsight (Dunbar et  al. 2013). The trainee makes their observations and decides on an action. Before carrying it out, they are guided to assume that the action is found to be wrong and try and identify (as though in hindsight) where their error was. In interprofessional education, where we focus on team functioning and intelligence of the system as a whole, optimal structures vary according to the acuity of the situation and stability of the environment. There are three broad types of team organizational structure: centralized (command and control), decentralized (scale free, “small world”), and distributed (Davis and Sumara 2006: 51–53). Centralized structures, traditional teacher-student hierarchies, present the most efficient information transfer from the top-down and work best in highly time-pressured environments such as the emergency department. However, they are less robust to perturbation, and they do not respond well to learner diversity or special needs. Decentralized, scale-free, or so called small world structures, connected hubs and spokes, also move information efficiently and are more resilient to shocks due to multiple strong and weak links between elements. This would be like naturally formed study groups connected by formal and informal communications. Small world structures are often the best compromise where efficiency and resilience must © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_11

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be balanced. Examples include brains, power grids, and airline routes. These might work best for supervision in multi-learner clinics. Distributed structures, where every node is connected to every other node, are extremely robust but highly inefficient. They are generally only useful in the most dynamic and unsettled contexts. Curricula based on “small worlds” do not focus on what are absolutes or foundational but, rather, on how ideas are connected. Enabling constraints are “structural conditions that help to determine the balance between sources of coherence and … sources of disruption and randomness” (Davis and Sumara 2006: 147). They are “not prescriptive (not imposed rules that one must obey to survive) but proscriptive (conditions that one must avoid to remain viable).” They are sufficiently coherent, but open to randomness, not “everyone does the same thing” nor “everyone does their own thing” but “everyone participates in a joint project” (Davis and Sumara 2006: 148). Sidebar 2.6 Mediated Expansion Enabling constraints work best, not what to do, but what not to do, what states to avoid. In novices, point out and frame unrecognized affordances (e.g., fear). In intermediates, identify and perturb their rule structure. In advanced, reflection techniques, such as prospective hindsight.

Example 2.3 (Ethnographic Study) In order to better understand these interactions between structural, operational, and educational goals in a teaching clinic, my research team performed a qualitative study (Smith et al. 2004). We conducted ethnographic observations and then analyzed these data with a mixture of free and template coding. We discovered three important findings. First, we identified breakdown, a situation where an actor was not achieving expected effectiveness, which was the most important category because of frequency and explanatory power. The next finding was that exposure to breakdown was a necessary ingredient for reflective learning. The final finding was that effective response to breakdown required six factors to be present; the patient is engaged directly, responsibility is matched to authority, tools are matched to tasks, information resources are matched to need, values are matched between co-participants, and expectations are matched with capacity. These are also important considerations when designing interprofessional training.

As the above study shows, breakdown—disruption in the smooth flow of activity—can be very important for directing attention to less than optimal activities, to self-reflection, and the toward seeking of new affordances and activities. Breakdowns should not cause fear, embarrassment, or a sense of failure but, rather, should be

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seen as opportunities for inquisitiveness and positive anticipation because they usually lead to insight and improvement. Role modeling this attitude to set the group norm is important.

References Davis B, Sumara D. Complexity and education. New York: Routledge; 2006. p. 51–3. Dunbar M, Helms S, Brodell RT. Reducing cognitive errors in dermatology: can anything be done? J Am Acad Dermatol. 2013;69(5):810–3. Reeves S, Lewin S, Espin S, Zwarenstein M. Interprofessional teamwork for health and social care. Wiley-Blackwell: Chichester, UK; 2010. Smith CS, Morris M, Francovich C, Hill W, Gieselman J. A qualitative study of resident learning in ambulatory clinic. Adv Health Sci Educ. 2004;9:93–105.

Chapter 12

Inner Wisdom

While we have spoken of affordances as a relationship between the organism and its environment, this is a “macro-state” viewpoint. Affordances may also connect the analytical perspective to the intuitive perspective internally, within the individual. This is a “micro-state” viewpoint and often includes relaxation of direct cause-­ effect relationships and constraints of time. Techniques to access inner wisdom can reveal deep emergent relationships, reminiscent of the field of quantum possibility in Chap. 2 or the implicate order in Chap. 4. There are several traditions that discuss inner wisdom—attending to transpersonal information, beyond rationality, to obtain innate guidance. I will briefly cover three of them below: depth psychology, mindful meditation, and Native American spiritual beliefs. While I was not raised in any of these traditions and may not have a full understanding of them, I have done extensive reading and much practice and will present them to the best of my knowledge. I do not claim to speak for them authoritatively.

Depth Psychology This tradition is based on the work of Carl Jung and Sigmund Freud. It postulates layers to our personality. Freud conceived of three fundamental layers that should work together cooperatively and harmoniously (Hall 1954). The subconscious id is where primitive drives (primarily sexual according to Freud) manifest and tension from these unmet drives develops. The ego is the conscious “executive of the personality, controlling and governing the id and superego and maintaining commerce with the external world” (Ibid: 28). The superego is the moral ideal and arbiter, developed initially from parental expectations and, later, societal norms. Freud believed that improper integration and development of the sexual drive were the source of most neuroses. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_12

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Jung expanded Freud, going beyond sexuality as the only important nonconscious drive and hypothesizing deeper layers to the nonconscious.1 The deepest layer, and the source of inner wisdom, was the collective unconscious. Jung identified the “collective unconscious” after his “dream of the house” in which he visited successively deeper floors (Jung 1989). He believed that this represented a form of instinct from primitive, collective memory. Jung believed that, as we developed civilization, new aspects of personality overlaid and integrated with older, more primitive aspects: “In this civilizing process, we have increasingly divided our consciousness from the deeper instinctive strata of the human psyche, and even ultimately form the somatic basis of the psychic phenomenon.” (Jung 1968: 36) “their origin is so far buried in the mystery of the past that they seem to have no human source. But they are in fact “collective representations”, emanating from primeval dreams and creative fantasies.” (Ibid: 42)

Jung felt that the “collective unconscious” communicated with images and symbols rather than language and that these often violate rational expectations of proximity, temporality, coherence, and logic. For example, a dream may include a conversation with a father who is dead and it happens in a house, in a country he never lived in. Nonetheless, after reflection, it is seen to have deep meaning for an issue that the person is currently struggling with. The primary carrier of “collective unconscious” messages is dreams. Often dream images are communicated as archetypes, “common inherited patterns of emotional and mental behavior” (Ibid: 378) rolled into a sort of avatar such as the “hero,” “trickster,” or “anima” (idealized woman): “Archetypal images are relatively limited in number, as they correspond to the typical and fundamental experiences of humans since primordial times. They appear relentlessly in all mythologies, fairy tales, religious traditions, “mysteries”, and rites of passage, which are all descriptions of universal human experience.” (Pascal 1992)

Jung felt that an integrated self was obtainable with a balance between rational analysis by the ego and the symbolic, corrective messages from the collective unconscious through dreams. However, there is a “shadow side” to the collective unconscious that could be dissociative and destructive. One final element Jung hypothesized is synchronicity, “a meaningful coincidence of outer and inner events that are not themselves causally connected” (Jung 1968: 226). These were felt to be “archetype-activated by the unconscious of the individual concerned.” For example, Jung was interviewing a female patient who recounted that her husband forced her to have an abortion of a fourth pregnancy because of cost. She said that she prayed for that child’s soul every day. As she told the story, a bird hit the window and died. She said that this had happened before when she told the story. This was considered by Jung to be a synchronistic event  I use the term nonconscious to signify mental contents that are not consciously available. The more common terms “unconscious” and “preconscious” each carry too much baggage and specificity in certain fields. 1

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because in many cultures, birds symbolize the human soul (Pascal 1992: 202–203). Peat, a quantum physicist, sees this phenomenon slightly differently. If we see the system as static and linear, where meaning is provided from outside, then synchronicity makes no sense. However, if we see it as dynamic and nonlinear, relational events could be an “explicit expression of the meaning of the whole system … Synchronicities, therefore, could be said to involve the meaningful unfoldment of potential” (Peat 1988). Each part, both mental and material, may cohere as a whole like a hologram. This is a more “micro-state” viewpoint. The source of wisdom in depth psychology is the collective unconscious, emanating from primitive dreams and fantasies. The vehicle is through archetypes— universal, primitive, and stereotypes. The outcome is growth and development created by integrating language and the rational ego with symbolic messages from dreams and synchronistic events.

Mindfulness Meditation Mindfulness meditation is a secular practice derived primarily from Buddhism. Mindfulness sounds easy. One definition is “awareness that arises from paying attention on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn 2018a: xxxiv). A common beginning place is to follow the breath. Once you start mindfulness practice, however, you realize how hard this is. You start out following the breath, and before you know it, you are worrying about what someone said to you this morning, or planning your afternoon activities. The mind, with its thoughts and emotions, is like a wild horse that needs to be tamed: “[Currently] it is harder to pay attention to any one thing and there is more to pay attention to. We are easily diverted and more easily distracted. We are continuously bombarded by texts, push notifications, appeals, deadlines, communications, and way too much information that we don’t need and can’t possibly take in and process. Things come at us fast and furious, relentlessly. And almost all of it is man-made; it has thought behind it, and more often than not, an appeal to either our greed or our fears.” (Ibid: 133)

The “Four Noble Truths” of Buddhism can be stated as life is suffering, suffering is due to attachment (originating from the desires of a presumed permanent “self”), suffering can be left behind, and this takes systematic practice (Ibid: 123). The systematic practice, as outlined by the Buddha, includes dharma (the teachings), sangha (group practice), and individual practice. With time and practice, mindfulness meditation leads to some ability to control these thoughts and feelings, allowing them to pass by like leaves floating down a river. We need not get attached to them and, instead, can focus on the present, the sounds, sights, touch, smells, and tastes occurring right now. There are several guides with excellent meditation exercises (Hanh 1992; Kabat-Zinn 1994; Chah 2005). Mindfulness meditation can be practiced while sitting, lying, walking, or even dancing. With depth of individual practice, sharing in group practice, and studying the teachings, one begins to see the core of Buddhist philosophy—getting beyond

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thoughts, language, remembering, planning, and worrying to being totally in the present moment. You realize that all things are interdependent and temporary. In this state, one can become calm and settled. One begins to have pure kindness, compassion, and empathetic joy for all sentient beings. At the same time, you realize that all things are impermanent and “grasping” is pointless. You will lose things you possess. Your relationships will eventually dissolve, if not on their own, then through death. Your feelings of desire, pain, and anger are not permanent; they will pass. All living beings (including you) will die, a separation of awareness from the conscious self: “The deeper we go within ourselves, the more expansive we become. We allow everything to show itself, even that which is buried in the unconscious. There is no need to repress the unwanted parts of our situations, ourselves, or others. We realize that everything is a product of our dynamics, our histories, and our reactivity–and that it”s all part of the human condition. We can allow thoughts, feelings, ideas to come and go without being swept away by any of them.” (Ostaseski 2017)

The source of wisdom in mindfulness meditation is the interdependent web of sentient existence. The vehicle is greater attention to the present moment without judgement. The outcome is acceptance of impermanence and loving kindness toward all sentient beings: “Every object, well contemplated, opens a new organ of perception in us.” (Goethe in Kabat-Zinn 2018b)

Native American Spirituality Of course, Native American spirituality incorporates multiple perspectives and points of view. However, there are some significant commonalities. Two important common themes are harmony with nature and importance of ancestral ways. This is reflected in the following saying: “Honor the sacred. Honor the Earth—our Mother. Honor the Elders. Honor all with whom we share the Earth: Four-legged, two-legged, and winged ones, swimmers, crawler, plant and rock people. Walk in balance and beauty.” (anonymous in Jean 2003)

Probably the most sociologically studied Native American tribe in the USA is the Diné (Navaho) people of the four corner areas (Utah, Colorado, Arizona, and New Mexico). They have a mature concept, Hózhó, which roughly translates as balance, order, harmony, or beauty. Unlike these English concepts, however, Hózhó simultaneously has multidimensional meaning: intellectual order, moral goodness, aesthetic harmony, emotional happiness, and physical health (Painter 2014). Hózhó is a grand metaphor for understanding the world and the individual’s place in it. The Diné are said to “walk in beauty.” When an individual commits a crime, falls ill, or destroys nature or tribal artifacts in Navaho culture, they are said to “act like a Beligana” (literally one who

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struggles, often a white person). The treatment is a “Blessing Way” or a “Beauty Way” ceremony. This is conducted by a Hataali (singer or medicine man) and has many components such as oral literature, drama, dance, poetry, music, and sand painting. It tells the story of the Diné coming to their present location from the “third world.” The ceremony is a vehicle for reconnecting with the tribe’s past, heritage, and respect for natural beauty. Many tribes’ spiritual beliefs include a continual discourse between humans, animals, and the natural world (Lake-Thom 1997). For instance, an unusual animal behavior (e.g., dolphin swimming up a freshwater river) portends a natural disaster such as a tidal wave or hurricane. Westerners may interpret this behavior of the dolphin as a protective instinct. Native Americans may interpret it as a specific communication (omen) from the dolphin. Animals have special powers and often intervene in human affairs. Natives are frequently taught from a young age the “Grandfather stories” (Ibid: 48) that explain the personalities and origin of the characteristics of various animals. While there is often tribal and geographical specificity to these stories, nonetheless, there is much commonality: “Nature was the native people’s laboratory and school. The concept of ‘power’ was a significant part of the learning process. Myth served as a form of theory while ritual provided one with the opportunity to experience, synthesize, and internalize power.” (Ibid: 49)

The ongoing array of omens and signs from the animal world are symbolic and behavioral and must be interpreted carefully. They can have good or bad implications depending on the context. In addition, native beliefs and interpretations can be misunderstood and stereotyped by whites: “I believe nature is common to all people … [but] Natural signs and omens are considered superstitions, and direct experiences are labelled hallucinations.” (Ibid: 7)

A measure of the ecological foundations of Native American spirituality is the connection between individual action, collective well-being, and the natural world, which is the concept of “honorable harvest” (Kimmerer 2013). This practice states that, when harvesting plants or hunting animals, one should: –– –– –– –– ––

Ask permission of the one being harvested and listen to their answer Thank them for their sacrifice Do not take the first, or the last Take only what you need, use all you take Share

Currently, one of the predictors of health and well-being in Native Americans is their participation in cultural practices—ability to speak tribal language, participation in rituals, and “feeling connected to the community” (Hodge and Nandy 2010). The source of wisdom for Native American spirituality is the natural world and its rhythms. The vehicle is multicomponent rituals (frequently including song, dance, story, paintings, and costumes), tribal myths, and, in many traditions, interpretation of animal signs and behaviors. The outcome is maintenance and growth of harmony and balance.

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Summary These three traditions are very different. The transcendent wisdom variably originates within the collective unconscious, the interdependent web of sentient beings, or the natural world and tribal heritage. These may represent specific affordances from the intuitive perspective. However, there are commonalities. Sidebar 2.7 Inner Wisdom Intuition and folk wisdom are important. They need to be balanced with science and rational thought to achieve optimal growth and development of learners. Training programs should consider providing access to mentors and time to practice one or more of these techniques.

In all of these traditions, modern culture, while containing many advantages, also overpowers traditional, historical, and intuitive wisdom and the great field of possibility. A new balance must be sought between modernity and deep inner wisdom, getting in sync with the natural rhythms of the earth, the cycle of life, and the insight of the generations. Lessons are primarily transmitted through nonverbal means— symbols, omens, rituals, dreams, and archetypes. They must be interpreted by our rational, language-based modern minds, and this requires quiet, attention, patience, and experience. By and large, the purpose of these transpersonal traditions is to further equanimity and help individuals develop their fullest potential. They also remind us of a possible “shadow” side to this wisdom, especially if not interpreted well or if taken in an instrumental or self-serving way. Example 2.4 (Meditation) As an example of the importance of these practices, I was working with several international medical graduates (immigrants and refugees) to help them get licensed to practice in the USA.  One common problem was “choking” during the certification exam, because of its importance in their life, and then not having time to finish the test. They asked about possible treatments, and I offered mindfulness meditation. Very few of them were familiar with this practice. We began each study session with a variety of 10-min meditations designed to recognize and control anxiety, and it worked quite well, allowing them to recognize their anxiety earlier and then take control of it through breathing practices.

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References Chah A. Everything arises, everything falls away. Boston: Shambhala; 2005. Hall CS. A primer of Freudian psychology. New York: New American Library; 1954. Hanh TN. Peace is every step. New York: Bantam Books; 1992. Hodge FS, Nandy K. Predictors of wellness and American Indians. J Healthcare Poor Underserved. 2010;22(3):791–803. Jean T. 365 Days of walking the red road. Aron, MA: Adams Media; 2003. Jung CG. Man and his symbols. New York: Dell; 1968. Jung CG. Memories, dreams, reflections. Ed. A Jaffe’. New York: Vintage Books; 1989. p. 160–1. Kabat-Zinn J. Wherever you go, there you are. New York: Hyperion; 1994. Kabat-Zinn J. Meditation is not what you think. New York: Hachette Books; 2018a. Kabat-Zinn J. Falling awake. New York: Hachette Books; 2018b. p. 3. Kimmerer RW. Braiding sweetgrass. Minneapolis: Milkweed Editions; 2013. Lake-Thom B. Spirits of the earth. New York: Plume; 1997. Ostaseski F. The five invitations. New York: Flatiron Books; 2017. p. 194. Painter E. Hózhó: the Navajo concept of balance and beauty; 2014. www.Quora.com. Accessed May 16 2020. Pascal E. Jung to live by. New York: Warner Books; 1992. p. 89. Peat FD. Synchronicity. The bridge between matter and mind. Toronto: Bantam Books; 1988. p. 81.

Part III

The Social Domain

1.1  IP Problem: Tacit Social Affordances Vignette: Each week, we held a seminar to discuss interprofessional challenges. One of our psychology postdocs was on an outside rotation, so she participated by speaker phone. Because she could not easily tell when to speak, she instead decided to adopt the role of process observer. She collected data about which profession spoke and for what percentage of the time. Initially, male physicians represented >80% of total speaking time. Once this data was fed back to the group, participant behavior changed to be more egalitarian. Humans are an inherently social species. We naturally congregate, work, and play together. We develop “ingroups” and “outgroups.” In interprofessional education, the behavioral norms, rituals, cultural “memes,” prohibitions, stereotypes, etc. contribute significantly to the functioning of the team: The community [is] a cultural one, formed not on the basis of explicit rules and regulations but out of a set of ethical habits and reciprocal moral obligations internalized by each of the communities members. These rules or habits give members of the community grounds for trusting one another. (Fukuyama 1996)

Also, the social environment and the natural environment are completely interdependent. Our social actions and behaviors have altered the natural landscape significantly: It is also a mistake to separate the cultural environment from the natural environment, as if there were a world of mental products distinct from the world of material products. There is only one world, however diverse, and all animals live in it, although we human animals have altered it to suit ourselves. (Gibson 1979/2015).

Social affordances are often tacit and difficult to discuss. Developing exercises to reveal them and make them safe for discussion is very important for interprofessional education. Examples 1.1 (seating arrangement), 1.4 (gamification), and 2.1 (flip chart exercise) are a few mentioned in earlier chapters that we found useful.

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I will not attempt to exhaustively cover the full range of social theories in this part. Instead, I will focus on the ones that have contributed the most to my understanding of interprofessional education. Example 3.1 (Organizational Culture Model) Our first venture into studying cultural differences and their effect on team function was to confirm Schein’s “Organizational Culture” model in a medical setting in a clinic that was rapidly changing to a “patient-centered medical home” (Smith et al. 2000). In this model, “operators” are the frontline staff who create the work product. “Engineers” design the processes by which the operator group delivers its products and services. “Executives” are far removed from the action; they rely on imperfect information and are responsible for the strategic survival of their organization. Quantitative analysis confirmed that this model agreed with the findings in a medical clinic.

References Fukuyama F. Trust. New York: Free Press Paperbacks; 1996: Gibson JJ. The ecological approach to visual perception, New York: Psychology Press, pp. 122; 1979/2015. Smith CS, Francovich C, Gieselman J. Pilot test of an organizational culture model in a medical setting. Health Care Manager 2000;19(2):68–77.

Chapter 13

Behavioral Settings

Have you ever wondered why the same person behaves so differently at a high school basketball game than in a library? Most of the affordances in human environments are human made, altering existing properties of the environment (Gibson, Gibson 1979/2015). These evolve to control social behavior, and they lead to a supervenient social level of affordances called behavioral settings. We do not behave the same way in a library as we do at a basketball game: same person, different behaviors. Barker (1968) studied behavioral settings as ecological units: self-­ generating, having a time-space locus, and self-creating an unbroken boundary that separates internal from external patterns (Ibid: 11). Behavioral settings are standing patterns of normative behavior within a particular surrounding milieu. The boundary of the setting coincides with the boundary of the behavior (e.g., gymnasium in the case of a basketball game). In Barker’s analysis, the boundary and the geographical range of behaviors have a specified degree of interdependence (mathematical correlation) in order to designate it as a behavior setting. This allows study of the coherence between structural and normative features of the environment and behavioral features of the individual. What is it about the structure and affordances of a library that allow/constrain us to whisper, while those of a basketball game allow/constrain us to scream loudly for the home team. Hamm (in Schoggen 1989) calls for greater recognition of: “the importance of behavior settings as vehicles of functional and social meanings and of symbolic meanings of historical experiences.”

How does this occur? Somehow, the behavioral outputs are triggered by the ecological inputs, but there is not a sequential, linear relationship. There are often simultaneous inputs, dead ends, and recursion (circular influences). A social input has a requiredness, or direction, with respect to the behavior of the receiver, and the person who provides an input selects the one from those available to him that he presumes, on the basis of experience or primitive theory, is most likely to be effective … The

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13  Behavioral Settings ensuing behavior of the recipient provides an immediate test of the correctness of the presumption (Barker 1968: 149).

The theory of affordances holds that the environment affords the possibility of action for the organism, not that it causes or stimulates action (Reed 1986: 108): The nonsocial, ecological environment does not demand behavior, it enters psychology only as permissive, supportive, or resistive circumstances (Barker 1968: 150).

The nature of these behavioral settings is that they are stable, have a time/space locus, occur at a collective level, self-generate a boundary, and have great coercive power over the behavior that occurs within them (Schoggen 1989: 14–20). Regulation of the behavioral setting occurs through physical components (e.g., a “speed bump”), human components (e.g., staffing ratio), or programmatic components (agendas, lesson plans, rules) (Ibid: 368–370). Engagement of the behavioral setting from the individual’s standpoint revolves around effort after meaning (locating an affordance, exploratory) and effort after value (utilizing the affordance, performatory) (Reed 1996: 102–106). Joint appropriation of affordances in the environment is critical to group learning. A triadic relationship that interpenetrates “my” environment, “other” environment, and the natural world is manifested through exchange and movement. This is not simply to utilize a resource, but is a joint exploratory movement, to “share parts of the environment with others and to discover what is persistent (so potentially an affordance) and what is changing (Ibid: 136–137). Coordinated movement becomes a sharing of the affordances of the environment: A culture is not something separate from individuals, nor can individuals be completely cut off from their cultures. To become an individual is to take one’s place within the local human environment, with its collective efforts after meaning and value (Ibid: 139). Sidebar 3.1 Behavioral Settings Behavioral settings are self-organizing and self-defining. They do not cause behavior; instead, they are permissive, supportive, or resistive to specific behaviors. They influence behavior through physical, human, and/or programmatic means. Coordinated movement allows the group to have joint efforts after meaning and value, and joint appropriation of affordances.

Let me offer an example that might make the importance of behavioral settings more understandable in the context of interprofessional education.

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Example 3.2 (Selecting Primary Care) Because of provider shortages, many primary care training programs try and increase the percentage of their graduates choosing rural primary care careers. In a study of contributing factors, our team identified that an elective 1-month block rotation in a rural office doubled the chances of going into rural primary care (Dick et al. 2011). Daily interactions with the same preceptor and exposure to the benefits of nonurban culture (i.e., skiing from your own backyard), both unique features of these behavioral settings, may contribute to these choices.

References Barker RG. Ecological psychology. Stanford, CA: Stanford University Press; 1968. Dick JF, Wilper AP, Smith CS, Wipf J. The effect of rural training experiences during residency in the selection of primary care careers: a retrospective cohort study from a single large internal medicine residency program. Teach Learn Med. 2011;23(1):53–7. Gibson JJ. The ecological approach to visual perception, New York: Psychology Press; 1979/2015, pp. 133. Reed ES. Encountering the world. New York: Oxford University Press; 1996. Reed ES. Seeing through history. Phil Soc Sci. 1986;(16);239–47. Schoggen P. Behavior settings. Stanford, CA: Stanford University Press; 1989. p. 254.

Chapter 14

Language: Ritual and Stories

Language is an effective tool that supports/constrains behavior through discourse, rituals, stories, and norms. The symbolic system of language is complex: Symbols cannot be understood as an unstructured collection of tokens that map to a collection of referents because symbols don’t just represent things in the world, they also represent each other (Deacon 1998).

Linguistic symbols, by virtue of the fact that they are a self-referential and recursive system, refer to things in the world largely using other symbols. This is important because Symbolic reference strips away any necessary link to … personal experience (Ibid: 451). The abstraction of language makes it powerful, allowing the sharing of cultural or historical knowledge that transcends personal experience and observation. It provides a nongenetic means of transferring behavior. However, We cannot help but see the world in symbolic categorical terms, dividing it up into opposed features, and organizing our lives according to themes and narratives (Ibid: 416).

Language, therefore, can act as a filter that makes categorization of the world more efficient, but it can also create “blinders” regarding other possible ways to see the world. This is very common in interprofessional education. One study examining discourses (socially constructed and perpetuated systems of written and spoken language) found at least two broad discourses (Haddara and Lingard 2013). The first, a utilitarian discourse, is focused on interprofessional collaboration as a means to achieve better patient care and outcomes. It uses language such as “evidence,” “outcomes,” “length of stay,” and “mortality.” This discourse uses standards derived from the classical model and may be more useful in standardized episodes of care (e.g., a “care plan” for hip replacement). The second, an emancipatory discourse, sees interprofessional collaboration as necessary to reduce physician dominance in healthcare. It uses language such as “power” “struggle,” “conflict,” and “collaboration” and is evidence of the differences in enculturation between the different © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_14

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professions. Clearly, attention to language and broader discourse will be important for interprofessional training. Example 3.3 (PCM Identifies Operational Problems) Here is an example that may clarify how specific language can help reveal differences in discourse and make them available for discussion. My research team created and validated a “perception-of-care map” (PCM) from recursive analysis and modeling of a large observational database (Example 1.8, page XX) (Smith et al. 2006). We found five main perspectives of care: structured care, educational care, relationship-based care, algorithmic care, and efficient care. Within each perspective, we created two individual statements, extracted directly from our earlier data, for sorting by order of importance to each subject. For instance, Structured Care Have the same doctor for more than 1 year. Let the patient know about the lab results. When this tool was used at five primary care sites, it successfully detected operational problems identified by an independent group from each clinic and demonstrated important differences in the perspectives favored by different professional groups (Smith et al. 2005). This provided a structure and strong empirical evidence for interprofessional discussion of recurring problems in these clinics.

Rituals Rituals are standardized sequences of meaningful action and are common in the health professions (e.g., handwashing). As Seligman et al. (2008: 4) state: The dominant [supposition] … has been a search to clarify the meaning of rituals, to show the ways in which their symbols encode and evoke systems of cultural discourse.

Rituals are often maintained by revered objects as placeholders. For instance, the ritual of the physical examination is partly sustained by the white coat, stethoscope, or reflex hammer. In these cases, the ritual simultaneously functions to designate the object as revered and show respect for the revered object (Collins 2004: 17). Furthermore, appropriate participation in the ritual has implications for group membership: The central mechanism … is that occasions that combine a high degree of mutual focus of attention, that is, a high degree of intersubjectivity, together with a high degree of emotional entrainment—through bodily synchronization, mutual stimulation/arousal of participants’ nervous systems—result in feelings of membership that are attached to cognitive symbols; and result also in emotional energy of individual participants, giving them feelings of confidence, enthusiasm, and desire for action (Ibid: 42).

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Ritual [is] a particular form of orientation to action, a frame that tells us how to understand actions like lighting a candle or sitting quietly in a chair (Seligman et al. 2008: 5).

Rituals generally have a mutual focus of attention and high emotional energy, and recursive participation in the ritual can increase “social capital”: There are two main aspects of [social capital]: shared trust among coparticipants …, and, more generally, a set of ground rules, customs, or procedures that define what the actors are doing and how they can expect each other to do it (Collins 2004: 165). What is important in interprofessional education is that there are often a number of “stuck” rituals among and between professions (e.g., nurses or pharmacists following “doctors’ orders”). Attention to revered objects and discussion of their importance and meaning can make the “stuck” rituals visible and allow discussion and growth (see Example 1.4, Gamification, where “physician” wears stethoscope around neck). Sidebar 3.2 Rituals Rituals are standardized sequences of meaningful action. Rituals are often anchored by revered objects. Proper performance of a ritual has identity and group membership implications.

Stories Stories, particularly coherent causative narratives, have a dominant place in interprofessional education and practice. Stories, a form of art, are the vehicles that evolved to function efficiently for explaining things, ordering interactions, and facilitating cooperation (Boyd 2009): “First … organisms evolve simple neural systems as they become sensitive to relatively constant sources of environmental information [affordances]. Second, animals develop minds that can respond to the less constant, more diverse features of the biological world in rough-and-ready ways, through networks of more or less modifiable modules, innate or developed through experience [expanding the life world]. Third, … human minds … in problematic or novel situations consciously attend to information and run inferences or scenarios that they asses through evolved emotional systems.” (Ibid, 48)

Stories have a structure that helps to order significant social information about what happened in an efficient way. This involves Events (actions, happenings) and Existents (characters, settings) in the “content” plane (Chapman 1980: 19). In addition, there is discourse about how/why events happen which: “establishes the norms of the narrative [which] are general cultural codes, whose relevance to the story we have already considered.” (Ibid: 149)

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Stories, then, are a natural way for humans to order events, existents, and norms in complex social situations in order to explain, judge, and predict actions: “We keep track of the personality of others, because doing so helps us to predict their behavior and plan our own” (Boyd 2009: 222). “Our minds automatically send information worth further processing up to our highest evolved mental systems, the social cognitive systems that track patterns of agents and actions” (Ibid: 233).

Stories are powerful. In real-life situations, matching a narrative (story) structure has been found to predict juror decisions better than either Bayesian or Boolean statistical methods as new facts are sequentially revealed (Pennington and Hastie 1998). Rituals and stories provide structure, order, boundaries, norms, and subjunctive (“as if,” “could be”) idealized forms (Seligman et al. 2008). It is clear, from this perspective, that identifying our existing rituals and stories, and recording our newly minted ones, is critical to group formation, regulation of behavioral settings, and cooperation in interprofessional education. Sidebar 3.3 Stories Stories represent an efficient way to list and order significant social information. They are critical to the formation of a functional group.

References Boyd B. The Origin of Stories. Cambridge, MA: Harvard University Press; 2009. Chapman S. Story and Discourse. Ithaca, NY: Cornell University Press. 1980. Collins R. Interaction Ritual Chains. Princeton, NJ: Princeton University Press; 2004. Deacon TW. The symbolic species: the co-evolution of language and the brain. New York, NY: W.W. Norton & Co; 1998. p. 99. Haddara W, Lingard L. Are we all on the same page? A discourse analysis of interprofessional education. Acad Med. 2013;88(10):1–7. Pennington N, Hastie R. The story model for juror decision making. In: Hastie R, editor. Inside the juror. The psychology of juror decision making. Cambridge, UK: Cambridge University Press; 1998. p. 192–221. Seligman AB, Weller RP, Puett MJ, Simon B.  Ritual and its consequences. Oxford: Oxford University Press; 2008. Smith CS, et al. Testing the exportability of a tool for detecting operational problems in VA teaching clinics. J Gen Intern Med. 2005;21:152–7. Smith CS, et al. Developing and validating a conceptual model of recurring problems in teaching clinic. Adv Health Sci Educ. 2006;11:279–88.

Chapter 15

Semiotics

American pragmatist philosopher C.S.  Peirce developed an influential theory of meaning-making. This theory, termed semiotics, contained two significant advances over the “standard” mind-body dualistic theories (Houser and Kloesel 1992). 1. Instead of the standard dyadic (mental-material) model, it was a triadic (sign/ob ject/interpretant) model (Fig. 2.1). 2. “Signs” are configured as one of the three types of tokens: iconic (similarity), indexical (physical/temporal connection), and symbolic (abstract convention, generalizable). The simultaneous triadic relationship of sign-object-interpretant is complex (Peirce 1903). For instance, in Fig. 15.1, the three arrows emanating from a single point are intentional and are designed not to reduce semiosis into three simultaneous dyadic relationships that could be suggested by lines between the components. Blunden states, “Signs do not occupy a separate reality from Objects or Interpretants, but all are interchangeable forms of reality distinguished only by their momentary role in some semiotic relation” (Blunden 2005). A simplified definition of the three components is as follows: Sign: Object: Interpretant:

A token that stands for the semiotic triad Focus of attention The significance of the S-O relationship

Peirce did not see the components of semiotic triads as individual elements and also did not see them as static, but rather as dynamic and iterative (Atkin 2013). By chaining up in “semiotic cascades”, he proposed a mechanism for translating internal, tacit, analog signals (e.g., emotion, proprioception, proto-category) to generalizable, explicit, digital (language) signals (Fig. 15.2). In the example shown in Fig. 15.2, the first perception is a bodily, emotional one (fear and anxiety). This iconic token leads to a proto-category “sick” (symbolic) and © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_15

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Fig. 15.1  The standard model of mind-body dualism (top). This model assumes brain representation of phenomena and correspondence between those representations and the “real” world. The semiotic model (bottom). Here, “signs” represent some aspect of the triggering “object” with an interpretation (often collective) of its significance or meaning Abdominal tenderness FAST exam + Low blood pressure, high pulse, cool, clammy, pale

O

S

Trauma Paent

S

O S Fear Anxiety

O

I “Shock”

I Internal Bleeding Exploratory Laparotomy

I “Sick” Needs rapid assessment

Fig. 15.2  An example of semiotic chaining. (See text for explanation)

a search for important clinical elements. Finding an abnormal physical examination and vital signs (indexical tokens) leads to a more sophisticated category “shock” (symbolic). In the symbolic realm, we can leverage abstract categories and generalizable causative rules. For instance, –– “Shock”  +  abdominal tenderness → need for a Focused Assessment with Sonography for Trauma (FAST) exam –– “Shock” + positive FAST → internal bleeding and need for emergency exploratory laparotomy

Biosemiotics

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Wiley’s Combination of Peirce and Mead Peirce’s view of semiotics was ultimately linguistic and future oriented, focusing on planning, anticipation, elaboration of knowledge, and hypotheses. Wiley (1994) integrated Peirce’s concepts with those of another pragmatist, G.H. Mead (1967), who focused on learning from experience. Wiley’s integration of past-present-future led to the concept of semiotic power, the energies that underlie and empower signs in order to create meaning. This also highlighted the importance of reflection, internal dialogue, and adaptation in the semiotic process. In the above example, the initial fear and anxiety may come from a prior patient that had similar warning signs but was not attended to fast enough and had a poor outcome. This reflection and learning-from-experience change actions in the present and models of the future.

Biosemiotics Both Peirce and Mead focused primarily on the linguistic realm. Hoffmeyer (2008) and others have extended semiotic insights into the broader biological realm (biosemiotics), leading to concepts such as semiotic niches and semiotic emergence. Biosemiotics necessarily leads to broader conceptualization of the sign, object, and interpretant. My version is seen below. Indicator (Sign): Affordance (object): Meaning (interpretant):

Becoming aware of a lifeworld signal Potential resource. Information when perceived, value when used Receptivity (attracted to/repulsed by). Includes history and possibility. Recognition of a “difference that makes a difference” (Bateson 1979)

The biosemiotic concept has also led to an awareness about the limited field of indicators or signs that any individual is attuned to. We have discussed this in earlier chapters as affordances and the lifeworld. It may well be that, in healthcare training, learning is the process of enriching this field of indicators so as to be better able to carry out recognition-primed decision-making, the mature process of problem-­ solving in novel and time-sensitive situations (Chap. 9). It consists of tacit pattern matching followed by evaluation using mental simulations (Klein 1999). These novel high-stakes situations are compared to prior situations, and the salient features, or lack of important features, become prominent (often tacitly). This leads to a hypothesis about the novel situation and a mental simulation of actions suggested by that hypothesis. These features of biosemiotics suggest specific guidelines for interprofessional training. In the case discussed in Fig. 15.2, it would be minimally useful to teach a novice the abstract (symbolic) rule “shock + positive FAST exam requires an exploratory laparotomy.” This decontextualized “fact” may not be retained or its

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nuance may be misunderstood without context. Instead, asking the trainee to reflect on whether they thought the patient was “sick,” how the patient made them “feel” (iconic approaches), or which clinical elements supported a hypothesis of “sick” (an indexical approach) will provide a scaffold for the downstream symbolic reasoning. Homo sapiens are apparently the only species that communicates using abstract symbols (Deacon 1998; Harari 2014; Hegel 1977). This allows us to interact about imagined things that do not exist in the physical-biological world such as laws, corporations, and theories, as well as plans, fears, and memories. In our attempts to understand multifaceted reality and to predict and control the future, we seek meaning. Because reality is complex, meaning is also complex. Humans are generally learning simultaneously at the nonassociative (habitual), associative (conceptual), and semantic (symbolic interaction) levels. Interpretation, representation, and meaning occur in these broad triadic biosemiotic relationships through following the rule (Wiley 1994; Hoffmeyer 2008; Deacon 1998; Singer 1984): Sidebar 3.4 Biosemiotics This influential model of meaning-making suggests a sign (or awareness thereof), an object, usually an affordance (the focus of attention), and the meaning (a publicly negotiated interpretation that connects the two). Signs can be one of the three types of tokens: iconic, indexical, and symbolic. Humans privilege abstract symbols, allowing interactions about imaginary entities (e.g., rules, theories).

Regularities → Recognition → Behavioral Change

References Atkin A. Pierce’s theory of signs. Stanford Encyclopedia of Philosophy; 2013. https://plato.stanford.edu/entries/peirce-­semiotics/. Accessed 19 Feb 2021. Bateson G. Mind and nature. A necessary unity. New York: Bantam Books; 1979. Blunden A.  Charles Sanders Peirce: the subject as semiosis. Philosophical Foundations; 2005. https://www.ethicalpolitics.org/ablunden/works/semiosis.htm. Accessed 19 Feb 2021. Deacon TW. The Symbolic Species: the co-evolution of language and the brain. New York, NY: W.W. Norton & Co.; 1998. Harari YN. Sapiens. A brief history of humankind. London: Vintage Books; 2014. Hegel GHW. Phenomenology of spirit. (Miller, A., Trans.). Oxford: Clarendon Press; 1977. Hoffmeyer J. Biosemiotics: an examination into the signs of life and the life of signs. Scranton: University of Scranton Press; 2008. Houser N, Kloesel C. The essential Peirce, vol. 1. Bloomington: University of Indiana Press; 1992. Klein G. Sources of power. How people make decisions. Cambridge, MA: MIT Press; 1999. Mead GH. Mind, self, and society. Chicago: University of Chicago Press; 1967.

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Peirce CS. Nomenclature and divisions of triadic relations, as far as they are determined. In: The Essential Peirce, Manuscript 21, Volume 2, The Pierce Project, editors. Bloomington: Indiana University Press; 1903. Singer M. Mans’ glassy essence. Bloomington, IN: Indiana University Press; 1984. Wiley N. The semiotic self. Chicago: University of Chicago Press; 1994.

Chapter 16

Revisiting Identity

I briefly visited identity in Chap. 7. Here, I will go into more depth. From the perspective of structural symbolic interactionism, the self and identity are related. Identity is the set of meanings that define who one is as an occupant of a particular role in society (Burke and Stets 2009: 3). The self originates in the mind of persons and is that which characterizes an individual’s consciousness of his or her own being or identity. The self has the ability to take itself as an object, to regard and evaluate itself, to take account of itself and plan accordingly, and to manipulate itself as an object in order to bring about future states (Ibid: 9).

Remember from Chap. 6 that there are two senses of self, the “me” or objective self and the “I” or subjective self. These are both internal to the person. This simultaneous objective/subjective stance is what allows reflexivity. Reflexivity is a key component of our individual–group function and, therefore, important to interprofessional education. According to Mead, The “self” grows out of the mind as the latter interacts with the environment to solve the problem of sustaining the biological organism (Mead 1967).

Identity has several components (e.g., male/female, father/mother, doctor, team leader), but they are all tied to the interaction between the individual and the group. Let me cover the main three identities—role, social, and personal—in more detail. But first, some general comments about symbolic structural interactionism are given. In this theory, for each identity, there is a control system with input (perceptions by ourselves and others), a comparison to a standard, and an output (social behavior). Unlike the typical view of a control system (e.g., thermostat), it is not trying to regulate the output (temperature in the case of a thermostat, behavior in the case of identity); rather, it is trying to adjust the output (behavior) to decrease any gap between perceptions and the desired standard (Burke and Stets 2009: 61–68). It is important to note that the identity differences I am about to describe are somewhat academic and analytic. In the real world, the boundaries are more fuzzy. Nonetheless, these distinctions can be helpful in understanding a given interprofessional training situation. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_16

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Role Identity Roles are specific positions within the social-structural milieu defined by action. In the case of interprofessional training, these might be “primary care provider,” “medication management,” “check-in and vital signs,” “mental health provider,” etc. Roles typically come with specific resources, opportunities, and expectations. The role identity is the internalized meaning of the role for the individual and has two components: role, the public set of expectations for this social position (conventional, defined by others), and identity, the individual’s understanding of what this role means to them (uniquely defined by the individual). Roles “provide structure, organization, and meaning to selves and to situations” (Ibid: 113). Importantly, roles cannot exist without counter-roles such as teacher/student, provider/patient, and leader/support (Ibid: 115). Thus, there is a dynamic between each of the agents in a situation. Each is dedicated to playing a complementary role, evaluating each other, and reacting to those evaluations. Internal identity standards for roles are specified in terms of competence. If the public feedback about the role performance validates the individual’s internal identity standard, it results in positive affect, increased self-efficacy, increased affinity with the group, and continuation of the same behaviors. If it does not, the individual will be less satisfied with their role and eventually change their behavior, detach from group activity, or leave.

Social Identity Social identity is membership in a group. In the case of interprofessional training, these could include “nursing service,” “University Medical Center,” “Republican,” or “outdoor enthusiast.” A social identity helps to increase uniformity (and thus predictability), to organize a situation, and to make sense of behavior. The social group is a fuzzy category with a central prototype. This prototype is not constituted of characteristics from the average group member but, rather, from the ideal group member (Ibid: 119). Individuals can have several social identity categories. The one which best organizes the situation and makes sense of peoples’ behavior becomes the activated category. For instance, although an individual may have social identities relative to gender, race, age, parenthood, or profession, it will likely be the “nurse” identity that is activated in most healthcare situations. Benefits of taking on a particular social identity include self-enhancement and uncertainty reduction. Drawbacks include problems stemming from “ingroup”/”outgroup” distinctions and pressure toward over-conformity. Internal identity standards for social identities are specified in terms of worthiness. Role identities are individual, having to do with me: “I am a trainee,” “I am the caregiver.” They are action oriented. Enacting the role identity integrates actions among complementary agents and helps to maintain social order. Social identities have to do with we: “We are nurses,” “We are the clinic team.” They are membership

References

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oriented, fostering conformity and predictability. Enacting these identities helps to predict and make sense of behavior.

Person Identity Both role and social identities are depersonalized. Part of their effectiveness involves generalizing or stereotyping the individual. Person identity is the opposite. It is based on culturally recognized characteristics that the individual has internalized as representing their own uniqueness. They are not predispositions, like personality traits, and are maintained by the perceptual control process just as the role and social identities are. Internal identity standards for person identities are specified in terms of authenticity. Does this behavior (role, social identity) feel authentic for me, for who I am? Sidebar 3.5 Identity Individuals have multiple identities. They try and stabilize them by adjusting behavior to minimize the difference between identity as perceived by self and others and internal standards. Role identity is based on the category of activity performed and is judged by competence. Social identity is based on group membership and is judged by worthiness. Person identity is based on unique characteristics and is judged by authenticity.

In all these identities, verification “is accomplished through the control of active and potential resources through the manipulation of meaning using signs [actual resources] and symbols [potential resources] in the situation” (Ibid: 127).

References Burke PJ, Stets JE. Identity theory. New York: Oxford University Press; 2009. Mead GH. Mind, self, and society. Chicago: University of Chicago Press; 1967.

Chapter 17

Boundaries and Bridges

Boundaries Humans create anonymous social groups larger than can be organized by personal knowledge of each individual (Bolender 2010). These are constituted by markers or suites of markers—characteristics that are passed between generations either by explicit teaching (e.g., manners, proper language, meaning of group symbols) or subliminally (e.g., gestures, personal space boundaries, speech cadence) (Moffett 2018). Markers are sustained by rituals. Group rituals have the dual roles of establishing group boundaries and also providing a mechanism for transcending them: “the performative aspect of ritual is critical because ritual addresses the relational aspects of role, and of self and other. Ritual both posits boundaries and allows the move between boundaries. By recognizing limits, ritual provides as well the vehicle for transcending them” (Seligman et al. 2004).

Thus, boundaries can accentuate differences and can cause tension. Once boundaries are established, they can also lead to confusion about individual versus group traits: “When an individual perceives someone else to be a member of an out-group, that person will tend to react more to perceived group characteristics than to the other person as an individual. Stereotypes and prejudice occur more frequently in this scenario” (italics in the original) (Allen 2011).

Individuals are aware of these stereotypes about their own profession. This awareness is the first step in “stereotype threat,” worry about performing according to the stereotype, that can lead to “choking.” This occurs due to the cognitive load of energy devoted to vigilance, rumination, self-doubt, performance monitoring, and suppression of negative thoughts (Steele 2010). Knowledge and know-how are the tacit knowledge embedded in brains and networks of people (Hidalgo 2015: 79). Groups are knowledge/know-how amplifiers, containing more information than an individual could. Group size is limited by the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_17

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cost of linkages: transactional costs (communication, transportation) and relational costs (trust, social capital). Sometimes, the group gets large enough that optimization requires specialization. Loosely linked team structures encourage horizontal communication, with functional boundaries that are more porous and adaptable. This requires trust. Without trust, groups compensate by being more hierarchical (Ibid: 119). Boundaries between health professions can manifest as hierarchy, power differentials, in-group–out-group dysfunction, and inequalities in resource distribution. This centrifugal force, pushing groups apart, creates significant difficulty for interprofessional education and teamwork (Hall 2005; Paradis and Whitehead 2015): “different professions … work together but the subtleties, the mechanisms, and the understanding of interprofessional working in a team is not always present in their thinking. Furthermore, power struggles, ideological and theoretical differences add to the challenges for the team.” (Reeves et al. 2010: 37)

Our team studied the boundaries created by profession-specific discourse (see Fig. 17.1, from Smith et al. (Smith et al. 2015), with permission). We found that physicians and pharmacists adopted a mechanistic discourse (empirical for physicians and therapeutic for pharmacists). Nurse practitioners (NPs) and psychologists adopted a relational discourse (caring for NPs and conceptual for psychologists). This leads to differences in the presumed basis for truth: empirical observation for physicians and pharmacists, theory for psychologists, and context/beliefs for NPs. These differences presumably come from variance in temperament, training milieu, and common within-group narratives. Trust and fear are an oppositional dynamic that poses significant barriers in interprofessional education. It must be addressed and mitigated. The biological archetype of “stranger” is an unpredictable quantity that is differentially perceived according to cultural practices as “contaminating” or “enriching.” Seeing enrichment leads to appreciation of diversity. Seeing them as “contaminating” can lead to wariness or fear. All too often, this gets culturally amplified from stranger/fear to enemy/hatred. Fig. 17.1 Conceptual model of each profession’s approach to patient care. (Original available at www.tandfonline.com)

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Sidebar 3.6 Boundaries Imagined strict boundaries between categories are a deep human instinct. Stereotypes can decrease the cognitive load associated with dealing with an individual, but risk conflation between the individual and group level. Boundaries also support hierarchy, power differentials, and inequalities. Stereotypes are common in healthcare training.

Example 3.4 (Organizational Cultures as Barriers) We applied Schein’s concept of “organizational cultures” to our training clinic. We found that frontline clinicians, process designers (e.g., local software developers), and executives had conflicting views about workload, appropriateness of resource allocation, and value of guidelines (Smith et al. 2000). These conflicts demarcated value boundaries between these groups.

Bridges Countering this centrifugal force due to differences is a centripetal force of affiliation. For instance, recurrent interactions with a stable group can change behavior: “The very possibility of achieving stable mutual cooperation depends upon there being a good chance of a continuing interaction.” (Axelrod 1984: 16)

Cooperative behavior is more likely if you are nice (never defect first), your rules of behavior are clear, you retaliate quickly for an uncalled-for defection (timely feedback), and you are forgiving (no overreaction) (Ibid: 20). The concept of communities of practice is based on an apprentice model of learning and may also support team cohesion (Lave and Wenger 1995; Wenger 1999). In this model, the learner is legitimate (sanctioned) and peripheral (close to the expert performance of the task) and participates in an authentic part of the task commensurate with their knowledge and skill. For instance, a student in the emergency room during a “code blue”: 1. Is part of an expected curricular rotation (legitimate) 2. Is near the expert performance of life support (peripheral) 3. May draw blood for analysis (participates), a level commensurate with skills

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Sidebar 3.7 Bridges The following can mitigate the negative effect of boundaries: –– –– –– –– –– ––

Recurrent interactions between individuals Shared goals Achieving stakeholder and organizational support Proximity to group role modeling and expert performance Safe, protected time for authentic dialogue about stereotypes Joint creation of “boundary objects”-artifacts representing the processes and knowledge involved

Designing and nurturing distributed learning communities of practice, such as interprofessional education, require additional attention to four areas in order to support affiliation (Wenger et al. 2002): (1) stakeholder alignment, (2) structure that promotes local variations and global connections, (3) social and communication structures that promote team identity and visibility, and (4) systematically developing the private space of the community. Empirical studies of successful teamwork suggest that it is important to have a collective identity, shared goals, clear process guidelines, open communication about expertise-based knowledge, and “boundary objects”, tangible representations of knowledge such as drawings and prototypes that facilitate boundary crossing (Edmondson 2012). A good example of a boundary object is the colored flip bars above the patient room door used in many ambulatory clinics. These facilitate a smooth flow of labor among professions as each task is accomplished (check-in, vital signs, examination, procedures) by different professionals and the corresponding bar is flipped, signaling to everyone where the patient is in the visit process. In studies of interprofessional health training, key elements for successful interventions include champions from each profession, professional and organizational support, and team-wide role modeling (Reeves et al. 2010: 133). Example 2.5 from the summary of Part II on page XX (high-risk care conference) is a great example of how building bridges between professions can lead to real improvements in care.

References Allen BJ. Difference matters. Communicating social identity. Lon Grove, IL: Waveland Press; 2011. Axelrod R. The evolution of cooperation. New York: Basic Books; 1984. Bolender J. The self-organizing social mind. Cambridge, MA: MIT Press; 2010. Edmondson AC. Teaming, how organizations learn, innovate, and compete in the knowledge economy. San Francisco: Jossey-Bass; 2012. Hall P. Interprofessional teamwork: professional cultures as barriers. J Interprof Care. 2005;Suppl 1:188–96. Hidalgo C. Why information grows. New York: Basic Books; 2015.

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Lave J, Wenger E.  Situated learning. Legitimate peripheral participation. Cambridge, UK: Cambridge University Press; 1995. Moffett MW. The human swarm. How our societies arise, thrive, and fall. New York: Bantam; 2018. Paradis E, Whitehead CR. Louder than words: Power and Conflict in Interprofessional Education Articles, 1954-2013. Med Educ. 2015;49:399–407. Reeves S, Lewin S, Espin S, Zwarenstein M. Interprofessional teamwork for health and social care. Chichester, UK: Wiley-Blackwell; 2010. Seligman AB, Weller RP, Puett MJ, Simon B.  Ritual and its consequences. Oxford: Oxford University Press; 2004. Smith CS, Francovich C, Gieselman J. Pilot test of an organizational culture model in a medical setting. Health Care Manager. 2000;19(2):68–77. Smith CS, et al. Professional equipoise: getting beyond dominant discourse in an interprofessional team. J Interprof Care. 2015;29(6):603–9. Steele CM.  Whistling Vivaldi. How stereotypes affect us and what we can do. New  York: W.W. Norton & Co.; 2010. Wenger E. Communities of practice. learning, meaning, and identity. Cambridge UK: Cambridge University Press; 1999. Wenger E, McDermott R, Snyder WM.  Cultivating communities of practice. Boston: Harvard Business School Press; 2002. p. 123–4.

Part IV

Nonlinearity

1.1  IP Problem: “Either/Or” Thinking Vignette: An interprofessional group of learners has decided to form a study group. A (male) physician steps forward to suggest that they identify their goals. The (female) pharmacist wonders aloud, “Why are the doctors always in charge?” The group discusses this. Some believe that physicians have more training in leadership and group dynamics (Expertise). Others state that doctors are no different than the rest of them but have been socialized to expect to be in charge (Entitled). The group initially interacts as though this is an “either/or” categorical determination. Then, someone points out that every one of them has individual expertise AND has acted entitled at times, suggesting more of a “both/and” nuanced approach. They come to the conclusion that expertise-entitlement are two sides of a larger coin that might be called “capability” or “status.” The group agrees to try to always match an individual’s talent to the task at hand, transparently discussing that person’s strengths and the coordinated action required, rather than making a categorical assumption based on their profession. Predicting this match turns out to be very difficult. You have already gotten a hint of how affordances, lifeworlds, and behavioral settings are comprised of complex interactions, self-referential connections, positive and negative feedback loops, and emergence at different levels. Trying to understand these dynamics is important to help us with expectations, planning, and measurement. In this section, we will address these traits head-on and demonstrate why they make interprofessional training so unpredictable and difficult to control. We will see that, because of this nonlinearity, it is difficult to rely on a cookbook approach or a one-size-fits-all recipe for designing, implementing, and measuring interprofessional education. Nonetheless, we will find that some variables are critical to outcomes, and they seem to reveal the deep laws promised by critical realism. We will see that certain behaviors, such as “ringing” (rapid cycling of data that does not settle down quickly), may portend an upcoming radical state change or “tipping point.” Finally, we will identify some order between rigidity and chaos.

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Example 4.1 (Nonlinear Diagnostic Development) My team conducted a study of diagnostic reasoning across the medical training continuum (Smith et al. 2014). A cognitive landscape map showed a critical fold that generated nonlinear problem-solving behavior (see Fig. 1 and description).

Fig. 1  A cognitive landscape map showing a critical fold, typical learner trajectory (in red), and a critical state change that occurs for faculty with a combination of experience and cognitive off-­ loading. (Reproduced from Smith et al. 2014: 265 with permission)

This landscape map demonstrates that first- and third-year medical students handle increasingly complex cases with increasing experience. As second-year residents, they are largely still solving problems analytically, but they are increasingly “cognitively off-loading,” using chunking of information in general rules and prototypical memories to decrease the amount of “bits” (separate informational items) being handled while problem-solving. Faculty, with further experience and cognitive off-loading in their area of expertise, have made a “critical state transition” from analytic reasoning to intuitive problem-solving (F1). Faculty faced with a problem for which they have less experience (F2) jump back up to analytic reasoning.

Reference Smith CS, Hill W, Francovich C, Morris M, Robbins B, Robins L, Turner A. Diagnostic reasoning across the medical education continuum. Healthcare. 2014;2:253–71.

Chapter 18

Complex Adaptive Systems

In this chapter, I will focus my discussion on three main characteristics of dynamical complex systems: self-organization, emergence, and stratification (Wheeler 2006: 155).

Self-Creation Many dynamical complex systems are self-organizing, ranging from chemical reactions to galaxies (Nicolis and Prigogine 1989). Biological systems go beyond self-­ organization to include self-reproduction. Principles of living systems were described in 1972 by Chilean biologists Varela and Maturana (1972). Their description now appears to apply to many levels of open, dynamical, complex biological systems—from cells to societies. Six key elements comprising these systems (Capra 2000; Capra and Luisi 2015; Maturana et al. 1995) are the following: 1. Through normal operation, they establish a boundary. 2. Inside the boundary, they control internal organizing relationships. 3. Their current structure dictates their current behavior. 4. Outside the boundary, they exchange resources with the environment through structural coupling. 5. Internal structure can be changed in response to perturbations from outside. These changes cannot be determined, only triggered, by influences from outside. 6. Structure has more degrees of freedom than organizational relationships. Establishment of a boundary is critical to compartmentalizing operations. These boundaries might be the cell wall, skin, ego-self, tribe, or culture. By preserving internal organization, each entity establishes what type it is (housefly, human, corporation). For instance, if they have a single gut running their length, male and female gonopores, 22 segmental nerves, and multiple aortic arches that function as © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_18

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individual hearts, and all are appropriately connected, they are an earthworm. This will be conserved as the worm grows and changes unless irreparably disturbed. Current structure dictates current behavior means that behavior is structure determined. For instance, having two legs allows walking and running. Having four allows walking, trotting, and running. Having prehensile grasp allows certain tool use. Having a specific tongue and glottal structure allows speech, and so on. Adjusting internal structure, and thus the behavioral repertoire, forms one basis for learning. Structural coupling is extremely important. At its core, structural coupling is the act of creating a relationship. Every organism has features that they attend to (affordances, see Chap. 1), what the “environment” contains for them, creating unique organism-environment relationships. Basically, they are the important elements in the environment that afford the opportunity to be a resource and these elements select for behaviors. Structural coupling differentiates over time and forms the basis of development from novice to expert. With continued experience and reflexivity, we detect more affordances, discern more subtle differences between them, and develop an ever-broadening tree of potential structural coupling. Much of the internal organization and external lifeworld for biological systems consist of information. As Hidalgo (2015) states: “what makes our planet special is not that it is a singularity of matter or energy, but that it is a singularity of physical order, or information. Our planet is to information what a black hole is to matter and what a star is to energy.”

To understand information, we need to review a bit about system states (Ibid: 28-29). Equilibrium states can be either static or dynamic. Hidalgo’s example of a static state is dropping a marble into a bowl. After rolling around a bit, it settles to the bottom. A dynamic steady state could be a drop of ink in water. Once the ink diffuses, the molecules are not all resting in a fixed position (like the marble); they are moving. A steady state is reached when the number moving right to left equals the number moving left to right. His example of a nonequilibrium steady state is a whirlpool in a river. To maintain its orderly pattern, it requires a flow of material and energy. Hidalgo says that information emerges naturally from these nonequilibrium physical systems (Ibid: 32): “Self-organizing states … are rich in correlations, are less dissipative than transient states, and produce the physical order that is a prerequisite for life.”

Importantly, a biological system of enough complexity can structurally couple not only to the environment but also back onto itself. This creates the substrate for reflection on the consequences of actions, self-monitoring during conversation, and other complex behaviors. This reflexivity, based in language, creates a new level of complexity for human systems—agency: “Other living systems are deterministic through structural coupling – humans – living in language – are capable of getting beyond structural determinism to responsibility for their actions” (Maturana and Poerkson 2004).

Emergence

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This dynamic control creates an opportunity to break free from current structurally determined behavior by intentionally changing internal structure in a goal-­ oriented direction (learning). Sidebar 4.1 Self-Creation Humans are autonomous, steady-state, open systems that create and use specific information (affordances) from their lifeworld to thrive. Each person attends to different affordances and, therefore, has different knowledge and perspective.

Finally, structure has more degrees of freedom than organizational relationships. This means that structure (and thus behavior) can change without changing the type of entity it is (organizational relationships).

Emergence Another critical feature of complex dynamical systems is emergence, the creation of new features or properties appearing from an ensemble of individuals. Emergence is what makes “the whole greater than the sum of the parts” and what makes dynamical complex systems nonlinear and, thus, unpredictable. As stated earlier, this is not magic. No new parts are added to create the emergent property. It is simply a rearrangement of the relationships between the constituent parts, something like a phase shift from solid to liquid and to gas as energy flows into a water system: “Phases [of matter] are a primitive and well-studied case of emergence, one that conclusively demonstrates that nature has walls of scales: microscopic rules can be perfectly true and yet quite irrelevant to macroscopic phenomena (Laughlin 2005).

Individual elements in an ensemble are recursively connected, causing self-­ referential loops that create positive and negative feedback. The system has symmetry-­breaking bifurcations, where equally valid alternatives coexist. Taking a sequence of these bifurcations creates a unique history of choices over time. Bhaskar (1997) has stated: [emergent wholes] “are real because they are causal agents capable of acting back on the materials out of which they are formed”

However, not just any rearrangement of relationships leads to emergence. This bidirectional integration and influence (coupling) between the parts and the emergent whole must have a resonant character called imbrication to sustain the system. Parts and wholes must become mutually stabilizing; parts supply material, energy, and information; wholes provide boundary conditions, enabling conditions and constraints. So not all collections of parts come together to become functional supraordinate wholes. How does this work?

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One fruitful way to conceptualize this is as a phase space, a multidimensional surface on which all possible behaviors of a system are represented. This surface has peaks, valleys, and ridges that supply boundary conditions driving behavior (e.g., rolling down from a “ridge” to a “valley”). Within these phase spaces are attractors, areas where the behavior of the system tends to congregate (“valleys”). The system exhibits tendencies that constrain behavior but not deterministic laws that allow specific prediction. The attractors influence system behavior over a wide range of parameters. However, if things stray (or are pushed) too far, the system may jump into a nearby attractor basin (next “valley”), undergo a state change, and become a different type of system. Behavior may alternate (a bistable system, such as predator/prey numbers year by year) or show a symmetry-breaking bifurcation that causes irreversible change (e.g., a caterpillar to a butterfly): “a space with multiple attractors breaks the link between necessity and determinism, giving a system a “choice” between different destinies and making the particular end state a system occupies a combination of determinism and choice [italics in the original]” (DeLanda 2005).

The overall drivers of state change in phase space are coordination variables and control parameters. Coordination variables are the elements within the system that are driven by the control parameters. They evolve according to dynamical (usually mathematical) laws. Each stratum of the system has many variables, but only relatively few coordination variables. Control parameters are “naturally occurring environmental variations with a specific type of functional information” that lead the system through state changes (Kelso and Engstrøm 2006: 118). They control the spontaneous recruitment/annihilation of sub-systems in order to optimize performance (Ibid: 83). Control parameters come from the surrounding context, and coordination variables are within the system and are driven by control parameters. It is not a control parameter unless it can lead to qualitative changes in behavior. For instance, a horse changes its gait from walk to trot to gallop to optimize oxygen consumption at different speeds. This is achieved through relatively sudden changes within otherwise stable phase relationships between limb movements (Kelso 1997). Desired speed is the control parameter, and change in phase relationship between limbs is the state variable. As another example, the control parameters for changes from solid to liquid to gas (coordination variables) in water are temperature and atmospheric pressure. Sidebar 4.2 Emergence Interaction between components can create new features in the system as a whole. The relationships are nonlinear, and this leads to unpredictability. Once created, these supraordinate features can feed back to facilitate/constrain the lower level components. If the relationships are mutually stabilizing (imbrication), the new entity will endure.

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Example 4.2 (Huddles) One of our sister interprofessional institutions (San Francisco) addressed the complex emergence that occurs in ambulatory clinic with preclinic “huddles” (Shunk et al. 2014). Changes in staffing (due to illness or transfer), in trainees (due to absence or a competing rotation), or in the patients themselves (“no shows,” new or different problems) cause unpredictable changes in operations. Using scheduling, checklists, contingencies, and designated huddle coaches, they created a structured means of responding to changes and organizing the upcoming half-day. Both team process and relationships improved.

In summary, emergence is responsible for new features in the system, for creativity, and for unpredictability. Not every rearrangement of parts can create an emergent whole. The relationship between parts and whole must be mutually reinforcing and is governed by dynamical relationships: damping and co-resonance.

Stratification Our minds, as we saw in Chap. 8, are actually more like two very different but integrated minds. Perhaps because of this, we have a tendency to see things in contradictory pairs, such as particle-wave, structure-function, energy-matter, or yin-yang. However, these contradictory pairs are almost always resolved at a higher conceptual level as complementarities (such as the expertise-entitlement discussion in the vignette, discussed further in this chapter) (Kelso and Engstrøm 2006). As self-­ creation and emergence operate, different interconnected levels or strata emerge. Each level has its characteristic timescale and resonance (preferences, tendencies, predispositions). Levels can be bound together (coupled), although maybe just transiently, into a coherent network forming cross-scale reinforcement (imbrication). So what causes coherent coordination across these strata? The control parameters and coordination variables mentioned above can lead to absolute coordination, such as hand clapping after a performance, or relative coordination, where elements lock in only transiently and then break away from one another again, like a child walking hand-in-hand with a parent on the beach (Ibid: 141). This tendency to coordinate— transient, metastable, and phase coherence—is a crucial feature of coordination dynamics and is represented by rapid creation and dissolution of neural assemblies (Ibid: 145–148). In interprofessional healthcare, this is especially important because of the degree of uncertainty and interdependencies between professions in our work. Gittel (2009) suggests focusing on relationships between roles rather than individual people, using a “relational coordination” model with four components: (1) include the personhood of the participants, (2) affect and emotion are important components of these relationships, (3) relationships occur in the context of

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reciprocal influence, and (4) the formation and maintenance of genuine relationships are mutually valuable. Coordination variables (or control parameters for that matter) cannot be formulaically identified. One selects the level of interest. Then, supraordinate levels provide information about constraints, and subordinate levels about likely coordination variables. These will be identified through intuition and empirical confirmation. Significant long-term cohesion across strata can create a panarchy. Allen and Holling (2008) define this as: “Panarchies are hierarchically arranged, mutually reinforcing sets of processes that operate at different spatial and temporal scales, with all levels subject to an adaptive cycle of collapse and renewal, and with levels separated by discontinuities in key variables. Dominant processes entrain other processes to their spatial and temporal frequencies. This entrainment (an interaction among process and structure dominated by one or a few processes within a range of scale) produces discontinuities (gaps) and aggregations (clumps) in … complex systems.”

Perhaps, an example will help clarify these last three sections. The example involves individuals, a spontaneously formed study group, and the broader educational organization (context), all parts of a possible panarchy.

Example 4.3 (Another Study Group Example) In this example, individuals have decided to join a study group. They have formulated goals and planned actions to achieve those goals. Their educational affordances could include books, online offerings, teachers, other students, and clinical experiences. They also have personal histories that affect their self-perceived agency and tendency to affiliate. The structure and behavior of the group will have regularities but will also be influenced by random events. At the local individual level, members will make the decision whether or not to join based on their own needs and the perceived benefits of group membership. They must then coordinate actions, meaning, and goals. They adjust to one another’s interpersonal styles, create roles and a division of labor, and develop a plan for action (Arrow et  al. 2000). Once they begin studying together, they develop second-order emotions toward each other such as trust. Trust is a good candidate for a state variable (Fukuyama 1995). It is an externally defined variable “attached” to an individual’s identity. Once the study group gets started, new elements emerge at the group level. These include status, an element that cannot exist without a group and which emerges spontaneously and non-deterministically. These levels are mutually reinforcing. Trust and coordination are necessary elements for status to emerge. Hierarchy and peer pressure facilitate or constrain individual behavior. Status might be a good candidate for a state variable (group level) that is interrelated with trust (individual level).

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The structure and tone of the educational organization, at the next higher level, further affect function. Elements that emerge at this level include resource flexibility (space available, time for dialogue), coordination of schedules, and political/economic competing demands for clinical productivity. Time allotted for dialogue could be a control parameter, closely related to trust, status, and overall group performance. In this model, the more time you have for dialogue, the more trusted you become, and the greater status you enjoy.

Designing for optimal interprofessional learning involves (1) freedom for trainees to choose their optimal learning modality, (2) processes that tend to equalize natural hierarchies, (3) feedback about chosen performance measures, and (4) protection from productivity demands (at least initially). Sidebar 4.3 Stratification Stratification is natural in groups. Higher levels should integrate the complementary nature of components at lower levels. In interprofessional education, special attention should be focused on trust, status, and peer pressure.

In complex adaptive systems, multiple and recursive interconnections, structural coupling to oneself, level-crossing feedback loops, a tangled hierarchy, and flow of energy and information can resonate with the system as a whole. This has forcing effects at all levels. Each level is changing all the time, and this should significantly change teaching and program evaluation. Here are several exemplary descriptions: “The undeniable consequence … that the old mechanical view of causation, of external forces acting on inert particles of matter, is dead. Physics now recognizes that natural processes cannot be described in these terms and that the phenomena we see in nature are expressions of a deeper reality in which apparently separate entities are united in subtle but well-defined ways” (Goodwin 1994). “The point to emphasize here, though, is that … the living world is a vast interconnected, interdependent web of relations—a complex whole in which emergence produces different strata of beings with generative fields which are complexly interwoven” (Wheeler 2006: 73). “Most of us agree that individuals exist and that they have causal powers that enable them to bring about change and to transcend social expectations. The critical realists believe that this also holds true for society. Since society cannot be observed as such, a perceptual criterion of ontological existence cannot be used. Instead, Bhaskar and colleagues rely on a causal criterion of existence and argue that society and/or different social strata have a real ontological existence to the extent that they are causally efficacious: “their causal power establishes their reality” [italics in original] (Hedstrom 2005).

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18  Complex Adaptive Systems “The realist account starts … in human exchanges with the natural world ... We bring the effects of our natural encounters to our social ones … In society the cultural realm is deeply stratified … structural properties do not need to be discursive [language-based] at all in order for their powers to be causally efficacious” (Archer 2000). “Species [and I would say professions] co-existing in the same habitat do so on the basis of niche differences … ecological realism is realism defined at nature’s ecological scale in a niche-specific way” (Turvey 1992).

Because the human world consists of physical and social influences, there are also two sources of complexity in the realist model (Hood 2011). Intransitive causation (causal, mind-independent complexity) occurs between the real causes (underlying, non-observable causal mechanisms) and actual events (all events, perceived or not). This is complexity that comes from how causal tendencies actually combine to manifest themselves in events. Transitive causation (hermeneutical, culturally interpreted complexity) occurs between the actual events and the empirically observed events themselves and relates to how events are explained and which conceptual theories are competing for those explanations. Here is an example that demonstrates the difference. Example 4.4 (Fire and Rust) Fire and rust have been conceptually related for more than 400 years. Early chemists believed that there was a colorless, odorless substance—phlogiston—that was intrinsic to the materials and was released, rapidly in the case of fire and slowly in the case of rusting. Once chemical elements were discovered, the theory changed from release of phlogiston to the uptake of oxygen (oxidation). There is a real, intransitive phenomenon going on that causes observable events, fire and rust. The cause of that phenomenon is unavailable to our direct perception, happening at an atomic level. Only its effects (empirical events) are visible. Then there are theoretical transitive explanations of these events, occurring between actual events and empirically perceived events. In the one case, there is release of an undetectable substance called phlogiston. In the other case, there is exchange of energy and the relationship between electron orbitals in oxidation. The phenomenon is intransitive and occurs in the physical world. The explanations are transitive and occur in the social world.

In critical realism, all levels (empirical, actual, and real) are multifactorial, dynamic, and mutually influencing. They interact across multiple different timescales. Presumably, oxidation has changed very little in the span of human history. But the explanation has changed dramatically. Both the real causes and interpretive theories demonstrate cross-level influences.

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References Allen CR, Holling CS.  Discontinuities in ecosystems and other complex systems. New  York: Columbia University Press; 2008. p. 3. Archer MS. Being human. The problem of agency. Cambridge, UK: Cambridge Univ Press; 2000. p. 116–7. Arrow H, McGrath JE, Berdahl JL. Small groups as complex systems. Thousand Oaks, CA: Sage publications; 2000. p. 42–3. Bhaskar R. A realist theory of science. London: Verso: Routledge; 1997. p. 12. Capra F. The Tao of physics, 25th Anniversary Edition. Boston: Shambala; 2000. Capra F, Luisi PL. The systems view of life. Cambridge, UK: Cambridge University Press; 2015. DeLanda M. Intensive science and virtual philosophy (continuum impacts). New York: Bloomsbury Academic; 2005. p. 35. Fukuyama F. Trust. New York: Free Press Paperbacks; 1995. Gittel JH. High performance health care. New York: McGraw Hill; 2009. Goodwin B. How the leopard changes its spots: the evolution of complexity. London: Weidenfeld & Nicolson; 1994. p. 160–1. Hedstrom P. Dissecting the social. Cambridge, UK: Cambridge University Press; 2005. p. 72. Hidalgo C. Why information grows. New York: Basic Books; 2015. Hood R.  A critical realist model of complexity for interprofessional working. J Interprof Care. 2011;26:8. Kelso JA. Dynamic patterns. Cambridge, MA: MIT Press; 1997. p. 71. Kelso JA, Engstrøm DA. The complementary nature. Cambridge, MA: MIT Press; 2006. Laughlin RB. A different universe. Reinventing physics from the bottom down. New York: Basic Books; 2005. p. 35. Maturana H, Poerkson B. Being to doing. The origins of the biology of cognition. Heidelberg: Carl-Auer; 2004. Maturana H, Mpodozis J, Letelier JC. Brain, language, and the origin of human mental function. Biol Res. 1995;28:15–26. Nicolis G, Prigogine I. Exploring complexity. New York: Freeman & Co.; 1989. Shunk R, Dulay M, Chou CL, Jansen S, O’Brien BC. Huddle-coaching: A dynamic support intervention for trainees and staff to support team-based care. Acad Med. 2014;89(2):244–50. Turvey M.  Affordances and prospective control: an outline of the ontology. Ecol Psychol. 1992;4(3):310. Varela F, Maturana H. Mechanism and biological explanation. Philos Sci. 1972;39(3):378–82. Wheeler W. The whole creature. London: Lawrence & Wishart; 2006.

Chapter 19

Complementarity

The concept of complementarity originated in physics with Bohr’s explanation of quantum mechanics (Bohr 1937). Complementary pairs, such as wave-particle, have the property in quantum theory that they are both valid perspectives; you cannot employ them simultaneously, and you need both of them for a complete description of a system (Caroll 2019). Unlike large-scale (macro-state) phenomena, such as billiard balls colliding, where these notions would be incompatible rather than complementary, entities at micro-state scale reveal unique interconnections and relationships. In macrophenomena, it is assumed that the observer and the measuring instrument are independent systems obtaining objective measurements without affecting the observed object. In quantum, at least in the Copenhagen version, the objects of interest, measuring device-observer, are inextricably linked (entangled): Only the “totality of the phenomena” together can provide a completely informative description (Bohr and Rosenfeld 1996).

Furthermore, Bohr believed that the concept of complementarity was generalizable: The lessons taught us by recent developments in physics … leads us to a general epistemological attitude which might help us to avoid apparent conceptual difficulties in other fields of science as well (Bohr 1937: 289).

And in the broader realm, Both modes of description, though formally incompatible, must be a part of the theory, and truth is discovered by studying the interplay of the opposites (Pattee 1982).

One should not interpret this necessity of two formally disjoint modes as implying either a contradiction … or that the system under observation is composed of [a mix of] polar opposites (Turvey 2019). The parallels between modern physics and Eastern mysticism have been noted before (Capra 1999):

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_19

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Chinese sages represented this complementarity of opposites by the archetypal poles of yin and yang and saw their dynamic interplay as the essence of all natural phenomena and all human situations (Ibid: 160). The Tao Begets one. One begets two. Two begets three And three beget the ten thousand things The ten thousand things carry yin and embrace yang. They achieve harmony by combining these forces (Feng and English 1991/1972).

We have the option of conceptualizing a system in discrete (symbolic) terms that are digital or in continuous (dynamic) terms that are analog (Turvey 2019: 282–284). However, A complex system does not have the option of operating in either the symbolic mode or the dynamic mode. In must operate in both modes, and often concurrently (Pattee 1987).

Example 4.5 (Digital and Analog Codes) Take DNA translation to protein as an example. The primary structure of the protein is the sequence of amino acids, linked by covalent bonds, which is dictated by the sequence of nucleotide bases being translated from DNA. This follows a discrete, symbol code (digital) and is quite stable. Once the protein string is created, more complex secondary and tertiary structures are formed as the individual amino acids interact through non-covalent “weak forces” (electrostatic, hydrogen bonding, etc.) forming the complex three-dimensional structure that gives proteins their functional capacity. These continuous, dynamic (analog) structures are more changeable, and the shape can be modified by receptor interaction or solvents (Turvey 2019: 282–284).

You recall from Chap. 4 (Critical Realism) that an assemblage of parts organized in the correct way can lead to an emergent whole, where parts and whole have an inter-causal impact on each other that stabilizes the arrangement due to many shortand long-range correlations. For example, a lake may have low nutrient (nitrogen) input balanced with low-to-moderate levels of plant production. Thus, it remains clear. However, as surrounding fertilization with nitrogen increases, it can reach a threshold that wind mixing and oxygen content of deep water cannot buffer, and an algae bloom occurs (Peterson 2008). Slow change in a control parameter (nitrogen input) leads to a drastic state change or tipping point. Another critical feature of emergent wholes is that their correlations allow information to be compressible, and it takes fewer “bits” of information to define the system (Hidalgo 2015). This is important because it allows the system to exist as an ordered entity despite the laws of thermodynamics and entropy. It is ordered internally, while exporting its disorder (entropy) outside the boundary of the system to the environment. So, the supraordinate whole is a simple, practical integration of the complementary pairs, but it must align with the deep, not directly knowable, layer

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of the real underlying mechanisms that generate events. Perhaps, complementary pairs appear to be incompatible views at one level only to emerge at the next higher level as a comprehensive whole. Example 4.6 (Electromagnetism) An example of this from physics is how the theory of electromagnetism explained the previously mysterious connections between electrical currents and magnetic field lines. Maxwell’s equations integrated the electricity-­ magnetism complementary pair into a far-reaching theory at a higher level that linked electromagnetism to light and radio waves. Electricity and magnetism as a complementary pair at one level integrated into the electromagnetic spectrum at the higher level.

Kelso and Engstrøm (2006) have widely generalized the concept of complementary pairs and have begun to work out the complex mathematical relationships (coordination dynamics) that entail among and between levels: What if experiments showed that the human brain is capable of displaying two apparently contradictory, mutually exclusive behaviors at the same time? And what if the phenomena were seen to be ubiquitous also in human behavior? What if there was a mathematically expressed scientific theory that attested directly to such complementary nature inherent in human brains and also in human behavior? A metastable regime of coordination dynamics was discovered in which no stable (or unstable) equilibria were present, only transient, coexistent “tendencies”—places where the parts of the system tended to coordinate as a collective unit the same time as they tended to function independently (Ibid: xi-xiii).

Their list of complementary pairs (delineated by a ~ relationship), only a small part of which is listed here, is a virtual who’s who of important historical concepts. In all, they list >450 complementary pairs in 20 fields of endeavor. Concept pair Yin~Yang Being~Becoming Faith~Reason Continuous~Discrete Collective~Individual Particle~Wave Genotype~Phenotype Organism~Environment

Proponent Lao Tsu Plato Aquinas Darwin Karl Marx Bohr Watson and Crick Gibson

So, it just may be that it would be useful to search for complementary pairs in interprofessional education. Some promising candidates might be health~disease, self~other, mechanistic~relational, thinking~feeling, mental~physical, external~internal, objective~subjective, and material~spiritual. Try this—look for a

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superordinate concept that might integrate each pair; it could point to the underlying rules and principles of reality. These would provide the foundations for important affordances to emphasize and teach. In interprofessional education, we must remember that trust enables networks, but networks enable trust (trust~network). Successful association between what were initially strangers or “others” increases trust, increases access to information (affordances), and increases social capital, making the network function more efficiently (Ibid: 120–121). Exercises that introduce teammates to each other and explore their functional and knowledge differences are critical for operationalizing “complementarity” thinking. Example 4.7 (Meet Your Colleagues) Another of our sister interprofessional centers (Seattle) created a curriculum called “Meet Your Colleague” (Rick and Kritek 2015). The team met for one half-day per week for approximately one-third of the year. Each session featured a new group of healthcare providers: nurses, pharmacists, clerks, physical therapists, etc. They discuss their training and a typical day in their job. Then they open it up for “anything goes” Q&A.

Example 4.8 (Two Truths and a Lie) At our site, we created an activity called “Two Truths and a Lie.” Each member of the interprofessional team wrote down two unexpected truths and one lie (although a commonly believed stereotype) about their profession. We then had the rest of the class guess which was the lie. During one session, the pharmacy resident wrote: –– We learn to fit crutches in pharmacy school. –– About half of our curriculum was biochemistry. –– We are not legally allowed to prescribe medication. Can you figure out which is the lie?

References Bohr N. Causality and complementarity. Philos Sci. 1937;4:293–4. Bohr N, Rosenfeld L. Complementarity: bedrock of the quantal description. Foundations of quantum physics II (1933–1958). Niels Bohr Collected Works. 1996;7:284–5. Capra F. The Tao of physics. 25th Anniversary Edition. Boston: Shambhala; 1999. Caroll S. Something deeply hidden. New York: Dutton; 2019. p. 75. Feng G-A, English J.  Chapter 42: First two stanzas. In: Tsu L, editor. Tao Te Ching. London: Wildwood House; 1991/1972. Hidalgo C. Why information grows. New York: Basic Books; 2015. p. 17–24.

References

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Kelso JA, Engstrøm DA. The complementary nature. Cambridge, MA: MIT Press; 2006. Pattee HH.  The need for complementarity in models of cognitive behavior. In: Weimer WB, Palermo DS, editors. Cognition and the symbolic process, vol. 2. Hillsdale, NJ: Earlbaum; 1982. p. 21–30. Pattee HH. Instabilities and information in biological self-organization. In: Yates FE, editor. Self-­ organizing systems: the emergence of order. New York: Plenum Press; 1987. p. 325–38. Peterson GD.  Self-organization and discontinuities in ecosystems. In: Allen CR, Holling CS, editors. Discontinuities in ecosystems and other complex systems. New  York: Columbia University Press; 2008. p. 21–2. Rick C, Kritek PB. Realizing the future of nursing: VA nurses tell their stories. Washington, DC: Government Printing Office; 2015. p. 479. Turvey M. Lectures on perception. An ecological approach. New York: Routledge; 2019. p. 98.

Chapter 20

Dynamics

Coordination Dynamics What do I mean when I speak of dynamics? I am referring to time-dependent changes in the structure, processes, and function of the group. As we saw in Chap. 3, reality is laminar. It exists in independent hierarchical layers, each of which is potentially causative. Coordination dynamics avoids a purely reductionist or purely holistic approach to relating these different levels (Kelso and Engstrøm 2006: 109). Our first step is to choose a level of interest in which to identify relevant coordination variables and equations of motion. I choose the “team”, a functional unit (e.g., the clinic, hospital ward, emergency department). Going a level up, (e.g., the health system, the profession) elaborates the “context” and the boundary conditions for operation. Going down a level, “individual learners,” allows an examination of the very different coordination variables between individuals at that level. Coordination dynamics is a method for looking at the influences between levels and their effect on operational patterns. Level Top Mid Bottom

Focus of observation Context (health system, profession) Teams (clinic, ward, etc.) Individual learners

Each level operates at a different timescale. For instance, individuals typically have 4-week or 1-month block rotations as well as year-long intermittent commitments (e.g., continuity clinic, conferences, procedure clinics). The clinic, on the other hand, operates daily (at least M-F), with trainees overlapping on a daily or weekly basis. The training programs (context) tend to operate on a weekly schedule (e.g., major conferences), a monthly or 4-week block rotation schedule, and a yearly schedule with major changes in duties and curriculum as trainees advance. It would © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_20

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be rare for each professional training program to follow the same schedules. One reason why these programs and levels integrate~segregate is determined by their strength of coupling and the intrinsic differences in their natural frequencies. They can exhibit absolute coordination (phase locking) with strong coupling and comparable natural frequencies, or they may exhibit only relative coordination, locking in only transiently, if these are weaker (Ibid: 141). Example 4.9 (Startup) In our center, we were integrating five training programs (medicine, nursing, nurse practitioner, pharmacy, and psychology). We believed that it was very important to have several shared activities between these trainees (clinic, quality improvement teams, grand rounds, etc.) to foster understanding of each other and to build trust. In order to achieve our goals of integration, it took 2 years of planning, trial and error, and adjustment. Coordinating schedules between existing training programs was one of the hardest tasks we had to accomplish in those early years.

Besides managing time integration, another dynamical principle is seen in Fig.  20.1. Dynamical patterns created by collective behavior (higher levels) constrain individuals (lower levels) by controlling resources and delimiting structure, while individuals, through their action, can entrain with or constrain higher levels by maintaining or perturbing them. This mutual feedback can lead to resonance or damping between layers. Diversity with overlapping reinforcement of function can lead to cross-scale reinforcement, which is remarkably robust. This is called imbrication. This is an important ingredient for the resilience and adaptability of interprofessional educational programs. Let me say this in another way. I believe that the goal in forming interprofessional curriculum is to identify and create experiences for individuals to see “others” as potentially enriching and interesting, as opportunities for collaboration, and less like someone to be wary of or feared. Beyond these general principles, one then looks for specific control parameters (in the environment) and coordination variables (in the system). Control parameters are as follows: Fig. 20.1 Interactions between levels

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Naturally occurring environmental variations and~or specific types of functional information that move a system through its patterned modes of coordination and cause them to adapt and change. Conversely, control parameters may play a stabilizing role, sustaining a pattern that would otherwise undergo a global change such as a state transition (Ibid: 118).

If you observe a qualitative state transition when an external variable has been smoothly changing, you know that the variable is a control parameter. For instance, as you slowly increase the heat on a pot of water, you get a sudden transition from liquid to gas (boiling). In this example, heat is a control parameter. Coordination variables represent key aspects of collective behavior in the system. The information in the raw system (large number of degrees of freedom) is compressed and becomes more manageable when the correct coordination variable(s) are selected. Coordination variables evolve in time according to dynamic laws, often driven by control parameters. In our pot of water example, barometric pressure and average kinetic energy of each water molecule are coordination variables, while boiling (liquid-gaseous state) is the control parameter. Frequently, the dynamical system evolves to a point of bifurcation or alternative stable states (see unstable fixed point in Fig. 20.2). These states can be conceived as attractor basins (“valleys”) divided by stable and unstable fixed points that can be attractors (1 in Fig. 20.2) or repellers (2 in Fig. 20.2). These are often depicted in two- or three-dimensional maps such as Fig. 20.1. It turns out that a stable attractor is always accompanied by an unstable repeller (Ibid: 162), and this may be the dynamical genesis of complementary pairs. These “individual coordinating elements couple together to form coherent, self-organized coordinated states” (Ibid: 176). One might ask to what extent does coordination dynamics relate to learning. The answer is apparently to a great extent. For instance, when learning a coordinated

Fig. 20.2  Depiction of two attractor basins with stable and unstable fixed points

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movement (patterns of relative timing of two limb movements-such as patting your head and rubbing your belly at the same time), what changes is the coordination dynamics (abstract, functionally specific equation of motion) (Schöner et al. 1992). The dynamical properties occur on two timescales that must be coordinated: learning (slow) and performance (faster). Stability of the memorized pattern can be explained by an equation of motion with an attractor basin at the to-be-learned pattern. This newly learned behavior may be transferable to other similar behaviors, suggesting a deep change in the coordination dynamics, or baseline equations of motion controlling limb movements. Developmentally, several habitual motor skills (brushing teeth, tying shoes, writing one’s name, walking down stairs) are sequences of movement with a beginning, contour, intensity, and end. Each is learned (not innate) (Sheets-Johnstone 2016: 49). In fact, phenomenologists believe that a general pattern is that habits of the mind are “surely spurred by expectations” that begin with the experience of movement (Ibid: 54). We develop from “I move” (kinesthetic sensation) to “I do” (agency) to “I can” (reflexive possibility) (Ibid: 23; Husserl 1989). Linguists have noted the great extent to which our cognitive concepts are based on this kinesthetic (felt, qualitative sense of movement) and kinetic (perception of body as a quasi-object in movement in ourselves and others) (Johnson 1992; Lakoff 1987). The following are examples of the power of these metaphors (Lakoff 1987: 383; Johnson 1992: 35): Container metaphor He was filled with anger She couldn’t contain her joy Harry weaseled out of the contract Hand out the information

Dynamics are an important consideration for learning. On the one hand, there are the dynamics intrinsic to the learner (memory capacity, previous experience, preferred natural frequency) and on the other hand there are the functional dynamics of the situation (task to be learned, environmental constraints, motivation, etc.): Intrinsic dynamics are important because they place constraints on what can be learned, and more generally on what can be changed and stabilized in memory. From this perspective, the transition from novice to expert entails the modification of a system’s intrinsic dynamics by functional information … Functional information and intrinsic dynamics are complementary aspects of a complementary pair central to the science of learning. (italics added) (Kelso and Engstrøm 2006): 204)

Adaptive Cycle Theory As multiple individuals and several groups (work unit, training program, department, profession) interact, the dynamics become complicated. Each of these entities operates on its own natural frequency, and with its own attractor basins, which can lead to resonance (coordination) or damping with other entities. These dynamics lead to cyclical behaviors of the system. Groups of entities tend to organize within the ecosystem as “panarchies”:

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Panarchies are hierarchically arranged, mutually reinforcing sets of processes that operate at different spatial and temporal scales, with all levels subject to an adaptive cycle of collapse and renewal (Allen and Holling 2008: 3).

Each layer of the panarchy tends to follow an adaptive cycle of two phases of growth followed by two phases of reorganization, occurring in nested sets based on spatial and temporal scales (Ibid: 5). The growth cycles are exploitation and consolidation, while the reorganizing cycles are destruction and reorganization. These can be thought of as an oscillation between two stable complementary attractor basins (stability~change) dictated by the rigidity~adaptive capacity of the panarchy. This is not unlike the exploit~explore behavioral choice described in foraging (Addicott et al. 2017). Larger entities (e.g., department) tend to be on slower timescales, while smaller ones (e.g., individuals) occur on faster timescales. Some of these entities operate as “keystone processes” that are powerful enough to entrain other processes, causing “clumping” of compatible entities with gaps between the clumps (Hollings 1992). For instance, if someone calls for help in an emergency situation, groups have a tendency to remain locked in a passive attitude, where individuals would already have acted (Scheffer 2009: 246). These dynamics, in some cases, can lead to critical state transitions (tipping points) that are extremely difficult to reverse. These can be disastrous, as in the fouling of a lake with increasing nitrogenous runoff, but can also be positive, as in the civil rights movement of the 1960s with increasing public concern. Example 4.8 (Social Network Analysis) After our program had been operating for a few years, we believed that trust and collaboration had increased (coordination variables). There was also an apparent critical state change (attractor basin switch) from a doctor-at-top hierarchical social structure to an egalitarian “small worlds” structure. We suspected that social structure was a control parameter and collected evidence of this using serial social network analysis (Smith et al. 2023).

This example demonstrates several of the dynamical principles mentioned in this section. We choose to examine the mid-level of team function. Trust is a naturally occurring continuous variable that occurs between pairs of individuals (individual level below) and is influenced by professional stereotypes and organizational biases (context level above). In the aggregate, a continuous change in interprofessional interaction may be associated with a rapid state change (increased trust and collaboration) at the team level, making social structure a good candidate for a control parameter. This is manifest by increased trust and collaboration between individual pairs, the state variable. This formulation assumes that working together more equally can lead to increased trust and collaboration. Egalitarian Structure → Trust and Collaboration

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However, the causal link may be reversed. Recurrent opportunities for collaboration may increase trust and change the social structure. Which of these is correct is an empirical question. This example also demonstrates the complementary nature of control parameters~coordination variables.

References Addicott MA, Pearson JM, Sweitzer MM, Barack DL, Platt ML. A primer on foraging and the explore/exploit tradeoff for psychiatry research. Neuropsychopharmacology. 2017;42:1931–9. Allen CR, Holling CS.  Discontinuities in ecosystems and other complex systems. New  York: Columbia University Press; 2008. Hollings CS.  Cross-scale morphology, geometry, and dynamics of ecosystems. Ecol Monogr. 1992;62:447–502. Husserl E.  Ideas pertaining to a pure phenomenology and to a phenomenological philosophy. Rojcewicz R, Schuwer A (trans.). Dordrecht: Kluwer academic Publishers; 1989. p. 273. Johnson M. The body in the mind. Chicago: University of Chicago Press; 1992. Kelso JA, Engstrøm DA. The complementary nature. Cambridge, MA: MIT Press; 2006. Lakoff G. Women, fire, and dangerous things. What categories reveal about the Mind. Chicago: University of Chicago Press; 1987. Scheffer M.  Critical transitions in nature and society. Princeton, NJ: Princeton University Press; 2009. Schöner G, Zanone PG, Kelso JAS.  Learning as change of coordination dynamics: theory and experiment. J Motor Behav. 1992;24(1):29–48. Sheets-Johnstone M.  Insides and outsides. Interdisciplinary perspectives on animate nature. Exeter, UK: Imprint Academic; 2016. Smith CS, Fisher AK, King IC, Naidoo SW.  Pilot study of repeated social network analysis to assess (SNA) to assess structural changes in an educational program evaluation. SN Soc Sci. 2023;3:20–32.

Part V

Application

This seems to be an interesting, coherent theory but how do you actually put it into practice? What curriculum does it imply? What activities are important? How do you measure the success or failure of this educational intervention? These are the topics of this final section. Before moving on, let me take this moment to summarize my ecological theory of interprofessional education as reviewed in Fig. 1. It begins with affordances and reciprocal relationships between the learner and their environment. These can be explicit (e.g., name tag holder in Fig. 2.2) or hidden (e.g., the “fear” vignette described under the interprofessional learner problem of ‘Hidden Affordances’ at the begining of Part II on page 29). Learning involves an expansion of the lifeworld, the set of meaningful features (affordances) in the environment that the learner is able to recognize and appropriate. This can occur through curricular elements that facilitate intrinsic expansion (unmediated reflection on experience) or mediated expansion (external means such as books, videos, or instruction). Thinking of our curriculum, both its experiential and its intentional didactic elements, as behavioral settings allows us to examine all elements and affordances as

Fig. 1  Overview of the key elements of an ecological theory of interprofessional education

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to their effect on permitting, supporting, or resisting desired behaviors. Realist considerations, however, preclude our reduction of this understanding to fixed algorithms and prescriptive recipes. First, due to the limits of our perception, bias from expectations, and fundamental changing nature of reality, we cannot accurately perceive any static underlying laws driving the system. Second, because multiple interactions, with positive and negative feedback loops, are occurring across multiple levels, the system behavior is nonlinear (e.g., small changes can have large effects, and this may not be reproducible). This has tremendous implications for design and evaluation. Instead of linear, measurable cause → effect relationships, we should expect to find complementary dynamics. The approach should: –– Look for critical state changes and try to identify the control parameters in the environment related to these (e.g., amount of face time together influencing trust and a change from hierarchy to egalitarian social structure). –– When faced with seemingly valid but contradictory explanatory narratives, search for a unifying supraordinate narrative that includes each as subsets (special cases) of the broader model. Use this to better characterize the critical state and coordination variables. –– Expect this to be an iterative process. In Part V, I will review the previous chapters by rearranging and integrating them into a framework for designing, maintaining, and evaluating interprofessional training. To begin, we must remember that we live in a world made up largely of intermediate-­sized material objects (buildings, computers, hallways, people, etc.). These objects obey the classical model: linear cause → effect relationships, simple hierarchies, observers independent of the objects they observe, no influence without proximity, and unidirectional time. This creates “conditional camouflage” that leads us to expect mechanistic models, linear mathematical descriptions, discoverable universal laws, and reductionism in our exploration of the world. As we previously discussed, however, once we are studying people and social systems, this model does not work as well. For instance, studying a process such as a clinic visit is complex. First, what is the unit of analysis—the patient, the provider, their profession, their role, the individual clinic, the department, or the hospital system in which the activity is embedded? There will likely be effects from all of these, they will be dynamic (changing), and they will be complexly connected in “tangled hierarchies” (Hofstadter 1999) with positive and negative feedback loops and emergent unpredictable behaviors. Given the complexity of micro-states and interprofessional education, making causative inferences can also be problematic (see Example 1.6—spouse abuse). Example 5.1 (Smoking Cessation Intervention) Assume that we design an intervention to motivate smokers to quit and that it works well in our clinic. We publish the results, and the method is adopted by 20 other clinics. In half of them, it also works well. In the other half, it results in a slight decrease in smoking cessation and more frequent “no-shows” for clinic visits. How can we explain these results?

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Interviewing the patients from the two types of clinics, we discover an interesting additional variable. In those clinics where the patients were embarrassed by their smoking, the motivational interview worked well. In those where the patients were angry with the perceived intrusion, it was counterproductive. This is an excellent example of the need for critical realism: we do not have direct access to underlying laws and mechanisms because the limits of our perceptual systems and sociocultural expectations act as filters. In an attempt to simplify and focus the intervention and outcome study, these investigators did not initially consider patients’ emotional reaction to be relevant. This is understandable. Patients’ emotional reactions are probably complexly connected to their past history of interactions around smoking, their current life-stress level, which the provider reminds them of from prior interactions, and other personality traits. It would be difficult to incorporate all of these elements (and others) into a classical predictive model. All theories, models, and “facts” are contingent—and this is disquieting to those who want to decrease uncertainty and discover inviolable rules for designing interprofessional training. All human relationships are complex and unfold over time. This is counter to those who want to devise an interpersonal intervention and quickly assess it with simple metrics. The following chapters cover some of our hard-won rules of thumb for designing, maintaining, and evaluating interprofessional training.

Reference Hofstadter DR. Godel, Escher, Bach: an eternal golden braid. New York: Basic Books; 1999.

Chapter 21

Design/Implementation

Will you need teams (long term, will do many projects together), task forces (variable, project specific), crews (short term, coming together to do a specialized task with specialized equipment), or, more likely, some combination of these? These have different optima for emergent versus designed structures, and how specific processes and decision-making should occur prospectively (see Table  21.1). Regardless of the overall design, some preplanned exercises such as Examples 1.1 (seating arrangement) and 2.1 (flip chart exercise) can set the norm early in the experience for authentic sharing, curiosity, and risk taking that will be critical for interprofessional curriculum. Once the mix of teams, task forces, and crews is preliminarily established, each of these requires a different combination of key elements. These include members, projects, and resources and the interconnections between these: role (members-­ resources), division of labor (members-tasks), and job coordination (tasks-resources) (Ibid: 51–52). Where might you anticipate changes? Teams are most sensitive to changes in membership, task forces to changes in the project, and crews to breakdowns in the equipment or procedures (Ibid: 189–190). With regard to members, how big do you need the group to be? This is a function of the planned projects. Too small leads to overwork and burnout. Too big and the number of interpersonal ties goes up, complicating collaboration, and motivation goes down, with the possibility of “social loafing.” Increasing diversity will prolong the formation process but can expand the perspectives and alternatives considered by the group. Members have needs that must be met by the group (affiliation, achievement, power, access to resources) (Ibid: 74–77). Project outcomes involving activities toward group goals are hierarchical: the highest level requiring knowledge (purposeful thought), the mid-level following scripts (rules), and the lowest level being automatic (skill) (Ibid: 103). Member needs must be balanced with project outcomes, even when one or the other is tacit. Boundaries are another consideration. As you increase the number of professional training programs involved, the difficulties in coordinating schedules, © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_21

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Table 21.1  Features to consider with teams, task forces, and crews

Team Task force Crew

Structure Design early, emergent with time Mixed and evolving Emergent

Focus Ongoing projects Balance individual vs. team needs Problem specific (e.g., optimizing care for high-risk patients) Process specific (e.g., decreasing ED visits from the team’s patient panel

Most sensitive to changes in … Membership Project Breakdown in equipment/procedure

accreditation “must-haves,” and other specifics expand exponentially. Boundaries must be permeable enough to get resources in and products out, but must not be so porous as to allow outside influences to overwhelm the group (Ibid: 78). Design should take into account the difference between the classical model and critical realism. Instead of expecting linear hierarchical interactions and predictable outcomes that are fixed and specific, you should expect to frame outcomes in a more general way and have them be dynamic. Remember, all facts and theories are fallible and contingent. Expanding the lifeworld needs to be both external and internal. Externally, the curriculum needs to include experiential apprentice-like tasks (Lave and Wenger 1995). Scheduling interprofessional learners to work together on authentic, developmentally appropriate tasks proximate to expert performance is difficult but imperative. They will not learn to function as a team unless they have supervised experiences working together as a team with role modeling of collaborative interactions. Internally, one lifeworld expansion required is self-awareness about one’s own biases and stereotypes of other professions. Examples 1.4 (gamification) and 2.1 (flip chart exercise) are good ways to begin this process. Biases and stereotypes are often tacit, and you cannot keep them from happening. The goal is to recognize them, contemplate them, and give yourself “space” not to respond destructively to them. The inner wisdom traditions, particularly meditation, can help build this skill. Behavioral settings should be designed carefully to avoid inhibitory affordances (Fig. 2.2, name tag holder). Before the first day of training, walk through your training clinic (even if only in your mind if you are in the design phase) with the “newcomer’s eyes,” trying to experience the environment as it will appear to different apprentice trainees. Are there hierarchical differences between space allotments, available resources (including support staff), or signage? Consider redesigning these. Plan for conflict and create structures to deal with it. Create a venue for presenting claims and a mechanism for how claims will be evaluated. Be explicit about how disparate interests will be handled and how group decisions will be made. It is not too early to plan for evaluation during this phase. Although you will likely collect some common “hard” outcomes (e.g., utilization, blood pressure control, or medication compliance), you will also likely use measures from the social sciences that may require significant preparation, novel data collection, new analytical software,

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and time-series techniques (see this chapter). You may also need to develop qualitative evaluation plans. Design and creation of interprofessional groups require consideration of membership projects and resources. Teams are the broadest group, expected to carry out several projects together over time. How diverse a group of faculty and trainees do you want to include in the initial phase? Will you start with two professions and add on as you stabilize, or begin with a greater diversity, which may be more complicated but more rewarding. Do they all have the requisite skills needed and, if not, do you have a plan for training them? Supervision and trainees are initially inefficient. Will the institution support adequate space (e.g., exam rooms) and protection from productivity expectations? This may limit your size and scope. Task forces are directed at a single unbounded project (e.g., decreasing ER visits from the team’s patient panel). The membership considerations are different. Do you have adequate diversity, expertise, and representation from all stakeholders? Do they have release time together and adequate informational resources to understand the problem? What permission do they have/need to trial solutions? Crews are designed to efficiently manage common recurrent situations. Modeled after airline flight crews, each member is trained to handle a specific role and tight process control is often maintained by checklists and algorithms. Example 2.5 (high-risk patient care conference) demonstrates the breadth of improvements that may be expected with a carefully designed interprofessional crew applied to a recurring problem. These can be superb experiential learning venues for all levels of trainees. Below is another example of the crew approach. Example 5.2 (Polypharmacy Clinic) One of our sister centers (Yale/New Haven) developed a multipronged approach to polypharmacy in older veterans (Mecca et al. 2019). Patients are presented to an interprofessional team during a preclinic conference, a patient/family group visit occurs where common polypharmacy topics are discussed, and this is followed by a one-on-one trainee clinic visit with medication reconciliation and a structured precepting session with a geriatrician, pharmacist, or health psychologist. Over 6 months, some medications were reduced or discontinued in 85% of veterans resulting in significant improvement in cognitive function.

In order to highlight many of the points presented in this chapter, the example below and discussion that follows, describing the original request for proposals for the Center of Excellence in Primary Care Education project, demonstrate the difficulties of design in a real-world context (classical scientific model, economic pressure, political realities). It also shows the benefits of providing some room for flexibility and creative emergent solutions.

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Example 5.3 (Original RFP) In 2010, a request for proposals was released by the Department of Veterans Affairs for five Centers of Excellence in Primary Care Education (Department of Veterans Affairs 2010). These centers needed directors/co-directors that had to be a physician and a nurse practitioner (NP) with clinician educator faculty appointments. They were to design interprofessional training curricula within four broad areas: shared decision-making, sustained relationships, interprofessional collaboration, and performance improvement. All five sites had established physician training programs, but they all had to create new NP postgraduate training programs. Over the course of Phase 1 (the first 5 years), four out of five of the nurse practitioner co-directors left or retired (80%), while none of the physicians left. All sites developed creative and exportable curricula in the four key areas of curriculum.

As Example 5.3 shows, the initial decision regarding membership has significant consequences. Most physician faculty had academic appointments, were experienced in curriculum design, and had protected time for education. In contrast, NPs had little experience in academic roles, and VA facilities did not have a culture of providing protected time for NPs for education, leadership, faculty development, or scholarly activities (Harada et al. 2018). This asymmetry was compounded by the perception that local design needed to happen quickly in order to give the staff and the interventions time to create/measure improvements in critical objective outcomes (a classical assumption). The asymmetry between co-directors and the productivity tension that was assumed in a classical approach created tension in most of the dyads. Attention to the specific needs of groups, and providing adequate time for training, mentoring, and team building when there are asymmetries, is critical to success. The framing of initial goals and objectives in this example at an intermediate level, with enough specificity to relay important expectations and provide an overarching structure but not so much as to hamstring flexible creation of curricular methods, was very successful. Each site focused on different aspects of these broad goals, and this added to the breadth of interventions and greater chance for outside sites to find something useful and applicable to their context.

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Sidebar 5.1 Design Checklist • What are your broad goals for this curriculum? Specify them at an intermediate level in a way that transmits core expectations without hamstringing flexibility and emergence. • Who do you want to be included? –– What training programs exist in your medical center? What are your regional resources (which may require affiliation agreements)? –– Does this mix provide enough diversity and expertise to meet your goals? –– What are their statutory needs for accreditation (rotations, experiences, curriculum)? –– What are their existing rotation schedules? Can they be integrated? –– What is your capacity regarding exam rooms (ambulatory), ward teams (inpatient), and work rooms (with sufficient computer support)? This may limit size. • Identify any additional behavioral settings you may need to achieve your goals (see Example 3.2—Art Museum). • Provide rough expectations about the breadth and scope of task forces and crews that are expected (leaving room for flexibility and emergence). • Now, walk through your clinic with “beginner’s eyes,” making sure that you include designers from ALL participating training programs, looking for asymmetries and bias.

References Department of Veterans Affairs. VA Centers of Excellence in Primary Care Education RFP. 2010. https://www.va.gov/OAA/docs/CoEPCE_Stage_1_RFP.pdf. Accessed 25 July 2021. Harada ND, et al. Interprofessional transformation of clinical education: the first six years of the Veterans Affairs Centers of Excellence in Primary Care Education. J Interprof Educ. 2018. https://doi.org/10.1080/13561820.2018.1433642. Lave J, Wenger E.  Situated learning. Legitimate peripheral participation. Cambridge, UK: Cambridge University Press; 1995. Mecca MC, et  al. Assessing an interprofessional polypharmacy and deprescribing educational intervention for primary care post-graduate trainees: a quantitative and qualitative evaluation. J Gen Intern Med. 2019;34(7):1220–7.

Chapter 22

Maintenance

General Concepts Once interprofessional training is up and running, there are many new things to attend to. As mentioned in the last chapter, natural groups in interprofessional training are crews, task forces, and teams. These are specific arrangements of members, products, and resources. The team, or supraordinate group, will work on several projects at once and will typically last the duration of the interprofessional training program. Below them hierarchically are task forces and crews. Task forces are formed to address a single problematic process (e.g., “no shows”) and last until that project is improved. Crews are formed to approach common recurring problems and to improve results for those problems (e.g., taking medications incorrectly). Each crew is comprised of interchangeable specialists (e.g., primary care provider, pharmacist) and the structuring algorithms and checklists that control a standardized approach. The team (top of the hierarchy) provides direction and resources to the task forces and crews. It also constrains them. Task forces and crews, in contrast, either maintain teams by carrying out projects or perturb them when there are differences of opinion. For these groups to be enduring and stable, there must be a balance between responsibilitiesation, achievement, power, and resources (Arrow et  al. 2000: 98–102). How are the norms for interpersonal activity generated and followed? Are they emergently created by the group or imposed by the embedding system? Is achievement equitable? A particularly important area for interprofessional groups is establishing and maintaining norms around sharing credit for things such as leadership roles and authorship. Are mechanisms in place to address things like authorship norms and for handling conflict? With regard to power, as discussed in earlier chapters, much of the effort in interprofessional training is to move away from hierarchical power and toward egalitarian functioning. Pay attention to the feelings this creates for members. Those losing power need it to be replaced by other rewards of © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. S. Smith, Foundations of Interprofessional Health Education, https://doi.org/10.1007/978-3-031-33414-6_22

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perceived value such as academic product, new interpersonal connections (including mentoring roles), or greater access to resources. Those gaining power need to be aware of the responsibility that is entailed. They are not just “entitled” to power as a result of the interprofessional effort. They must take some responsibility for the breadth of team activities (teaching, research, clinical care, administration) and assure that their profession is represented in all of these activities. A good rule of thumb that we adopted was “Nothing about us without us.” With regard to group coordination, you are attempting to achieve predictable expectations between members. Each individual’s behavior is a type of affordance that other individuals will entrain to, moving over time as a group from engagement → reinforcement → habits → norms. This slowly changes individuals from wariness of each other toward the activated connections of trust. Notice that wariness~trust is a complementary pair. It is likely resolved at the higher logical level of “colleague,” but shared values and norms need to be in place to allow collegiality and these must be elicited through shared activities. Pay attention to the feedback loops in your system. There will be many, and they will be interconnected in complex ways. Negative (or corrective) feedback loops damp out changes or differences. They stabilize the system when it is perturbed. Social negative feedback loops may come in forms such as norms or corrective actions. Positive feedback loops exaggerate changes or differences. They destabilize the system when it is disturbed. Social positive feedback loops may come in the form of rewards. Larger systems will have longer, slower reaction times. Example 5.4 (Feedback Loops) Previous Example 2.5 (High-Risk Patient Conference) had both positive and negative feedback loops. This conference was structured in such a way that, when a previous presenter was back on clinic block again, the team started the conference with an overview and update of their prior presented case. This often documented how the situation had improved with a difficult patient, providing public recognition and positive reward (positive feedback) for the primary care provider and team. On the flip side, this conference was extremely time constrained. We always tried to start on time (a norm, negative feedback) and pointed out the effects of tardiness on team function when it occurred. This did not usually happen twice.

The context of interprofessional education is dynamic. Multiple feedback loops, self-referential connections, and hierarchies lead to complex behavior of the system. Different aspects will have their own timelines and resonant frequencies. As the system reacts to change, you can expect this complexity to create four broad principles of adaptation (Ibid: 209–211): nonlinearity, unexpected consequences, temporal displacements, and spontaneous innovation. Remember from our discussion of dynamics (Chap. 18) that it is important to identify control parameters

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(external to the system) and coordination variables (internal to the system) in order to better understand system behavior. According to adaptive cycle theory (end of Chap. 18), dynamic systems go through stages of growth (identifying exploitable resources, consolidating resource use) and reorganization (decline, reorganization). These will happen to varying degrees and different timescales in the various groups (crews, task forces, teams).

Teams Teams are the “ocean liners” of the interprofessional groups—they have a lot of inertia and do not usually change quickly. One key to maintaining teams is to determine, understand, and manage control parameters (external) and coordination variables (internal). Because these are complex adaptive systems with emergent behaviors, the goal is not to identify specific quantitative targets for singular average behaviors (e.g., an average “trust” score of at least 50%), but to track the trajectory of qualitative system-level behaviors over time in order to identify rules of interaction and critical aspects of the team’s context (e.g., trust increasing with more project time together) (Ibid: 43). Social systems are different than natural systems: “Learning, spread of information, and innovation play an overwhelmingly important role in societies. An important implication is that social systems never really shift back to a state that they have been in before … This implies that a partially different set of theoretical frameworks, including ideas such as adaptive cycles that are not captured in simple equations so easily, have been useful for describing social dynamics.” (Scheffer 2009)

Behavior of these parameters can reveal proximity to a “tipping point” (see Chap. 21), which may be either a negative thing (e.g., group dissolution) or a positive thing (e.g., group shifting to a more efficient social structure). Another consideration is the impact of time/activity scales across levels: team~context, team~task force, and team~crew. Ideally, although these each operate on different timescales, they should integrate smoothly with evidence of bidirectional influence in a high-functioning team. One special case of integration may be a “small world” structure rather than the more traditional hierarchical structure in healthcare. Hierarchical structures (top-­ down, command and control) are efficient in one direction and are good at executing stable algorithms but have difficulties with flexibility and resilience. They have trouble in complex environments, where adaptive precision is key, because there is often a lag time between the dynamic requirements of tasks and the understanding of the leaders. For instance, in the new type of combat required to respond rapidly to Al-Qaeda in Iraq, the old “command and control” structures did not work, and new “team of teams” structures had to be developed (McChrystal 2015). This “team of teams” structure, in graph theoretical mathematics, is known as a “small world” network (“six degrees of separation”). These are “highly clustered like regular latices, yet have small characteristic path lengths, like random graphs. They have specialized regions and yet exhibit shared or distributed processing and

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tend to facilitate communication, decision making, and resilience. Small world networks are stable. They resist change due to the filtering apparatus of using highly connected nodes. They are also efficient, being effective in relaying information by keeping the number of links required to connect a network to a minimum” (Watts and Strogatz 1998). Thus, they demonstrate an optimal balance between fixed order and randomness in responding to changing environments. In healthcare, hierarchical social structures of healthcare teams have been shown to have greater hospital costs and more readmissions than small world structures (Tasselli 2014). It seems reasonable that an important goal in interprofessional teams is an egalitarian, small world structure.

Task Forces Recall that the temporal structure of a task force is keyed to completion of a specific project. The goals of this project should be clear, focused, and achievable. It can be helpful to structure the broader task by establishing checkpoints and deadlines for goals and sub-goals of the project. These should, as much as possible, take into account the level of demand of the task with any externally imposed deadlines. Task forces typically operate as punctuated equilibria—extensive periods of study, brainstorming, and creativity punctuated by flurries of meaningful work. Task forces may use time swapping (working all together on one task, then another), time sharing (working on multiple projects simultaneously), or a mixture. Ideally, this is determined by member familiarity, feedback from the tasks themselves, and any applicable deadlines (Arrow et al. 2000: 139). Often, time sharing is the norm during routine function, while time swapping occurs during crisis. The task force should periodically undergo, even if informally, a needs assessment regarding adequacy of membership diversity (any missing stakeholders?), information resources (are critical aspects of performance being measured and fed back to the group?), and gaps in knowledge/skill (any training needs?). Attend to the group’s progress and development. There are many models of this, but one of the most common is forming, storming, norming, and performing (Tuckman and Jensen 1977). During the forming stage, tentative norms are developed. These are challenged during the storming stage and solidified during the norming stage. In dynamical terms: The group moves quickly toward an attractor, but the attractor is “weak” (has a small and shallow basin) and the system can easily be pushed out of the attractor basin … norms are weak because members are not yet committed to enforcing them … After the storming stage, in which the system jumps around, “exploring” phase space, it finds a stronger, more stable attractor and stays there (Arrow et al. 2000: 164).

Task forces need nurturance, accountability, and freedom to be flexible and creative. They also need coordination between members, tasks, and tools (Ibid: 50–51). This means careful attention to membership (Is there enough diversity? Are all

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stakeholder groups included?), member roles (Is the role matched to the individual’s personal, task, and process skills? Are there training needs?), and resources (information, protected time to work together). Besides these microlevel elements, global elements such as the division of labor, level of conflict, and overall productivity are important considerations (Ibid: 90–91). Example 5.5 and the discussion that follows are an example of these considerations. Example 5.5 (Low-Acuity ED Visits) Our training clinic created a task force to address the large number of low-­ acuity emergency department (ED) visits from our patient panels. In addition, there were institutional pressures to improve access to our clinics, more efficiently use our exam room space, and provide some after-hours availability. After seven PDSA cycles (Plan-Do-Study-Act), a Wednesday evening clinic was selected to address all of these concerns. This clinic was designed and implemented. It did expand access, improve space utilization, and provide new after-hours care. However, there was little impact on diverting patients from the ED (Weppner et al. 2014).

This example makes several of the points identified above. The task force was formed to address a specific goal, decreasing low-acuity ED visits coming from their patient panels, but then added several other institutional utilization goals—access, space utilization, and after-hours visits. This increased complexity made it more likely that improvements in one area (utilization) were coupled to worsening outcomes in another (low-acuity ED visits) through complex feedback loops. The task force had ample protected time to work together and good information sources (indeed, one of their earliest PDSA cycles created a Pareto chart of low-acuity ED visits to assist in planning). However, it did not include members from the ED team and only made assumptions about the relationship between the after-hours clinic and low-acuity ED visits. As it turned out, the variable availability (only offered one day/ week) and capacity (different numbers of trainees in after-hours clinic each week) limited the predictability, and therefor usefulness, of the clinic for ED diversion.

Crews When crews are initiated, the roles and structuring tools may not be optimal. The team should identify, share, and utilize a wide range of important affordances. This helps to expand the lifeworld for learners unfamiliar with more esoteric affordances. Once up and running, attend to gaps in important affordances. Decide if these are due to unmet role balance and/or inadequate algorithms and checklists, and then address the deficiency.

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Example 5.6 (Social Determinants of Health) After our previous Example 2.6 (High-Risk Patient Conference) had been operating for a while, we realized that an important affordance (in this case, information) was commonly missing—the social determinants of health (e.g., education, wealth, transportation, support systems). We examined the problem and decided that it was both a role and a tool deficiency. The team decided that psychology trainees would be the appropriate members to telephone the patient and obtain this information before the conference. These trainees and their preceptors designed a new checklist for these phone calls. Once we began calling, recording, and presenting this information, our understanding of the patient’s problems and the appropriateness of our plans improved considerably. Over time, the members of the crew must learn to balance analysis and intuition. This is a learnable skill through feedback and inner wisdom exercises (such as meditation). Analysis in crews is largely incorporated into the protocols and checklists that are designed and used. As Example 20.2 above shows, their performance should be continuously reviewed. As members recurrently activate neural connections while using these tools, procedures are reinforced, habits are molded, and group norms are formed. However, unexpected contingencies will occur. Experienced leaders in the crew should be identified ahead of time to decide when the contingency is great enough to warrant modifications that violate existing roles and routines. An airline flight crew follows specified protocols outlining crew responsibilities and actions until an emergency occurs. Then the pilot assigns novel goals and actions: for instance, Captain Sullenberger’s emergency landing on the Hudson river after birds destroyed both his engines on takeoff.

Sidebar 5.2 Maintenance Checklist • Balance project requirements with member needs. • Track qualitative trajectory (not specific values) of key variables. • For teams: –– Identify control parameters (external) and coordination variables (internal). –– Provide information about team function (e.g., process observer-talking patterns). –– Strive for a small world interactive model. • For task forces: –– Goal should be clear, focused, and achievable. –– Membership should be diverse and include key stakeholders.

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–– Tools should include important information resources and protected time. • • • • •

For crews: Find an important, recurrent problem. Provide initial roles and structuring tools (checklists, procedures). Allow flexibility for the group to modify roles and structuring tools. Allow permission and process for abandoning usual procedures in outlier cases.

References Arrow H, McGrath JE, Berdahl JL. Small groups as complex systems. Thousand Oaks, CA: Sage publications; 2000. McChrystal S. Team of teams. New rules of engagement for a complex world. New York: Portfolio Penguin; 2015. p. 20. Scheffer M. Critical transitions in nature and society. Princeton, NJ: Princeton University Press; 2009. p. 240–1. Tasselli S. Social networks of professionals in health care organizations: a review. Med Care Res Rev. 2014;71(6):619–60. Tuckman BW, Jensen MAC.  Stages of small group development revisited. Group Organ Stud. 1977;2:419–27. Watts DJ, Strogatz SH.  Collective dynamics of ‘small-world’ networks. Nature. 1998;393(6684):440–2. Weppner W, Schamber K, Willis J, Gordon T. Improving access in an academic primary care clinic: impact of an after-hours clinic (poster). Orlando FL: Institute for Healthcare Improvement, National Forum on Quality Improvement in Healthcare; 2014.

Chapter 23

Evaluation

Planning the Evaluation Who is this particular evaluation for? Funders will want to see the return on investment with improvements in concrete measurable outcomes (e.g., cost, educational outcomes, publications). Institutions will have their own metrics which will be used to make the decision about whether to continue the program (e.g., access, productivity, patient outcomes). Trainees will want to know what works. Faculty may want to know why and how it works. What is the evaluation trying to accomplish? Is it trying to describe program processes at various levels of detail? Is it exploring potential explanatory models? Is the goal trying to assess performance using concrete changes in outcomes? Or, is it trying to predict an outcome such as a system state change? Finally, is it making the case for an important return on investment? Each of these will require a different evaluation design.

Choosing the Level of Interest With the level of complexity seen in IPTs, we often evaluate only a bounded sub-­ portion of the overall program. Selecting this bounded sub-portion is important and can be aimed at simple, complicated, or complex levels (Patton 2011). Evaluations at the simple level assume that the sub-system is linear, stable, and closed. The metaphor is creating a foolproof recipe for others to follow that leads to a predictable outcome. Simple evaluations are frequently serial in-group comparisons focusing on a single process and one or a few outcomes. It may or may not have comparison groups. An example would be quality improvement (QI) projects

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(Dulay et al. 2020). They often use simple statistical tests of significance such as t-tests (for parametric variables) and chi squares (for nonparametric variables). Evaluations at the complicated level still assume linear relationships but involve multiple comparisons. They may include the possibility of instability but still assume a deterministic pseudo-closed system. The metaphor here is launching a rocket to the moon. There are multiple simultaneous differential equations, measurement of “actual” versus “intended” goals, and corrective systems to deal with minor instabilities. Typically, many variables are measured, promising correlations are identified, and more detailed experiments are performed to “establish causation” within these promising correlations. An example might be the hierarchical multivariate analysis of a major policy implementation (Nelson et al. 2014).1 However, Examples 1.6 (spouse abuse) and 5.1 (smoking cessation program) in this book show how this approach may come to erroneous conclusions in complex systems and highlight the need to consider critical realist approaches (described below). Evaluations at the complex level assume nonlinearity, recursive influences, and non-deterministic emergent behavior. The metaphor here is raising a child: non-­ predictable circular effects from internal (e.g., capability, mood, attention) and external (e.g., family dynamic, peer group, school) influences. Evaluation works best with multi-method, longitudinal designs followed over enough time to identify the dynamic timescales of important elements, how they interact and influence each other, and any qualitative state changes in the program. The goal is to identify the important coordination variables (internal) and control parameters (external) of the system. Examples will be provided below. This scope of evaluation should be reserved for the most important aspects of an intervention.

Choosing the Method Quantitative Methods: Quantitative methods measure presumably stable entities with numbers. These include experimental and quasi-experimental methods. Experiments are designed to test hypotheses or interventions. Ideally, they use isolation of the putative cause (independent variable) and the effects (dependent variables) and have controls for confounding influences. The randomized, double-blind, placebo-controlled trial is often considered the sine qua non of “scientific” studies under the “positivist” classical model. However, it is frequently either unethical or cost-prohibitive to conduct these, and a number of “quasi-experimental” methods have been proposed (Campbell and Stanley 1963). Experiments and quasi-­ experiments have high control and precision, but are often insensitive to context and, therefore, have low generalizability for social science research. Nonetheless, quantitative methods can be useful in the following circumstances: (1) to provide  Our program (the Centers of Excellence in Primary Care Education) was embedded in this larger VA policy change to the patient centered medical home model of ambulatory care. We have worked closely with these authors. 1

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some measures to help authenticate an anecdote; (2) as exploratory first steps to identify promising further inquiry; (3) because, to a first approximation, the experiment is relatively isolated from the environment; and (4) because the funders or institution expects this type of result. Qualitative Methods: Qualitative methods assume that meaning for an individual in a situation is a socially negotiated process (social constructivism). Therefore, qualitative data is primarily words. The dynamics of social discourse require “triangulation” (multiple points of view aimed at the same phenomenon) and “member-­ checking” (sharing preliminary conceptual models with the subjects) to support the conceptual model being developed. Methods commonly include ethnography (broad systematic study of a culture), participant observation, interviews, focus groups, and review of written documents. Qualitative methods have lower control and precision, but they are very sensitive to context and nuance. Qualitative methods are useful in the following circumstances: (1) collecting exemplary anecdotes, (2) understanding a process better by developing a potential conceptual model, (3) guiding further data collection to confirm/refute a conceptual model, (4) exposing the need for reworking or expanding a conceptual model, and (5) because the funders or institution expects this type of result. Mixed Methods: Because the strengths and weaknesses of quantitative and qualitative methods are complementary, they are often used together, either simultaneously or serially, to identify and confirm conceptual models and the impact of a program (Patton 2011; Grembowski 2001). A particularly useful mixed-method approach is realist evaluation (situated between positivism and social constructivism), which utilizes context-mechanism-outcome configurations (CMOCs) iteratively to identify and elaborate a theory (Wong et al. 2012).

Choosing the Purpose There is a sort of natural hierarchy to the purposes you might base an evaluation on. It depends on what stage your intervention is at and what the “consumers” of your evaluation are expecting. These purposes are roughly organized as descriptive, exploratory, performative, and predictive (Patton 2011: 23–26). Descriptive studies outline the classic elements: who, what, where, when, why, and how of an intervention. A potentially simpler organizing framework is what (the facts), so what (the proof of the facts), and now what (the consequences of the facts) (Ibid: 230–231). These are concrete, open-ended questions that particularly help to organize dynamic, complex environments. They are useful for identifying characteristics, trends, frequencies, and categories in the data and for comparing programs on a qualitative level. Exploratory studies take the hypothesized variables discovered from descriptive studies and examine the relationships between variables: exploring, rearranging, creating, and identifying emerging properties. Harkening back to Chap. 18 and the discussion of the adaptive cycle, this form of evaluation is particularly useful during

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the reorganization phase, after a period of creative disruption (Ibid: 207–210; Scheffer 2009). This domain is very dynamic, and a combination of quick scanning, rapid feedback, and swift adjustments is warranted. Performative studies examine the various outcomes expected as delineated in your conceptual model of how the program works (remembering it was developed using descriptive and exploratory data). A useful way to organize your thinking for this type of evaluation is a logic model with components of inputs, activities, outputs, and short-term, intermediate-term, and long-term outcomes (HRSA 2011). In the developmental evaluation framework, data from performative studies are fed back into the conceptual model to modify and adjust it. Performative data are useful for determining whether your program is working as expected and are frequently specified or required by funders. Predictive studies may be aimed at many types of predictions such as cost, time requirements, risk, transferability to other contexts, or even critical state changes (both positive and negative) within the system. Two truisms about predictive studies must be kept in mind: (1) the act of observation can affect what is observed, and (2) only that which gets measured makes it into the model. Finding naturalistic ways to obtain data and techniques to measure “difficult-to-assess variables” are important for predictive success. A unique type of predictive study, the dissemination study, is particularly important in interprofessional education programs.

Carrying Out an Evaluation Program In this section, several concrete examples are presented to solidify your understanding of the above concepts.

Descriptive Studies

Example 5.7 Resident Learning in Clinic (Descriptive) (Smith et al. 2004a) This is an example of a descriptive evaluation of the complex topic of medical resident learning in ambulatory clinic. Like many descriptive evaluations, it used primarily qualitative methods. It involved 130 h of ethnographic observations, generating 17 detailed field reports (2919 paragraphs of text). This study proceeded from broad general observations to more targeted, specific observations guided by the analysis (although the ethnographers were only told what to observe, not why—they were blinded to the analysis at the early stage). The study included two interesting methodological

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techniques. First, we employed an even mix of two types of observations, “primary process” and “key thread” observations. Primary process described the complexity of all that was happening in real time (e.g., telephone ringing, overhead pages, nurse calling for patient, conversations). Key thread observations explored the structuring behind specific interesting observations (e.g., exploring organization of nursing job tasks such as phone triage and managing patient flow). Second, analysts (not the observers) used a mix of template coding, derived from our structuring framework (activity theory) and free coding, themes that emerged from the data. It also proved important to have an analyst that was an “insider” (able to ground confusing observations in the political and historical context) and an “outsider” (able to question actions that the first analyst took for granted as “how we do things here”). The findings of this study were that breakdown, defined as an actor not achieving expected effectiveness, was the most important category of observation and was necessary for reflective learning. Effective response to breakdown required six factors: direct patient engagement, responsibility matched to authority, tools matched to tasks, information resources matched to need, values matched between co-participants, and expectations matched to capacity. In this type of evaluation, trustworthiness and generalizability of the findings can be enhanced by iteratively defining the necessary and sufficient criteria for an analytical category, grounding these categories in examples, and sampling to “saturation” (to the point of data redundancy) (Lincoln and Guba 1985). The “conceptual precision of emerging ideas and focus of data gathering” can also be enhanced by member-checking, reviewing major findings by checking back with key informants (Charmaz 2012).

Exploratory Studies Example 5.8 Organizational Culture Model (Exploratory) (Smith et al. 2000) Previous Example 3.1 (Organizational Culture Model) represents an example of an exploratory evaluation of a simple model of clinic using quantitative methods. This example tested Schein’s “organizational culture” model as a structuring tool to help explain a medical clinic that was rapidly changing to a “patient-centered medical home.” In the organizational culture model, “operators” are the frontline clinic staff (nurses, providers, receptionists, etc.) who create the work product. They rely on high levels of communication, trust, and

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teamwork. “Engineers” (information system managers and guideline developers) design the processes by which the operator group delivers its products and services, and they rely on technological accuracy that leads to reliability and efficiency. “Executives” (hospital directors, department heads) are far removed from the clinical action; they rely on imperfect information and are responsible for the strategic survival of their organization. They value low cost-to-benefit trade-offs, hierarchy, control, and coordination. Quantitative analysis confirmed significant differences between these groups in the predicted order for their answers to three questions: “Increased workload is negatively affecting quality and satisfaction,” “Guidelines and models are practical to use for daily activities in clinic,” and “[Our facility] devotes just the right amount of resources to support guidelines and models.” These differences confirmed Schein’s model. Simple quantitative studies are quite common in education. Simple experiments examine single or a small number of processes and outcomes. They assume that the experiment is “closed” and unaffected by the broader context, environment, or any unmeasured variables. Like this example, they often involve only a few quantitative outcomes and simple statistical tests of significance such as t-tests (for parametric variables) and chi squares (for nonparametric variables). It is understood that this type of study oversimplifies the actual intervention and causative inferences. However, as in this case, these studies can be useful for generating preliminary data and demonstrating research team capabilities that can help secure further funding. A complicated level of exploratory research is represented by Example 5.9 below. Data from the descriptive ethnography described in Example 5.7 above was used to create a cultural consensus analysis (CCA), a method used in anthropology to identify groups with shared or conflicting values. The data were independently reviewed by our anthropology colleagues to identify the most salient statements from the qualitative data. This set of 16 statements was modified to simplify reading level without affecting meaning and converted to 16 laminated cards, each containing one of the salient statements from the qualitative data (Smith et al. 2004b). Example 5.9 Testing CCA’s Ability to Detect Operational Problems (Exploratory) (Smith et al. 2005) This study tested the ability of the CCA cards described above to detect operational problems in five different teaching clinics. CCA card sorts with patients, medical residents, faculty, and administrators were performed. Our analysis focused on unique site-specific CCA differences. To diminish the effect of group differences observed consistently across all sites, we compared each site-specific ranking (by group and for each CCA statement) with the average

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for that group and statement across all other sites. By plotting the ranking of statements at this site against the average of all other sites, and doing this for each group, we created a box whose diagonal was the expected ranking for that statement by that group. We looked for outlier responses, those that were more than one standard deviation off the diagonal AND involved two groups in opposition (one which was more enthusiastic—above the diagonal—and one which was less enthusiastic—below the diagonal). Simultaneously, a blinded focus group of faculty, nurses, residents, other primary care providers (PAs and NPs), administrators, and patients—using a three-round Delphi process (anonymous multi-voting)—identified the biggest problems in that teaching clinic. The results of outlier CCA ranking pairs were found to be moderately to strongly associated with the problems identified by the focus groups. For instance, at site 1, the biggest problem identified by the focus group was “tension between faculty and administration over the [new] computerized medical record.” In the CCA sorting, administrators were enthusiastic outliers compared to other sites in the statement “Use the computer to check the patient record.” Faculty at this site were low-enthusiasm outliers for the same statement.

Finally, a more nuanced exploratory method that addresses the complex level is qualitative comparative analysis (QCA). This method “allows systematic cross-case comparisons, while at the same time giving justice to within-case complexity” (Rihoux and Ragin 2009). The method is particularly useful when the number of cases is relatively small. In this method, case studies are transformed into configurations of specific conditions (e.g., stimuli, ingredients, determinants) and then analyzed to determine which conditions are “necessary” and/or “sufficient” to produce the outcome of interest. Example 5.10 QCA of Australian Competencies (Exploratory) (Peddle et al. 2018) This is an example of an exploratory study with complex framing of the intervention using a particular mixed-method approach (QCA). This study addressed human factors in medical errors by analyzing competency documents from 11 health professions for 7 widely accepted nontechnical skills such as situational awareness, leadership, and communication. They discovered a notable lack of reference to “stress” and “fatigue.” It was stated that a shared taxonomy with a complete set of clear statements would best support collaborative practice and positive patient outcomes.

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Performative Studies Moving on to performative studies, we again see a wide range of methods that focus on simplified models to more nuanced analyses attempting to tease out the true complexity of interprofessional training in the clinic. Example 5.11 Ambulatory Firm System (Performative) (Smith 1995) This is an example of a performative study with simple framing of the intervention using quantitative measures. Ambulatory care was fragmented at our institution. We converted to a firm system, a team-based predecessor to the patient-centered medical home (PCMH) model. This was associated with increased continuity of care and improvement in several quality measures. Changes in these quality measures were assumed to have been the result of the intervention, but the study had only historical in-team controls and many things were changing within the institution and broader VA system during this time.

Performative studies, as in Example 5.11 above, can make simple framing assumptions using only a few outcome variables. However, more complicated experiments may better reflect the true nuance of interprofessional training in clinic. These complicated-level studies make the assumptions that the system is multi-­ linear, stable, and pseudo-closed. Example 5.12 LISREL Analysis of Patient Trust, Satisfaction, and Loyalty (Performative) (Platonova et al. 2008) This is an example of a performative study with complicated framing using a quantitative method, linear structural relations (LISREL) modeling. The study used a 64-item survey to assess eight variables: four exogenous variables (attractiveness of alternatives, switching costs, interpersonal relationships, and patient trust) and four endogenous variables (patient satisfaction, patient loyalty, intentions to recommend, and turnover intentions). Goodness of fit ranged from 0.96 to 1.00. They found that patient trust had the highest association with patient satisfaction and that these both affected loyalty.

Example 5.12 above, LISREL analysis, is focused on complicated systems. It is an approach that combines path analysis, factor analysis, and estimation of model fit to examine presumed underlying structural relationships between measured and hypothesized (latent) variables. Significance is assessed by “goodness of fit” (Bollen 1989; Violato and Hecker 2007).

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One performative method that focuses on the complex level is social network analysis (SNA) as in Example 5.13 below. Example 5.13 Pilot Study of SNA to Detect Structural Changes (Smith et al. 2023) This study used social network analysis (SNA)—a method that examines “actors” (nodes) and “relationships” (connecting lines) to reveal important insights about network structure—to look at co-presentation by more than one profession at teaching conferences in our interprofessional teaching clinic. Over the 4 years of the study (early in our interprofessional teaching clinic grant), the analysis revealed a change from a physician-dominant hierarchical structure to an egalitarian, profession-balanced “small world” structure.

Predictive Studies As exemplified by weather reports, predictive studies in complex systems require sophisticated methods and may only be accurate in the short term. Quasi-experiments in complex systems, such as interprofessional education, have very different core assumptions. They accept the interdependence, nonlinearity, and dynamics of interventions and the incredible sensitivity of outcomes to contextual features. Example 5.14 Developing a PCMH Implementation Index (Predictive) (Nelson et al. 2014) In 2010, the Department of Veteran Affairs (VA) began implementing a new model of ambulatory care called the patient-centered medical home (PCMH) designed to improve care through team-based continuity, improved access, and care management. A large database study was conducted (5.6 M veterans, 913 clinics, 5404 primary care staff) in order to create an index that measures the degree of PACT implementation. Composite scores of 53 items were constructed in eight major PACT categories using hierarchical multivariate analysis and other methods. High and low performance on this index was highly associated with independent measures of patient satisfaction, quality of care, hospital admissions for ambulatory-sensitive conditions, emergency department visits, and provider burnout.

These elite predictive studies attempt to address the nonlinearity of complex interventions through sophisticated statistical methods such as applied regression analysis, analysis of variance, and other multi-linear models (Glantz and Slinker 1990; Kleinbaum et al. 1988).

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Finally, a very powerful version of complex assessment in interprofessional education is the context-mechanism-outcome configuration (CMOC) of critical realism (Wong et al. 2012; Pawson and Tilley 2004). This method allows that the context of an evaluation has objective properties grounded in the real world (unknowable to us) and is influenced by social realities, norms, and expectations. The method is applied in sequential phases, beginning with a contingent, working context-­ mechanism-­outcome hypothesis. Then, data is purposefully collected to clarify the contexts, interventions (including opportunities or resources), mechanisms, and outcomes. Finally, relationships between contexts, mechanisms, and outputs are expressed (Pawson and Tilley 1997). This process is iteratively repeated to refine the hypothesis. Example 5.15 below shows this in action. Example 5.15 Realist Evaluation of an IPE Program for Medical Students (Predictive) (Haruta and Yamamoto 2020) The authors used a realist approach to evaluate a new interprofessional shadowing program at a community hospital in Japan. Although the mechanisms were initially hidden, many were subsequently revealed. Students felt that the rotation was legitimate, they became aware of their physician-centered thinking, and they deepened their sympathetic understanding toward other professionals. The study had implications for the design, implementation, and evaluation of IPE curricula in the future.

Planning an Integrated Multi-study Program It may be useful to plan a series of integrated studies that roughly follow this hierarchy of designs. Each would be contingent, and later study designs would be modified by the findings from the earlier studies. The final Example 5.10 demonstrates this as we focused on a particular activity in our interprofessional curriculum, an interprofessional care conference for high-risk primary care patients. Example 5.16 A Series of Studies of a Specific Intervention: PACT-ICU (Comprehensive) Study 1. The EFECT Model (Exploratory) (Bitton et al. 2013): This study was the outcome of one workgroup at an educational summit. The workgroup used a multi-round Delphi method (anonymous multi-voting) to identify the important educational learning competencies in the new patient-centered medical home model of care and training. These competencies were summarized with the EFECT model: Eliciting the patient-centered narrative, Facilitating a reflective team discussion, Evaluating the clinical evidence, Creating a shared care plan, and Tracking outcomes.

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Study 2. The PACT-ICU (Descriptive) (Weppner et al. 2016): This was a detailed description of a new clinical/curricular element, the Patient Aligned Care Team Interprofessional Care Update (PACT-ICU), based on the EFECT model and designed to provide team-based care to high-risk patients. It described the faculty-trainee roles, meeting structure, anticipated areas covered by each profession, lessons learned, and next steps. Study 3. Impact of PACT-ICU on Metabolic Parameters (Performative) (Buu et al. 2016): The performative impacts of PACT-ICU were conceptualized in three domains: patient outcomes, learner outcomes, and clinic-level outcomes. This study was a simple retrospective observational pre/post-­ analysis of chronic disease outcomes. It showed nonsignificant trends toward improvement in HgbA1c and BP. It was an opportunistic study with very small numbers of patients. Study 4. Impact of PACT-ICU on Learner Outcomes (Performative) (Sordahl et  al. 2017): This study examined learner outcomes using simple system methods (self-report survey, pre/post-changes in consult patterns). Significant improvements in knowledge about a holistic approach to patient care and team member roles occurred for trainees, staff, and faculty. In addition, there was a significant increase in within-primary care team consults. Study 5. Impact of PACT-ICU on Quality and Utilization (Performative) (Weppner et  al. 2018): This study looked at clinic-level outcomes with a sophisticated (complicated) design. The PACT-ICU team and a control team were compared using repeated measure ANOVA. This analysis demonstrated an increase in primary care team visits without an increase in primary care provider visits. There was a trend toward decreased urgent care and ED visits and significantly fewer hospitalizations. There was no difference between groups in the trend toward improvement in HgbA1c and BP. Study 6. Dissemination of PACT-ICU (Predictive) (King et  al. 2017): Although these studies individually showed modest results, the package seemed powerful, and we predicted that patient, trainee, and clinical care would improve if the model was adopted. We used the RE-AIM framework to evaluate this dissemination (Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance) (Glasgow and Vogt 1999). The PACT-ICU conference was successfully disseminated to all four sites and maintained at three, with similar trainee and patient outcome improvements as those at our own site, suggesting fidelity of the implementation process.

Summary Interprofessional training programs are complex. There is a strong trade-off between the cost and difficulty of an evaluation and the trustworthiness and generalizability of its findings. However, focused, simple, quantitative studies can be useful,

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particularly in support of anecdotal qualitative findings and/or as part of a larger program of evaluation. In general, sophisticated mixed-method approaches are ideal. These might include hierarchical multivariate techniques, analysis of variance, cultural consensus analysis, LISREL analysis, qualitative comparative analysis, social network analysis, implicit association tests, critical realist CMOCs, and many others. Planning the evaluation is paramount and should begin as the intervention is being designed. Sidebar 5.3 Evaluation Checklist • Who is the evaluation for? • What is the evaluation trying to accomplish? • Choosing a level of interest: –– Simple (easy, inexpensive, hard to generalize)—a recipe –– Complicated (multi-linear, deterministic)—moon shot –– Complex (nonlinear, emergent)—raising a child • Choosing a method: –– Quantitative (high control/precision, insensitive to context)—numbers –– Qualitative (very true to context and nuance, low precision)—words –– Mixed methods (complementary)—both • Choosing a purpose: –– –– –– ––

Descriptive Exploratory Performative Predictive

References Bitton A, Pereira AG, Smith CS, Babbott SF, Bowen JL. The effect framework for interprofessional education in the patient centered medical home. Healthcare. 2013;2013(1):63–8. Bollen KA. Structural equations with latent variables. New York: Wiley; 1989. Buu J, Fisher A, Weppner W, Mason B. Impact of patient aligned care team interprofessional care updates on metabolic parameters. Federal Practitioner; 2016. p. 44–8. Campbell DT, Stanley JC.  Experiments and quasi-experimental designs for research. Boston: Houghton-Mifflin, Co.; 1963. Charmaz K. Constructing grounded theory. Thousand Oaks, CA: Sage Publications; 2012. p. 111. Dulay M, Saxe JM, Odden K, Strewler A, Lau A, O”Brien B, Shunk R.  Promoting quality improvement in primary care through a longitudinal project-based interprofessional curriculum. MedEdPORTAL. 2020;16:10932. https://doi.org/10.15766/mep_2374-­8265.10932. Glantz SA, Slinker BK.  Applied regression and analysis of variance. New  York: McGraw-­ Hill; 1990.

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Glasgow RE, Vogt TM. Evaluating the public health impact of health promotion interventions. The RE-AIM framework. Am J Public Health. 1999;89(9):1322–7. Grembowski D.  The practice of health program evaluation. Thousand Oaks, CA: Sage Publications; 2001. Haruta J, Yamamoto Y. Realist approach to evaluating an educational program for medical students in clinical practice at a community hospital. Med Teach. 2020;42(1):101–10. HRSA.  HRSA Health Workforce Training Program Evaluation Toolkit. 2011. https://www.cdc. gov/eval/framework/index.htm. Accessed 7 Dec 2021. King IC, et  al. Translating innovation: exploring dissemination of a unique case conference. J Interprof Educ Pract. 2017;6:55–60. Kleinbaum DG, Kupper LL, Muller KE. Applied regression analysis and other multivariable methods. Boston: PWS-KENT; 1988. Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park, CA: Sage Publications; 1985. p. 202. Nelson KM, et al. Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Intern Med. 2014;174(8):1350–8. Patton MQ. Developmental evaluation. New York: Guilford Press; 2011. p. 194. Pawson R, Tilley N. Realistic evaluation. Thousand Oaks, CA: Sage Publications; 1997. Pawson R, Tilley N. Realist evaluation. London: Cabinet Office; 2004. Peddle M, Bearman M, Radomski N, Mckenna L, Nestel D.  What non-technical skills competencies are addressed by Australian standards documents for health professionals who work in secondary and tertiary clinical settings? A qualitative comparative analysis. BMJ Open. 2018;8:e020799. https://doi.org/10.1136/bmjopen-­2017-­020799. Platonova EA, Kennedy KN, Shewchuck RM. Understanding patient satisfaction, trust, and loyalty in primary care physicians. Med Care Res Rev. 2008;65(6):696–712. Rihoux B, Ragin CC.  Configurational comparative methods. Thousand Oaks, CA: Sage Publications; 2009. Scheffer M. Critical transitions in nature and society. Princeton, NJ: Princeton University Press; 2009. p. 76. Smith CS. The impact of an ambulatory firm system on quality and continuity of care. Med Care. 1995;33(3):221–6. Smith CS, Francovich C, Gieselman J. Pilot test of an organizational culture model in a medical setting. Health Care Manag. 2000;19(2):68–77. Smith CS, Morris M, Francovich C, Hill W, Gieselman J. A qualitative study of resident learning in ambulatory clinic. Adv Health Sci Educ. 2004a;9:93–105. Smith CS, Morris M, Hill W, Francovich C, McMullin J, Chavez L, Rhoads C. Cultural consensus analysis as a tool for clinic improvements. J Gen Intern Med. 2004b;19:514–8. Smith CS, et al. Testing the exportability of a tool for detecting operational problems in VA teaching clinics. J Gen Intern Med. 2005;21:152–7. Smith CS, Fisher AK, King IC, Naidoo SW.  Pilot study of repeated social network analysis to assess (SNA) to assess structural changes in an educational program evaluation. SN Soc Sci. 2023;3(20). https://doi.org/10.1007/s43545-­022-­00592-­5. Sordahl J, et al. Interprofessional case conference: impact on learner outcomes. Transl Behav Med. 2017;8(6):927–31. Violato C, Hecker KG. How to use structural equation modeling in medical education research: A brief guide. Teaching and Learning in Medicine. 2007;19(4):362–71. Weppner W, et  al. Interprofessional care conferences for high-risk primary care patients. Acad Med. 2016;91(6):798–802. Weppner W, et al. Impact of a complex chronic care patient case conference on quality and utilization. Transl Behav Med. 2018;8:366–74. Wong G, Greenhalgh T, Westhorp G, Pawson R. Relist methods in medical education research: what are they and what can they contribute? Med Educ. 2012;46:89–96.

Chapter 24

Conclusions

So, what is the ecosystem of interprofessional education? Interprofessional education, as a system, is influenced by a complex tapestry of human sub-systems: the physical facility and healthcare system within which it occurs, professional training and socialization, economic resources, trainee levels in their hierarchy of needs, conceptual models of illness, social determinants of health, spiritual beliefs, and many others. Each sub-system has its own characteristic natural timing, resonant frequency, and sphere of influence. Taken together, they reinforce or dampen each other, leading the system as a whole to switch periodically and spontaneously from one coherent attractor state to another. This cannot be understood only with the classical model of the world as stable entities interacting through singular forces in predictable ways. How then are interprofessional education curriculum designers supposed to intervene? What principles can guide us as we create interprofessional training at the liminal border between order and chaos? In this book, I advocate for approaching interprofessional education broadly as a dynamical ecosystem. Instead of looking for predictable linear causes and effects, we expect to find feedback loops, resonance, and nonlinear emergent causation. Instead of a recipe, we expect to follow coordination variables and control parameters to better understand the story of quasi-stable attractors in the system and potential state changes between them. The ecological approach suggested here focuses on a network of organism-­ environment relationships. One important window into this model is affordances, features in the environment that afford niche-specific opportunities for action to an individual. Another is the lifeworld, the set of features (affordances) that an organism is capable of noticing and utilizing. Finally, in our complex human environment, most of the affordances that we interact with are human-created. Behavioral settings are ways we humans structure the environment—permit, support, or resist individual behaviors—through human-constructed affordances (rule books, speed bumps, “quiet” signs, etc.).

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The task of the interprofessional curriculum designer is to structure the environment (behavioral setting) in such a way so as to expand the lifeworld of trainees in order to be able to find and utilize critical healthcare affordances. These critical healthcare affordances will be relatively invariant features based on deep underlying laws and principles. However, because these laws/principles are dynamic, and our perception is imperfect (limited, subject to socially generated expectations), we must infer them—slowly building them up from observations, reflection, dialogue, and experimentation. Indeed, if critical realism is correct, we cannot directly access natural laws and principles. So, how do we infer them? One approach is suggested by a large qualitative study our team did of teaching clinic (Smith et al. 2004). This study found that breakdown, “a situation where an actor (person or computer) or the group is not achieving expected effectiveness,” was a necessary ingredient for reflective learning. In interprofessional education, we are seeking to identify breakdowns, interruptions, or dissonance, particularly between professions. We explore these as bifurcations, choice points between different beliefs, and points of view … as complementary pairs. Then, following critical realism, we look for a logically higher level that might unify these, often dichotomous, points of view. Within that higher level, we search for affordances, invariant features of the individual-environment relationship, that may represent coordination variables (internal to the system) and/ or control parameters (external to the system). As interprofessional breakdowns and disturbances are identified—such as erroneous assumptions, biases, and stereotypes—they should gently be brought forward for reflection deliberation and group discussion. Care must be taken to make these experiences safe for all participants. Creative exercises such as gamification (Example 1.4, page XX), flip chart exercises (Example 2.1, page XX), and the like can help in the initial stages of group development. As the group matures, real-time projects that explicitly posture participants as experts in their field of practice can fine-tune acceptance, trust, and teamwork skills (Example 2.6, high-risk care conference, pages XX/XX; Example 5.16, A series of studies ..., pages XXX/XXX). Closing the feedback loop through evaluation also requires creative thinking. Some concrete outcome changes based on traditional models of cause and effect, such as a decrease in ED visits from the clinic panel, can help document value and frame further inquiries. To evaluate the breadth of the curriculum comprehensively often requires multi-method techniques that are sensitive to cultural changes: methods like cultural consensus analysis (Example 5.9, page XXX/X), qualitative comparative analysis (Example 5.10, page XXX), or social network analysis (Example 5.13, page XXX). These results begin to identify potential coordination variables and control parameters that can then be manipulated. While this does not lend itself to randomized controlled trials, it does provide evidence for a narrative about mechanisms of team function and effectiveness. What stance should interprofessional curriculum developers take? I believe that Rachel Naomi Remen (1999) said it best in her essay Helping, Fixing, or Serving. These represent different ways of seeing the world (and the training project). “When you help, you see life as weak. When you fix, you see life as broken. When you

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serve, you see life as whole.” “Fixing and helping create distance [a space between the teacher and trainees]. But, we cannot serve at a distance … from the perspective of service, we are all connected.” We should not deliver a curriculum but, instead, serve the growth and development of our trainees.

References Remen RN. Helping, fixing or serving? Shambhala Sun. 1999. Smith CS, Morris M, Hill W, Francovich C, Gieselman J. A qualitative study of resident learning in ambulatory clinic. Adv Health Sci Educ. 2004;9:93–105.

Glossary

Affordance  Reciprocal relationships between potential resources in the world and an organism. They must be noticed and utilized to be effective. Alternative Stable States  A bifurcation point in a dynamical system (e.g., “heads” or “tails” in a coin flip). Once a new state is reached, it is very difficult to return to the original state (e.g., algae bloom in a lake with increased nitrate runoff). Behavioral Setting  A human-made, social level of affordances that create permissive, supportive, or restrictive influences on behavior (e.g., a speed bump). Complementarity  Complementary pairs (e.g., wave/particle) are both valid perspectives; you cannot employ them simultaneously, and you need both of them for a complete description of a system. They are usually resolved at the next higher logical level (e.g., “wavicle”). Complex Adaptive System Self-organizing networks of interactions between multiple agents. Can exhibit unpredictable emergent behaviors and phase transitions (between alternative stable states). Control Parameter  An important variable from outside the system that influences the “state” of the system (e.g., applied heat when a pan of water boils). If it cannot cause a state change, it is not a control parameter. Coordination Variable  Key aspects of collective behavior inside the system that explain the state change. For the pan-of-boiling-water example above, these might be surface tension between and average kinetic energy of water molecules that involves a threshold phenomenon. Critical Realism  A philosophical position with a commitment to naturalism (mind-­ independent reality), but not to the foundational position of elementary particles or substances. It assumes a stratified, multimodal, dynamical world in which underlying causal mechanisms are not directly observable but must be inferred by agreement with a theory used to make a description or support an action. Effort After Meaning  Exploratory behavior. Leaving a current state-space to find a better one that may have more or better affordances.

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Effort After Value  Exploiting the affordances one has “at-hand.” Staying in the current state-space. Emergence  New features or properties appearing from an ensemble of individuals. Makes “the whole greater than the sum of the parts” and makes dynamical complex systems nonlinear and, thus, unpredictable. Identity  The fact of being, or feeling that you are, a particular type of person. Social identity (Worthiness) Role identity (Competence) Personal identity (Authenticity) Legitimate Peripheral Participation  A model of “apprentice” learning in which the learner is legitimate (sanctioned) and peripheral (close to the expert performance of a task) and participates in an authentic part of the task commensurate with their knowledge and skill. For instance, a student in the emergency room during a “code blue” is part of an expected curricular rotation (legitimate), observing the expert performance of life support (peripheral), and may draw blood for analysis (participates), a level commensurate with their skills. Lifeworld  The field of affordances that the individual is attuned to and can appropriate. Learning, then, is expansion of the lifeworld.   Intrinsic Expansion: Time-on-task improves our powers of discrimination for affordances even without instruction or direct feedback. Consciousness of the affordance is not required.    Mediated Expansion: Using external means such as books, videos, and instruction to facilitate acquisition of new affordances for learners. Semiotics  A theory of meaning-making that posits a triad consisting of object (O— the focus of attention), sign (S—a token that stands for the semiotic triad), and an interpretant (adjudicates the significance of the S–O relationship). Signs (tokens) have three types: iconic (similarity), indexical (physical/temporal connection), and symbolic (abstract convention, generalizable). A broader version, biosemiotics, replaces this triad with affordance (object)— potential resource. Information when perceived, value when used, indicator (sign)—becoming aware of a lifeworld signal—and meaning (interpretant)— receptivity (attracted to/repulsed by). Includes history and possibility. Recognition of a “difference that makes a difference.” Stratification  The tendency for complex systems to be layered, with each level affecting those above and below it. To be a successful entity, these influences must be coordinated. Structural Coupling  A relationship between an organism and the affordances in the environment. Leads to differentiation over time and forms the basis of development from novice to expert.

Index

A Actual events, 1, 19, 96 Affordance, 2, 3, 9–13, 20, 21, 23, 25–27, 29–33, 45–47, 49, 50, 53, 58, 61, 63, 64, 69, 73, 90, 94, 102, 116, 122, 125, 126, 143, 144 Alternative stable states (bifurcation), 107 Analytical perspective, 53 Archetypes, 54, 55, 58, 82 B Behavioral settings, 3, 63–65, 70, 116, 143, 144 Bhaskar, R., 19, 20, 95 Bohm, D., 25 Boundaries, 16, 17, 63, 64, 70, 77, 81–84, 89, 91, 92, 100, 105, 115, 116 Bridges, 81–84 C Classical model, 15–18, 29, 67, 116, 130, 143 Collective unconscious, 54, 55, 58 Complementarity, 3, 99–102 Complex adaptive systems, 1, 3, 17, 89–96, 123 Contiguity, 15, 16 Control parameters, 92–95, 100, 106, 107, 109, 110, 112, 122, 123, 130, 143, 144 Coordination dynamics, 3, 93, 101, 105–108 Coordination variables, 92–94, 105–107, 109, 110, 112, 123, 130, 143, 144 Crews, 115–117, 121, 123, 125–127

Critical realism, 19–23, 26, 32, 96, 100, 116, 138, 144 Critical state change (tipping point), 100, 109, 123 D Descriptive studies, 131 Determinism, 17, 90, 92 Direct perception (1st order awareness), 9, 32, 46 Dispositions, 25, 26, 31 Doctrine of cultural realism, 21 Dynamic theory of perception, 41 E Effort after meaning, 32, 64 Effort after value, 64 Emergence, 20, 73, 89, 91–93, 95 Emotion, 2, 9, 17, 20, 21, 29, 35, 39, 40, 45, 49, 55, 71, 93 Emotional entrainment, 68 Empirical events, 1, 19, 22, 96 Enabling constraints, 2, 50 Evaluation level of interest, 129–130 method, 130, 131 planning, 129–132, 138–140 purpose, 131 Exploratory studies, 131, 133–136 F Feedback loops, 17, 35, 95, 122, 125, 143, 144

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150 G Gibson, J.J., 9, 10, 32, 61, 63, 101 Group coordination, 122 I Identity, 2, 3, 21, 36, 49, 77–79, 84, 94 Indicators, 73 Inside/Outside, 27, 133 Inter-causal impact, 20, 100 Interpretants, 71, 73 Intersubjectivity, 68 Intransitive/transitive, 22 Intrinsic expansion (of the lifeworld), 45–47 J Jung, C., 53, 54

Index Performative studies, 132, 136–137 Person identity (authenticity), 3, 79 Practical order, 21 Predictive, 131, 132, 137–139 Primary process, 41, 133 Prospective hindsight, 49 R Real (events), 1, 11, 19, 20, 25, 26, 33, 91, 95, 96, 101, 133, 138 Realist evaluation, 20, 21, 131, 138 Recognition-primed decision making, 46, 49, 73 Reductionism, 15, 17, 18 Rituals, 3, 6, 57, 58, 61, 67–70, 81 Role identities, 3, 36, 78 Rules, 1, 2, 6, 7, 18, 23, 26, 27, 32, 33, 41, 42, 46, 49, 50, 61, 64, 69, 72–74, 83, 88, 91, 102, 115, 122, 123

K Klein, G., 46, 47 L Laughlin, R., 18 Life-world, 2, 3, 31–33, 45, 73, 116, 125 M Macro-state, 2, 17, 53, 99 Mediated expansion (of the lifeworld), 2, 32, 33, 49–51 Micro-state, 2, 17, 53, 55, 99 Mindfulness meditation, 55, 56, 58 N Natural frequency, 108 Natural order, 21 Neutral monism, 19, 20 O Objectivity, 15, 16, 18 Objects, 10, 11, 15, 16, 25, 27, 31, 56, 68, 69, 71–73, 77, 84, 99 P Panarchies, 94, 108, 109 Pawson, R., 20, 21 Perception-of-care map, 22

S Satisficing, 47 Secondary process, 41 Self, 35, 36, 54–56, 77, 78, 81, 87 Self-creation, 89–91, 93 Semiotic cascades, 71–73 Semiotics, 71–74 Signs, 11, 12, 29, 31, 49, 57, 71–73, 78, 79, 84, 143 Small worlds, 49, 50, 109, 123, 137 Social capital, 69, 82, 102 Social identity (worthiness), 3, 36, 78, 79 Social order, 21, 36, 78 Stories, 2, 3, 6, 46, 57, 67–70 Stratification, 1, 19, 89, 93–96 Strength of coupling, 106 Structural coupling, 1, 89, 90, 95 Symbols, 31 Synchronicity, 54, 55 T Task force, 115–117, 121, 123–125 Teams, 3, 6, 22, 23, 49, 50, 61–63, 65, 68, 77, 78, 82–84, 88, 93, 102, 105, 106, 109, 115–118, 121–126, 134, 136–139, 144 Thinking Fast and Slow, 41 Tilley, N., 20, 21 Triune brain, 39

Index U Uexküll, J., 31

151 W Waldrop, M.M., 17