In this article, we report findings from the first qualitatively driven study of patient–clinician communication in Hong Kong Accident and Emergency Departments (AEDs). In light of the Hong Kong Hospital Authority’s policy emphasis on patient-centered care and communication in the public hospitals it oversees, we analyze clinicians’ perceptions of the role and relevance of patient-centered communication strategies in emergency care. Although aware of the importance of effective communication in emergency care, participants discussed how this was frequently jeopardized by chronic understaffing, patient loads, and time pressures. This was raised in relation to the absence of spoken interdisciplinary handovers, the tendency to downgrade interpersonal communication with patients, and the decline in staff attendance at communication training courses. Participants’ frequent descriptions of patient-centered communication as dispensable from, and time-burdensome in, AEDs highlight a discrepancy between the stated Hong Kong Hospital Authority policy of patient-centered care and the reality of contemporary Hong Kong emergency practice. It is now internationally recognized that effective communication in health care is integral to ensuring patients’ safety and satisfaction with the quality of care they receive. Over the last two decades, researchers have successively linked effective patient–clinician communication with positive patient health outcomes, including patients’ satisfaction with, and confidence in, clinicians, adherence to recommended treatment, and accurate diagnosis  has also sought to advance a model of patient-centered care and communication. It posits patient-centered care as a core value driving health care delivery in the hospitals it oversees, and cites effective “two-way communication” as “indispensible for understanding and meeting a patient’s needs” . Moreoveinicians . Despiteinicians  and patiinicians . Hong Koinicians , p. 109.From a research perspective, AEDs provide unique contexts in which to study clinician–patient communication. Patients typically present as strangers to the AED, with no readily accessible medical records or established relationships with the clinicians (nurses or doctors) who will be treating them . PerhapsTo date, Hong Kong–based researchers have investigated the effectiveness of communication within AEDs through a quantitative lens, assessing the quality of clinicians’ communication practices through retrospective analyses of patients’ complaints or surveys of patients’ satisfaction . We sougIn this article, we report on the second and third components of this study, presenting the views of clinician participants—what they identified as important in their communication with patients and colleagues, their reported strategies for communicating effectively, their views on the relevance of interpersonally sensitive and patient-centered communication in their work, and what they perceived as impeding efficient and effective communication with patients in the AED , 27% for between 3 and 6 years (n = 16), and 52% for 7 years or more (n = 30). All identified Cantonese as their first language.Twenty-two doctors and 36 nurses completed the questionnaire. Respondents from both professions had varying degrees of seniority and work experience within the AED: 21% had worked in the AED for 2 years or less , and 16 individually (with 16 interviewees). Interviewees’ work experience in emergency care ranged from 1 year to 23 years in the case of nurses and from 2 years to more than 25 years in the case of doctors. Fifteen interviews were conducted in Cantonese. The remainder were in English. All interviewees had previously completed the questionnaire.organizational, informational, and interpersonal  staff shortages as posing serious communication obstacles between patients and clinicians—obstacles which, if not overcome, can jeopardize patients’ safety .Many interviewees (in particular nurse interviewees) discussed the impact of long working hours on staff morale and how this, when coupled with increased patient loads and demand, often resulted in very tense and regimented interactions with patients in their care. All interviewees, both doctors and nurses, regardless of discipline, level of seniority, or length of experience in the AED, at some point reflected on how time limitations and the nature of the emergency service they were working within tested their communication skills. This concern is supported by the questionnaire findings. More than 50% of questionnaire respondents cited long working hours as either “always” or “sometimes” negatively impacting on their ability to communicate effectively . Several interviewees reported working at minimum 12-hour days throughout their working week. Others discussed being regularly called into work on pre-organized leave days. This level of demand on staff was confirmed by nearly 90% of questionnaire respondents. A reported roll on effect of the level of understaffing at the AED reported in the interviews was that clinicians were no longer being encouraged or permitted to undertake communication training, unless they did so during their personal time. Indeed, two managerial staff who participated in a joint interview stated that the high degree of understaffing within the AED made it virtually impossible for them to release their staff to attend the communication training courses available and promoted by the Hospital Authority: “I cannot assign the basic manpower to the clinical [work] . . . How can I take out some nurse for training?” . These managers made it clear that while the staff shortage continued, clinicians’ attendance to communication training courses would continue to decline : “We have so many courses for communication tailor-made for nurses, doctors or other staff . . . but we don’t have time to send the nurses to go to those” . Notably, they did so while acknowledging the links that research has made between clinicians’ attendance and patient satisfaction, and indeed the Hospital Authority’s current policy emphasis on improving clinicians’ patient-centered communication skills.Interviewees’ reflections on the degree to which organizational factors affected their abilities to effectively communicate with patients were very closely linked to further discussions on the means and modes through which patients’ information was communicated among clinicians and in patient–clinician interactions. This was particularly apparent in interviewee discussions of clinical handover practices, that is, how, what, and when patient information and responsibility was transferred between clinicians over the course of a patient’s journey through the AED.Clinical handover in this AED was described as single disciplinary , and often delivered through written notes on medical files as opposed to face-to-face communication. That said, interviewees reported no prescribed or regular method of handing over patient information to each other: verbal or written, informal or formal—although face-to-face handover was stated by one doctor as the preferred method for medical staff if time allowed. Handover between nurses was described by many interviewees as a relatively ad hoc or even “rare” practice dictated by the time pressures and patient loads of each shift. . . . if you want to have a handover, you may spend at least 15 to 20 minutes; but patients still keep coming in! You can’t stop your service for the handover . . . so it will be practically very difficult for us to do a formal handover between doctors and nurses. Formal handover between nurses and doctors was described as exceptional by interviewees of both disciplines. Rather, interdisciplinary communication in the course of the AED patient’s journey was reported as occurring through brief written notes on the patient’s files. This was often justified by reference to what n = 15) reported problems associated with interdisciplinary communication. The vast majority,  did not perceive the current practice as problematic. Nonetheless, the routine absence of interdisciplinary handover or structured interdisciplinary communication arguably did affect the quality of the care patients received. Nurse interviewees regularly reported that they would often find patients who had not been provided with appropriate information on the treatment and medication they would receive and in some cases were not informed of their discharge instructions, or indeed whether they were being discharged from the AED at all. With doctors assuming that nurses would take on the “cover-up” role and nurses assuming that doctors would take charge of explanation (without communicating this to one another), patients would not receive information on post-consultation treatments and the subsequent steps involved in their care trajectories. Thus, while interdisciplinary handovers were often dismissed as timewasting, their absence created further time-burdens, with nurses often describing having to “chase” doctors to obtain the unwritten explanations of diagnosis and treatment. Omissions in information-giving were reported as particularly prevalent at discharge which, according to our follow-up patient interviews, sometimes resulted in patients’ lack of understanding of their diagnosis and thereby lack of compliance with treatment. From one nurse’s perspective, this was accentuated in situations of patients’ admissions to hospital wards, at which time “it’s not likely that a lot of [patients] get to see the doctor” (Interview).Among questionnaire respondents, only 26% Nurses were not alone in reporting inadequate information-giving to patients. As one doctor commented,Some nurses accepted that part of their role was to take on greater patient education responsibilities as a consequence of the greater organizational burdens placed on emergency physicians: “The doctors . . . have a quota. They need . . . to see the patient and then they have to see the next one. So maybe they don’t have time to educate the patient more” ; others perceived this as falling beyond the scope of their knowledge and responsibilities: “Actually if you ask me, I think . . . it’s the doctor’s responsibility [to explain] why we need to do such treatment . . . Because s/he is the person to order treatment, they should be the ones to explain” . For several, regardless of the doctor’s intentions to move on to other patients, in situations where they felt ill equipped to provide patients with adequate explanations they would ultimately insist on the doctor re-visiting the patient.n = 19) reported adverse incidents “sometimes” occurring because of failures in communication during handover. This, when coupled with interviewees’ accounts of handover practices within the AED in general  suggests that further research is warranted exploring the extent to which contemporary Hong Kong handover practices might negatively impact on patients’ AED treatment  but also back and forth between a multidisciplinary team of clinicians and the patient, and across languages. As one senior doctor described it, the multilingual nature of Hong Kong AED work can be seen in “two parts. One is you get the history from [the] patient in Cantonese and then you need to write in English. The second part is we learn in English, we tell the patient in Cantonese . . . ”n = 28) than when translating patient provided information in Cantonese to written English medical records . Interviewees were similarly more likely to describe difficulty in communicating English medical diagnoses in Cantonese to patients. This was largely put down to there often being no corresponding Cantonese phrases to the English medical terms. One way clinicians discussed overcoming this was to consult an English–Cantonese glossary. Where this failed, clinicians described adopting descriptive and “everyday” Cantonese terms to provide their patients with more accurate understandings of their conditions or treatments.Slightly more questionnaire respondents reported information sometimes becoming lost or changed in the translation of English medical knowledge to spoken Cantonese when communicating with patients .Many interviewees reported that when communicating with non-native Cantonese or English speakers, they would greatly simplify their language and, where this failed, rely on physical cues to ascertain the nature of the presenting patient’s ailment  of questionnaire respondents rated the importance of establishing empathy and rapport with patients as “high,” 53% (n = 31) described it as of “medium” importance. Only 22% (n = 13) cited the impact of time pressures on communication as unique to emergency medicine.)Interviewees provided divergent characterizations of the relationship between AED staff and patients. Some described their relationship with patients in business terms: “We are delivering a service to our patients . . . They’re actually our clients” (Senior Doctor). Rather than minimizing the importance of interpersonal communication with patients under their care, those who perceived AED patients as consumers of a medical service were often more likely to view securing patient satisfaction with the health care they received through building rapport as an essential component of their work. A significant number of interviewees, however, did frame building empathy and rapport with patients as a privilege, one that was more available to clinical staff outside the AED. Often this was expressed by reference to the shorter timeframes within which patients received care within the department. Indeed, some nurses reflected on how they would purposively minimize interpersonal communication with patients in an effort to get through the triage waiting list as quickly as possible.Nurses will not introduce themselves or their role in triage, because triage is so busy . . . they don’t want to talk too much to the patient, because if you build up rapport with the patient, they will ask, they will talk more and more. We have no time to . . . do that. n = 37) of questionnaire respondents stated “sometimes” and 19% (n = 11) stated “always.” As one nurse interviewee described it,[W]hen we . . . work in triage, we handle one case in two or three minutes. . . . Therefore we have . . . very little time to talk with the patient, . . . educate our patient or even to reassure our patient . . . We need to . . . concentrate on our assessment, history taking, and also the vital sign taking. Other than that, we are in a hurry for the next turn. Triage is the first stage in patient care within the AED. It represents the first encounter patients will have with clinicians and as such sets the stage for patients’ impressions of the quality of health service they will receive , p. 617.You tell me, you need time to build up empathy. If I spend 15 minutes to build empathy with the patient, then later the nursing officer will . . . complain [to] me . . . “you don’t do triage. Instead of doing the talking or the counseling the patient—it’s not your role—you have to make the triage first.”At least two nurse interviewees expressly rejected patient and policy expectations that they adopt more patient-centered communication strategies in triage, with one indicating that to do so would subject them to extensive criticism from their nursing peers:For several of those working beyond the triage desk, however, the time-strapped nature of emergency care led to the reverse view: developing rapport and empathy was essential to ensure not only patient satisfaction but also patient safety in terms of accurate diagnoses and patient compliance with treatment. For these interviewees, seeking out the patient’s agenda was regarded as the most important step in achieving rapport with, if not in delivering the best care to, their patients. Many interviewees however discussed a conflict between patients’ expectations and what was possible to achieve within the AED context. For some nurses, the unpredictable nature of the AED terrain made it difficult to always provide patients with the information they sought.We aren’t familiar with the patients . . . We have a reference frame [but] sometimes you just can’t answer what they ask. Sometimes . . . they ask things that are in the far future: “ . . . Can s/he recover? Can s/he walk again?” These, [questions we] can’t really give an answer [to] . . . For several doctors, episodes of patient dissatisfaction with the AED staff stemmed from mismatches between patients’ expectations of the kind of treatment offered and the reality of emergency medicine.A lot of patients think that they’re not dealing with emergency cases in the AED . . . Once they arrive, they say that they have to screen this and that, take a look at this and that. Because they can’t afford the private [clinics], they’re here . . . So I think how it turns out is that they come here [and] we cannot offer them [what they expect] . . . Sometimes they may have waited for a few hours and turns out they don’t get much in the end. Managing patients’ expectations of the nature of AED treatment was thus seen by many as integral to ensuring more effective and positive staff–patient interactions. While the Hong Kong Hospital Authority has introduced measures directed at improving patients’ understanding of the precise role and nature of AED services A few triage nurses we interviewed did discuss the small (and time-cognizant) measures they adopted to help patients understand the AED process and let them know their presence was not being ignored by staff, despite lengthy waiting times. These interviewees reported that they would often perceive a marked difference in patients’ attitudes and expressed frustrations with the AED system and staff following verbal acknowledgment, however brief, of the patient’s discomfort. Indeed, as one nurse observed, the expression of empathy often had a more positive impact on patient satisfaction than just attending to their physical needs:Another recommended patient-centered care strategy for orienting patients to AEDs and putting them at ease is for staff to introduce themselves to patients—letting them know who they are and what their role is . AED patI . . . firmly believe that . . . patient management is something that patients themselves should participate [in] . . . If they want to make their decisions, they have the intellectual [ability] to participate in the decision-making, I’d definitely involve them, give them information to let them make their own decisions. Providing adequate explanations is crucial in establishing empathy and rapport, one reason being that the more informed patients are, the more in control they may feel of what is often an unsettling and alien situation. Central to this is listening to patients, opening up the space to allow them to describe their concerns, which might be missed in more clinician-dominated consultations . This stI think for different people, what you tell them may be different . . . if s/he is quite smart, or s/he has a higher education level . . . then perhaps what you talk about would be different. And you have to know how much the patient knows about his/her condition. Some things are very hard to understand; I wouldn’t complicate things too much. I mean, simplify things as much as possible, to let him/her understand better. As the above quote indicates, however, the extent to which this was encouraged by doctors was often based on their individual assessments of patients’ desires to do so and their health literacy:Notably, clinicians who reported routinely engaging patients in treatment decisions did not do so necessarily because of a belief in the patient’s right to be truly informed in their health care or pointedly because of any policy agenda in favor of patient participation. Rather, these clinicians adopted patient-participation strategies because they perceived positive health outcomes associated with this practice. As one senior doctor observed, by providing patients with comprehensive information on the reasons for treatment and subsequent discharge instructions, patients would be less likely to return to the AED, “because if they don’t have enough information, they will come back very soon . . . for the same illness” . These clinicians’ observations align with findings of previous studies which have linked poor information-giving practices and lack of patient consultation in treatment decisions with prolonged stays in, or unscheduled returns to, emergency care  with patients, and the reduction in staff attendance to communication training courses because of staff shortages. Communication training, however, is essential to ensure AED staff develop the skills to competently and safely transfer patient information between each other, as well as to ensure that patients have a comprehensive understanding of their diagnosis and post-discharge treatment instructions. The common positioning of patient-centered communication as dispensable, time-burdensome, and distinct from emergency care by participants (and in particular interviewees) in this study highlights a discrepancy between stated Hong Kong Hospital Authority policy and the reality of contemporary Hong Kong emergency practice. Greater resources need to be allocated to communication training to ensure AED clinicians’ abilities to incorporate interpersonally sensitive, patient-centered communication in their interactions with patients, and improve their understanding of how this is integral to the quality, safety, and efficiency of emergency care.


The ability to perspective-take (cognitive awareness of another’s state) and empathise  are important characteristics for sensitive, co-operative and constructive parenting, which assists in developing adaptive functioning for children. For the first time, immersive virtual reality was used to place parents in the position of a child in order to assess impact on perspective-taking and empathy. This novel study was conducted with 20 non-high risk Spanish mothers (a pilot study with 12 mothers is reported in supplementary files). Mothers were virtually embodied as a 4-year-old child, experienced from the first-person perspective and with virtual and real body movements synchronised. They interacted with a ‘mother avatar’, which responded either in a Positive or Negative way. Participants reported a strong body ownership illusion for the child body that led to cognitive, emotional and physical reactions. Experiencing negative maternal behavior increased levels of empathy. In addition, the Negative mother led to increased feelings of fear of violence. Physiological data indicated greater stress in the Negative than Positive condition. Although further research is required to assess the effectiveness of such methods, any improvement in empathy that leads to a change in parenting behavior has the potential to impact on developmental outcomes for children. Although the relationship between empathy and parenting difficulties is less widely researched, arguably empathy has a significant role to play given the importance of both recognising and feeling a child’s emotions in being able to sensitively parent8. Positive warm parenting assists in developing adaptive functioning for children; a nurturing parent has the ability to demonstrate empathy towards the needs of their child and place those needs in high regard. In contrast, negative parenting can cause long-term negative outcomes for children. Parents with low empathic awareness of their child’s needs often have difficulty helping children meet those needs - normal developmental needs are seen as the child being ‘annoying’. Hence, developing empathy in parenting has the potential to improve outcomes for children and young people. This is particularly true for families where there is risk of child maltreatment (CM).Empathy deficits have been associated with a range of disorders and offending behaviors, most notably risk of offending10, with a high rate of recurrence11. There is a significant impact on mental health and other provision for victims, interventions for abusers, as well as costs for public child care, criminal justice, social work and specialist education13. Whilst it has been shown that some people demonstrate remarkable resilience to CM14, for others the effects of such victimisation can be seen both in childhood and in adulthood in a variety of domains, including physical, psychological, social and interpersonal relationships17. Notably, when combined with risk factors , poor parenting styles  have been identified as mediating the likelihood of a maltreated child becoming a maltreating parent . In contrast, realistic expectations and attributions can reduce risk and improve outcomes for children.Vast numbers of children are abused and neglected by their own family each year19.Helping a parent remember how it feels to be dependent on others to meet your needs has the potential to be a crucial step in developing more positive parenting responses and improving outcomes for children. However, whilst some things can be taught through parental education , empathy and perspective-taking are seen as difficult to teach. Indeed, this difficulty has been noted in work with sexual offendersThus, if the ability to perspective-take and empathise are important characteristics for positive parenting but are hard to teach, we are left with two questions: how can we help parents understand what it feels like to be a child? If we help parents understand what it feels like to be a child, can we improve their empathy and parenting?20, entitled ‘They know the words but not the music’). In contrast, an individual might be poor at PT but able to empathise once they are helped to recognise the emotion, and it is this situation in which it may be possible to enhance parenting. Thus, there is potential to help parents learn to recognise their child’s emotions which may, in turn, impact on their ability to empathise.It is important to distinguish between the different aspects of awareness of another’s state, which can be both affective and cognitive. Empathy is described as the ability to identify with and understand another’s situation, feelings and motives , whilst perspective-taking (PT) is the ability to see things from another’s point of view (cognitive), i.e., recognition of, but not necessarily feeling, an emotion. For example, it is widely argued that psychopaths are able to PT and recognise the emotion of their victim, but are unable to demonstrate any emotional response of their own; similarly, they can describe emotion, but not feel it  provides a possible forum in which parents could be reminded how it feels to be a small child , with the potential to encourage perspective-taking (PT) and empathy. Although therapeutic techniques exist , IVR could potentially increase the effectiveness of this method and make it accessible also to those who struggle to do such work imaginatively, as illustrated in26. Studies have examined how behavioral tendencies in a virtual environment can be predicted from dispositional measures of compassion and empathy27, or how participants’ empathic feelings towards animated characters can be enhanced through different simulated virtual scenarios30, targeting, for example, bullying behaviors32 or training with patients34.Past research has shown that empathy and helping behavior can be enhanced and promoted through the use of prosocial media, console gaming and virtual reality38, with changes in cognition and perception. For example, embodiment of participants in a dark-skinned virtual body seen from first-person perspective (1PP) led to a reduction of implicit racial bias37, which was sustained over time39. In relation to children, previous research has shown that virtually embodying adults into the body of a young child leads to changes in perception of sizes in the environment and implicit self-identification, with a shift of implicit attitudes about oneself towards being childlike that does not occur when the body is adult size40.IVR has been successfully used to generate illusions of ownership over whole virtual bodies of different gender, race or even ageIs there evidence of an illusion of body ownership with the virtual child body and does the strength of the illusion differ between the two virtual interactions?Does the IVR system reproduce in participants the feelings of a young child, hence evoking perspective-taking (PT)?Are participant experiences in the IVR system affected by whether the maternal-figure interaction is positive or negative?Is this IVR experience associated with changes in levels of empathy?Therefore, the aim of this study was to establish whether embodiment of mothers into the body of a young child and engaging in an interaction with a virtual mother facilitates perspective-taking and empathy. To address this question, a pilot study was conducted with twelve non-high risk mothers (results reported in supplementary file), followed by a main study with another twenty non-high risk mothers (reported below). Participants were embodied in a child body while experiencing either a positive (Positive) or negative (Negative) interaction with a virtual mother. In order to induce a level of subjective body ownership, the technique of visuomotor synchrony was used . Specifically, the research questions were:The study was approved by the University of Birmingham STEMM ethics committee (ref. ERN-12-1542) and by Comissió Bioètica of Universitat de Barcelona (IRB00003099). The study was also carried out in accordance with relevant codes of conduct. i.e., the British Psychological Society and the Heath and Care Professions Council. Ethical considerations included gaining informed consent, right to withdraw, limits of confidentiality and sources of support, if required. The person undertaking the pre/post interviews and assessment was a qualified clinical psychologist, in order to ensure that any participants who became distressed received appropriate support. Following completion of the second phase, participants were debriefed. All participants were contacted by email one week later to make sure there were not any undesired ‘after-effects’ from the IVR exposure.A pilot study was conducted to test the technical aspects of the system prior to the main study (see supplementary information). Following this, the Mind in the Eyes test was added for a measure of general empathy in the main study.This was a within-groups counter-balanced design with a single binary factor ‘Behavior’. Participants were randomly allocated to one of the two designed groups: experiencing the Positive mother first and then the angry mother (Condition ‘Positive’), or the angry mother first and then the Positive  with normal or corrected vision took part; one dropped out due to simulation sickness so data are reported on 20 participants. All participants were the biological mother of at least one child ; children’s ages were 6 months to 15 years . All participants reported little or no prior experience of virtual reality. . Participants were fitted with the head-mounted display (HMD), the body-tracking suit and physiological data recording devices. The view through the HMD was individually calibrated.During experimental phase one (five minutes), participants entered a virtual living room, which included a virtual mirror and children’s toys. Their body was substituted by a 4-year-old virtual child body, seen from first-person perspective (1PP). Head and body movements were mapped in real time to the virtual body, seen both by looking directly down at their real body and in the virtual mirror Fig. . FollowiIn phase two, participants were asked to standstill/relax for baseline physiological data. During phase three, the virtual mother entered and initiated conversation with the participant Fig.  – either41 (PSI), the Mind in the Eyes test of empathy42, the Adult Adolescent Parenting Inventory – version 243 (AAPI-2) to assess parenting and child rearing attitudes (including a measure of empathy), a post-experience questionnaire and a semi-structured interview , two related control questions  and one on agency about the virtual body (Agency). Figure The extent to which participants felt body ownership over the child virtual body and agency over its motor actions was assessed by a questionnaire after each experimental condition Table . ScoringFeatures; TwoBodies) had medians between −2 and 0, and mostly their interquartile ranges (IQR) do not overlap those of MyBody and Mirror. The most overlapping IQRs are between Mirror and Features for the Negative condition. A Wilcoxon matched-pairs signed rank test rejects the hypothesis of equal medians . Hence if this difference is significant all of the other paired tests (Mirror or MyBody against Features or TwoBodies) will also be so. Although there are no differences between conditions with the illusion questions, MyBody, Mirror and Agency have greater scores than the control questions .Overall, body ownership and agency were high (median scores 1–3). The control questions (Violence) and how much they experienced the possibility that they might be physically assaulted by the virtual mother (Assaulted). There were very low scores for both Violence and Assaulted (with some outliers) with the Positive mother, but high scores with the Negative mother  and clinical group means for Over-reactivity and Total score Table , but wercategory and remained so post-intervention. However, looking at the score, post-intervention was significantly higher than pre-intervention , rising from 8.1 to 9.0  towards a greater tendency to restrict power and independence . This outcome seems to reflect extreme changes in scores by a few participants , but requires further investigation.There were changes in empathy over time, F(3) = 3.673, p = 0.018 (assumption of sphericity met), but no interaction between time and order F(3) = 0.846, p = 0.475 .There were a number of significant negative correlations between parenting beliefs/styles and AAPI-2 parenting, including empathy Table . When orWhen order of presentation was considered, Positive-Negative had correlations between empathy and parenting styles  at pre-first exposure with none at post-first or second exposure. For Negative-Positive, relationships were found with risk of physical punishment at each of the four assessment points , whilst lack of empathy was only negatively correlated at the post second exposure  mother with laxness .This task (pre- and post- each intervention) involved describing the emotional state of a person based on only an image of their eyes (see Supplementary Information), with images appearing in random order. It is a standard measure of empathy, not necessarily related to parenting. Correct classification pre and post intervention was measured. The variable of interest was dFaces = FacesPost – FacesPre, with greater values indicating an increase in emotional recognition. Figure The numbers of Skin Conductance Responses (SCR) were recorded during the baseline (SCRBase) and the experience (SCRExp). The amplitude of each SCR was also recorded ; dSCR = SCRExp - SCRBase, and dSCRAmp = SCRAmpExp - SCRAmpBase. Of interest was whether the numbers and mean amplitudes are greater for the Negative than for the Positive mother. Supplementary Figure The electrocardiogram was used to compute heart rate deceleration (HRD) during the experimental period while the mother virtual character approached the participant. Greater deceleration indicates greater distress or disgust. Supplementary Figure It was a very strong experience seeing myself there, small and with another adult person”.Feeling like a child, with frequent comments about size difference: “Better understanding how their sons/daughters feel.I had more fear”; “I felt like crying”Fear of the mother and of being hit: “Experiencing the negative mother as dominating; hence ‘shutting off’ because she would not listen:you stay there, like paralysed”;○“I felt more comfortable being silent, just observing her… it wouldn’t make things better but worse”.○“I had to take a few steps back, move backwards”○“Well I think maybe I remembered the previous situation so I couldn’t trust her I was thinking that in any moment she was going to scold me again”Order made a difference. When the angry mother came first, participants generally did not trust the ‘Positive’ mother: “It is true that these last days I have been thinking about this”.Almost all said the experience made them think about their own parenting: “sometimes there are situations that go beyond your control … I think that will continue to happen to me, that I will have bad days”), but others noted it had made them more mindful and that might continue .Some noted the difficulty of maintaining change  and more generally (Mind in the Eyes). Pre-post empathy scores (AAPI-2) significantly changed in a positive direction. The fact that the parents were not initially high risk reflects the participants’ recruited for this study. It was seen as important for ethical reasons to explore these concepts with non-high risk parents before applying the procedure to those parents identified as high risk of child abuse.42, the fact that participants performed better at assessing emotional states following their negative interaction with the virtual mother, supports the idea that the method improves feelings of empathy towards the child.Interestingly, there was no interaction with order of presentation . This appears to suggest that the effect comes from experiencing both a positive and a negative mother avatar, rather than which comes first. Having said that, the verbal feedback from participants is that experiencing the Negative mother first affected how they viewed the Positive mother, i.e., with more suspicion and expecting anger. Therefore, the lack of order effect may have resulted from the way in which empathy was being measuring in this study. Indeed, if we look at the Mind in the Eyes test, which has been widely used across different groups and cultures46.This finding is in line with several psychological interventions where patients are subjected to negative experiences, which can be distressing, temporarily, but which ultimately aim to improve their symptoms, and help overcome psychological problems. For example, in the case of phobias, treatment is largely based on exposure-therapy, which involves exposing the patient to the anxiety source in order to help them overcome their distress. Moreover, evidence suggests that patients suffering from post-traumatic stress disorder may benefit from imaginatively re-experiencing traumatic events, eventually leading them to the extinction of fear-related responses47, where IVR was used to increase self-compassion in self-critical individuals. Participants delivered a compassion speech to a crying virtual child and then watched their speech, either embodied as that child or in a third person non-embodied condition. Being embodied as a child led to greater degree of self-compassion, whereas the non-embodied group had no significant changes. Similarly, participants in ref.21 were embodied a self-alike virtual body, describing a personal problem, or a Sigmund Freud virtual avatar, from which they offered themselves counselling. Whilst self-counselling was positively evaluated by participants, mood and happiness improved when the counsellor resembled Freud. Hence, although embodiment can be effective in improving self-compassion , seeing one’s own body from a different location only — literal perspective taking – might not be as efficient as originally thought. In our study, the embodiment as a child (not an adult) was important.Our results fit with a recent studyOne unexpected finding was the significant shift in power and independence, but in a negative direction . This may result from one or two participants who had an extreme shift  but requires investigation to establish the implications and/or why some people have this response. One option would be to consider this qualitatively, since it may be that the experience shifted the way in which those participants viewed the questions; for example, rather than reading the scenario as restricting independence, were they read as being more supportive and involved? However it is very important to consider why some individuals have this reaction before it is trialled with a high risk group.in-vivo exposure, or better17.In terms of future study, one factor to be taken into consideration is the ‘conversation’ taking place between the virtual mother and the participant, as well as the mother’s body language and facial expressions. Our study was based on a predetermined script – we aimed to keep the dialogue between the two conditions as close as possible, but also within a relatively neutral context – therefore, it would be valuable to examine in the future how variations in the script may affect the results. In addition, comparing IVR to different media-based techniques, such as watching the scenario on TV or a computer screen, would add further valuable knowledge to the effectiveness of our method. Interestingly, it has been shown that interventions that have been carried out using virtual reality exposure therapy, result in therapeutic outcomes comparable to those obtained using In conclusion, this study demonstrated that it was possible to use an IVR environment to enable mothers to take the perspective of a child and, in the short term at least, to create change in levels of empathy. Notably, the Negative mother had more impact on changes when assessing empathy generally and in self-report (not on the AAPI); thus, it suggests that the negative element of the experience is necessary. However, future research is necessary to consider a number of factors, including maintenance of increased empathy, impact on actual parenting behavior change and length of intervention. Indeed, there were indicators that some elements of parenting beliefs on the AAPI changed only temporarily but the changes in empathy did persist over time. Most importantly, it will be necessary to more fully explore the issues of power and independence before this approach could be developed with high risk parents. However, these are promising early findings – not least because these changes have occurred even with non-high risk parents – and clearly indicate that there is value in exploring these avenues further.Supplementary informationMovie S1


The aim of this paper was to explore the contribution of Mary Seacole to nursing and health care, notably in comparison with that of Florence Nightingale.Notes on Nursing, is ignored or misconstrued.Much information is available, in print and electronic, that presents Mary Seacole as a nurse, even as a pioneer nurse and leader in public health care. Her own memoir and copious primary sources, show rather than she was a businesswoman, who gave assistance during the Crimean War, mainly to officers. Florence Nightingale's role as the major founder of the nursing profession, a visionary of public health care and key player in advocating ‘environmental’ health, reflected in her own Discussion paper.The Times digital archive; Australian and New Zealand newspaper archives, published memoirs, letters and biographies/autobiographies of Crimean War participants were the major sources.British newspapers of 19th century and USA and many countries and the UK much material shows her influence also on hospital safety and health promotion.Careful examination of primary sources, notably digitized newspaper sources, British, Australian and New Zealand, show that the claims for Seacole's ‘global influence’ in nursing do not hold, while her use of ‘practice‐based evidence’ might better be called self‐assessment. Primary sources, moreover, show substantial evidence of Nightingale's contributions to nursing and health care, in Australia, New Zealand, the  Wonderful Adventures of Mrs Seacole in Many Lands, 1857 – received favourable coverage, in Australia and New Zealand and Britain; however, never as a source on nursing or health care. Nightingale, by contrast, became famous for her work in the Crimean War, her vigorous championing of better conditions for the soldiers, her detailed research on what went wrong at the war hospitals and how to improve them, to her founding of a nursing school and decades of work mentoring nurses, facilitating the introduction of nursing in many countries and making hospitals safer.The purpose of this paper was to challenge the presentation of Mary Seacole (1805–1881) as a nurse of global influence and significance. That she was a remarkable person who deserves honouring is not in question, but it is questionable that her accomplishments match those of Florence Nightingale (1820–1910). Both of these women became known during the Crimean War (1854–1856), but Seacole's renown was mainly for her business in the Crimea, whose customers were officers. She received ongoing, sympathetic coverage for her bankruptcy and her fine memoir – Typical presentations today of Nightingale and Seacole go well beyond ordinary ‘revisionism’ in history. Revisionism is appropriate and indeed welcome, when new material comes to light, or new concerns, such as with the extension of human rights to previously excluded or discriminated‐against groups. Yet revisionist authors must also respect sources, giving precedence to reliable primary sources. Secondary sources must be carefully scrutinized, especially in a field when so many have been shown to be faulty; that is, when their claims are examined against primary sources. In the case of Seacole, 10 common myths about her achievements have been challenged with solid primary sources McDonald , yet theen route to the California Gold Rush. After several months of futile efforts, she decided to seek a position as an army nurse, aware that Nightingale and her team had already left . While getting her business ready to open, she kindly gave out hot tea and lemonade to soldiers waiting on the wharf for transport to the general hospitals, ‘all the doctors would allow me to give’ Seacole  p. 101. In her memoir, Seacole described precisely three occasions when she gave assistance on the battlefield, postbattle: 18 June, 16 August and 8 September 1855 . Yet this is frequently made out to be a regular occurrence. A book by nurses, for example, states that she ‘frequently ventured out onto the battlefield, selling goods and caring for wounded soldiers from both sides’ .On her second foray onto the battlefield, she gave first aid after selling goods to spectators (Seacole pp. 164–7).Seacole is noted, in a memoir, for providing lunch for a cricket match Astley , p. 145.Her third and last foray onto the battlefield – all were postbattle – took place at the second failed British attempt on the Redan (Seacole pp. 169–72).For New Year's Day of 1856 she held a party and took plum pudding and mince pies to the nearby Land Transport Corps Hospital (Seacole p. 187).In April 1856, the fighting by then long over, Seacole went out on excursions to see the Crimean countryside; a newspaper story recounts Russian soldiers giving her a religious medallion , Sydney . Yet she looked down on ordinary Turks, ‘the degenerate descendants of the fierce Arabs, for lacking in ‘pluck’ (p. 106). While they were not as dishonest as the French or Greeks (p. 111), she wrote: they were ‘deliberate, slow and indolent’, given to ‘the sacred duties of eating and praying and getting into out‐of‐the‐way corners at all times of the day to smoke themselves to sleep’ (p. 109).Seacole wore three medals, but not the Medjidie, for her portrait by Challen and her photograph by Maull. If she had won any medals, it is likely that she would have worn them. However, the evidence is unequivocal that she did not win the Crimean Mayo . For theTellingly, Seacole wore no medals in her portrait on the cover of her memoir, nor, in the text, did she claim to have won any. If she had won so much as one, this would have made history – the first woman to be so honoured. Nightingale won no medals – she was not eligible either – but the Queen sent her a brooch in lieu of a medal.It is known that Seacole wore medals, varying numbers of them, while out walking in London. An assistant surgeon who knew her saw her in Charing Cross wearing the Crimean medal Reid , p. 13. It seems that Seacole did not wear medals at the Surrey Gardens events, or they likely would have been mentioned in the extensive coverage given them. At one, she is noted to have been seated next to Lord Rokeby Standard , who wouThe final point on the medals issue is Seacole's failure to mention any in her will. She made detailed dispositions of her goods: the diamond ring of her late husband, her own jewellery, watch, trinkets, ornaments, furniture, pictures, prints, engravings, plate, linen, china and household effects . One not on their list praised the book, calling its author an ‘itinerant licensed victualler’ and a ‘jolly old soul’, who had not written ‘a line’ of it. Still, she deserved credit for it was her life. The ‘little volume’ would give ‘a couple of hours’ amusement’ . There is nothing in any of the reviews to demonstrate medical or nursing competence.The book reviews found were et al. Seacole is described as an ‘African‐Jamaican’ several times, with an explicit statement that she respected her ‘African‐Jamaican heritage’ , I should have been just as happy and as useful’ (Seacole p. 48). Clearly her skin was not as dark. For skin colour for herself she preferred ‘yellow’ , ‘brunette’ or ‘a little brown’ (Seacole p. 4).Newspaper coverage of Seacole in the post‐Crimea period continued, but was far less frequent than that for Nightingale and not at all of the same weight or on the same subjects. As before, stories show that she was well remembered, but are not on nursing or health care. One in a Scottish newspaper noted her being injured in an omnibus accident. When she got off she was ‘instantly recognized by an officer and some of the Crimean heroes’, who both offered their assistance and abused the driver for his carelessness . Nightingale as well contributed on such challenging issues as midwifery mortality and how to reduce it .et al. In a puzzling admission, Seacole held that ‘few constitutions permitted the use of exactly similar remedies and that the course of treatment which saved one man would, if persisted in, have very likely killed his brother’ (Seacole p. 32). However, for cholera and other bowel diseases, the same treatment does work: oral rehydration therapy, discovered only in the 1960s. Seacole's ‘remedy’ not only contained substances that are toxic in any dose, lead acetate and mercury chloride, but they and such other ingredients as mustard poultices and emetics, dehydrate the patient. And, while Seacole claimed some successes, she also acknowledged ‘lamentable blunders’ in her remedies, even that, when she later came across notes of her treatments, she was made to ‘shudder’ (Seacole p. 31). Yet her supporters continue to claim that she learnt ‘practice‐based evidence’ and acquired ‘Western medical knowledge’ from European doctors in Jamaica , cut souvenir buttons off the coats of dead Russians and accepted ‘plunder’ and ‘trophies’ stolen by soldiers from Russian churches (Seacole pp. 167 and 174).The evidence shows that the serious work to found the profession of nursing was led by Florence Nightingale, who did major work also on hospital safety and the institution of public health care. Post‐Crimea, she conducted research to determine how to reduce death rates, then founded the first nurse training school in the world, which in time sent out trained nurses and matrons to establish professional nursing in many countries. Without ever going to India, she worked for decades on improving health care there, along with social and political reform, famine prevention and relief. She documented the high rates of morbidity and death in colonial aboriginal schools and hospitals. Her work was global and it was globally influential.Primary sources on Seacole have shown wide interest in her life and circumstances, but not any contributions to nursing or health care. International coverage is similar to that in the U.K. Her book was favourably discussed, wherever it was reviewed, but nowhere treated as more than enjoyable reading. Excerpts appear to have been selected for general interest. By contrast, international coverage of Nightingale over the same period shows her to have been taken as a major contributor to the establishment of nursing and the reform of hospitals and a vigorous advocate of broader social and health care reforms, both for the military and the civil population. There was much coverage also of her work on such other concerns as the vote for women, health in India and relief in numerous famines and wars. Seacole should be credited for the contribution she actually made and Nightingale for hers.Finally, there are lessons to be drawn from the analysis about the reinterpretation of people's contributions over time, or revisionism. The tendency to consider that all people in a particular era share the same values and prejudices is overly simplistic. Nightingale was white and of a privileged family background, but she was highly critical of British imperialism and views of racial supremacy. Her papers on aboriginal peoples show this. Her work on Indian health concerns was accompanied by support for Indian nationals; for example, she wrote a campaign letter for the first Indian to be elected to Parliament.Not everyone shares the prevailing set of attitudes and some indeed oppose them. Clearly there would be no social change if this were not so. Change requires leaders both of the privileged group and the one seeking recognition‐independence‐equal rights. Nightingale, thanks to her family, was especially conscious of race issues – her grandfather was a leading abolitionist. She can be seen as carrying those concerns forward, indeed as an early contributor to anti‐racism.No evident conflict of interest.The (sole) author conducted all the research and wrote the paper.substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;drafting the article or revising it critically for important intellectual content.


Implementation science seeks to promote the uptake of research and other evidence-based findings into practice, but for healthcare professionals, this is complex as practice draws on, in addition to scientific principles, rules of thumb and a store of practical wisdom acquired from a range of informational and experiential sources. The aims of this review were to identify sources of information and professional experiences encountered by healthcare workers and from this to build a classification system, for use in future observational studies, that describes influences on how healthcare professionals acquire and use information in their clinical practice.This was a mixed studies systematic review of observational studies. DATA SOURCES: OVID MEDLINE and Embase and Google Scholar were searched using terms around information, knowledge or evidence and sharing, searching and utilisation combined with terms relating to healthcare groups. ELIGIBILITY: Studies were eligible if one of the intentions was to identify information or experiential encounters by healthcare workers. DATA EXTRACTION: Data was extracted by one author after piloting with another. STUDY APPRAISAL: Studies were assessed using the Mixed Methods Appraisal Tool (MMAT). PRIMARY OUTCOME: The primary outcome extracted was the information source or professional experience encounter. ANALYSIS: Similar encounters were grouped together as single constructs. Our synthesis involved a mixed approach using the top-down logic of the Bliss Bibliographic Classification System (BC2) to generate classification categories and a bottom-up approach to develop descriptive codes (or “facets”) for each category, from the data. The generic terms of BC2 were customised by an iterative process of thematic content analysis. Facets were developed by using available theory and keeping in mind the pragmatic end use of the classification.Eighty studies were included from which 178 discreet knowledge encounters were extracted. Six classification categories were developed: what information or experience was encountered; how was the information or experience encountered; what was the mode of encounter; from whom did the information originate or with whom was the experience; how many participants were there; and where did the encounter take place. For each of these categories, relevant descriptive facets were identified.We have sought to identify and classify all knowledge encounters, and we have developed a faceted description of key categories which will support richer descriptions and interrogations of knowledge encounters in healthcare research.The online version of this article (doi:10.1186/s13012-017-0564-1) contains supplementary material, which is available to authorized users. The knowledge is embodied. We know how to cycle and yet cannot fully explain it. So, rather than conceiving of a single knowable reality, mindlines are based on a more “fluid, embodied and intersubjective view of knowledge” that accommodates context and multiple realities [Well-evidenced interventions intended to improve patient well-being may not be used optimally across healthcare professions –8 with midelines , 19. Insidelines , as, forealities . In thisealities . ImplemeA number of reviews have sought to collate the sources of information clinicians use and the ways in which they seek them –28. ThesOur prior reading suggested that in order to describe the breadth of occasions when clinicians come across phenomena that have the potential to change their knowledge, the more familiar terms in the literature around knowledge transfer, translation, exchange and sharing would not be sufficient. They could not account for the unplanned way in which the mindlines work suggested healthcare professionals developed their knowledge-in-practice. We found “encounter” to be a broad enough term to help describe these occasions as it may be expected or unexpected, brief or protracted, experiential and involve a degree of “dealing with” something or someone –31.alter another individual’s prior knowledge but is not in itself knowledge.Many definitions of knowledge exist but we adhered to an interpretivist perspective of knowledge as discussed above in the context of mindlines and knowledge-in-practice-in-context. Working from Stenmark , we concresponse to the information or experience, rather than being an encounter with knowledge.We therefore defined a knowledge encounter as a circumstance in which an individual interacts with information or an experience that has the potential to influence their knowledge-in-practice. Knowledge here, therefore, is the potential for knowledge to change in To identify the sources of information and professional experiences (referred throughout this article simply as “experiences”) encountered by healthcare workers that could influence their knowledge-in-practice and the contexts within which they are encounteredTo build a classification system, for use in future observational studies, that describes influences on how healthcare professionals acquire and use information in their clinical practiceThe aims of this review were the following:A systematic mixed studies review was conducted to identify the information sources and experiences that health professionals reportedly encounter. “Mixed studies reviews” include quantitative, qualitative and mixed methods studies to provide a more holistic view of a given problem , 36.Observational studies in English or German that sought to identify sources of information and experiences, and the ways in which these were encountered, were eligible. Studies that only explored a narrowly restricted source, e.g. internet, were excluded. Experimental study designs were excluded because we were interested in gathering data from existing practice rather than a modified one.All healthcare professionals responsible for patient  care were eligible. Studies involving a majority of undergraduate students were not eligible. We defined as eligible healthcare professionals any clinical professional that fell within the MEDLINE MeSH term “Health Occupations”. This includes: allied health occupations , chiropractors, dentists, medical doctors, nurses, optometrists, podiatrists and veterinary practitioners. We included all of these, including veterinary practitioners, because we felt that whilst there are differences in the contexts within which information or experiences are encountered, the underlying process of professional learning and development are sufficiently similar across professional settings.Any information source or experience related to patient care  was eligible.The following databases and search engines were searched: OVID MEDLINE, OVID Embase, and Google Scholar. Embase was searched from the first records in 1974 to June 6, 2014. Medline was searched from 1946 to week 4 of May 2014 using terms relating to information, knowledge or evidence and sharing, searching and utilisation combined with terms relating to the various healthcare groups. [For search strategy, see Additional file We carried out backward citation searches for all included studies in Google Scholar and forward and backward citation searches in Web of Science for the more comprehensive studies , 33, 37 Potentially eligible studies were identified from the databases and Google Scholar searches, exported to EndNote X6 and duplicates removed.Titles and abstracts of all studies were screened for potential inclusion in the review by one author (DH). Where a study was potentially eligible, the full text was retrieved and the final decision on eligibility made by DH.A purpose designed data extraction form was used to extract data from eligible studies. This was piloted by DH and SM. The final data extraction was completed by DH. From eligible studies, the following were extracted: Author; contact details; citation; year; study design; whether study was reliant on recall, real-time data collection or both; instrument/tool/method used and, in the case of quantitative instruments such as questionnaires, the status regarding validation and reliability; study period if longitudinal; participant description ; setting—primary, secondary or tertiary; sources of knowledge; themes or categories used/developed by the authors; types of knowledge considered, i.e. tacit, explicit or both; and references of potentially relevant studies or reviews.The sources of information or experiences were collated in a spreadsheet by DH. Where descriptions of sources were different but shared the same meaning, these were grouped together by DH as a single construct.The quality of the included studies was evaluated using the Mixed Methods Appraisal Tool (MMAT) , 42.Our preliminary reading of the literature suggested that information sources and experiences, and the way they are encountered, are multifaceted and would benefit from a classification system that could accommodate this. Kwasnik states that “classification is the meaningful clustering of experience” and argued that the way we classify knowledge can assist in discovery of new knowledge . Our intWe chose to adopt the facet classification approach to describe the important contexts within which information and experiences are encountered because facet classifications recognise that there is more than one way to view the world and that facets themselves are flexible to accommodate new phenomena over time . This apwhat is being done, what are its parts or properties, how is this achieved, by what means and by whom, where, and when? [To describe and organise the experiential and information sources, we adapted the Bliss Bibliographic Classification System, known as BC2. This system classifies, for any piece of knowledge, nd when?  and was nd when? .After extracting the data, we developed a classification of knowledge encounters together with a description of facets that described key elements of information and experiential knowledge sources that healthcare workers encountered. We used a constant comparative method with extensive discussion between the authors as the classification was refined.Our synthesis involved a mixed approach using the top-down logic of the BC2 classification to generate thematic categories and a bottom-up approach to develop facets (or codes) for each category from the data. That is, we altered, added or removed the specific terms used in the BC2 classification, for example from “What is being done” to “What information or experience is encountered”. We then read and re-read the extracted sources, using the constant comparison technique to develop descriptive codes. As an example, when an article reported “colleagues via internet”, we recognised that “someone” was involved in the encounter. Similarly, someone was involved in an article that reported “mentor” and another that included “patients’ experiences of illness”. Thus, we created a category to describe someone from whom a healthcare worker might have obtained information in their knowledge encounter. We called that category “from whom did the information originate or with whom was the experience”, to fit the BC2 logic. Then we re-read our data to generate facets for each category. The facets were higher level descriptive codes of the people involved in the encounter. For example, from the following raw data, we created the facet “practitioner”: “peers”, “observation of others’ practice”, “formalised supervision”, “systematic self-evaluation”, “specialist” and “email contact with specialist”. In a similar way, the facets of “Non-practitioner (colleague)”, “Patient”, “Researcher”, “Educator”, “Regulator”, “Employer” and “Salesperson” were generated.Nine thousand one hundred thirty-eight potentially eligible reports were screened by title and abstract. Of these, 113 were potentially eligible, and therefore, the full text was retrieved. 37 of these were not eligible. 76 studies were eligible for inclusion in the review from the 2014 search –120. TheFour studies used a mixed methods design (interviews and surveys), 22 used qualitative methods  and 54 used quantitative methods . Of the 80 studies, only 24 allowed for the inclusion of knowledge encounters that were experiential or tacit.Seventy-one of the studies included a single group of healthcare professionals, and 9 involved two or more healthcare groups. Across the studies as a whole, the quality was evaluated by MMAT as moderate or low quality. The study characteristics are summarised in Table journal, but there is an implicit requirement for a verb, i.e. to read a journal. On other occasions, the verb was recorded, e.g. informal conversation with colleagues. Thus, what authors described as “sources” were often “encounters with sources” and might be intentional or unintentional.One hundred seventy-eight individual descriptions of encounters with information sources or experiences were identified across the 80 studies ?How was the information or experience encountered (“How?”)?What was the mode of encounter (What mode?)?From whom did the information originate or with whom was the experience (“From / with whom?”)?How many participants were there (“How many?”)?Where did the encounter take place (“Where”)?We modified the BC2 classification to add categories where differentiation was required and remove redundancies. In summary, the classification we developed included the following six key questions about the knowledge encounter , we adopted the common denominator of “codified knowledge”.Higgs and Titchen  describeOne source of information that arose from the data was that produced by commercial companies, often for the purpose of marketing. It is not clear whether this has been subjected to quality control in the sense of codified knowledge. We therefore included an additional category of “product or service knowledge” though we acknowledge that there may be occasions when the product knowledge truly reflects codified knowledge, i.e. when it is based on peer-reviewed research.” might be someone whose “practice is observed” or with whom an “informal conversation” is had. Colleagues might take on the role of an educator or as a “mentor” or “peer opinion leader”. They might also be an employer and responsible for creating “locally developed guidelines”. In many cases, it was not possible for us to define the role due to lack of contextual information, but there were sufficient examples of different roles across the included studies for us to develop a number of facets to describe the various roles others play in knowledge encounters.There were multiple roles individuals or organisations could be envisaged to perform depending on the context of the encounter. From a relational perspective, a “colleague” may be dependent on the interpretations of fellow practitioners, whilst the reading of a research article in a “journal” alone would entail the source being a researcher.Given that an individual can perform several different roles, we defined this category according to the primary role taken by the individual(s) or organisation at the moment of information or knowledge encounter. Thus, a “journal clubThere was a challenge in how to classify non-human sources such as journal articles and “video”. We determined that the primary role of the individual(s) or organisations creating the particular information source would follow the same categories as for the in-person encounters. Thus, a research article may be written by a researcher who might write another article that explains a clinical technique as an educator. The descriptive facets for this category can be seen in Table practitioner”.These facets could equally be ascribed to the self or to other colleagues. In such a case, personal reflection by a healthcare professional on their practice would be described by the facet “The faceted classification developed here is a complex one. We want to test its feasibility in future studies. We created a series of five scenarios based on a composite of the sources extracted for this review, for dentists to work through, with a description of what was intended by the different facets . Each scThere are a number of potential limitations associated with this review.The search for studies used a combination of formal search strategy and citation searching. It is possible that we have missed potentially relevant studies because authors have used terms we did not include in the search strategy and because we confined the eligible studies to English. However, as we were not seeking to quantify the encounters with knowledge sources, we feel that we reached a saturation of both classifications of knowledge encounters and descriptions of their key facets in the studies we did identify.The screening of titles and abstracts was conducted by a single reviewer. This increases the possibility that potentially eligible studies were not included. Similarly, it is a limitation that the coding and design of the classification were done by one author.The discreet facets identified may not reflect all the facets that a particular knowledge encounter may include. Thus, users of the classification will have to make a choice about which facet is most appropriate of all those that could be used.We have also identified limitations of the studies included. The literature on knowledge sources identified here has been largely dependent on recall of exposure to different sources. Apart from three studies that used brief periods  of observation , 77, 101We used the MMAT to assess the quality of the studies. We value the attempt by the authors of MMAT to provide a means for evaluating and comparing the quality of different study designs when conducting mixed studies reviews. However, whilst it was apparently straightforward to use with individual studies, we found that we were unsure what the results meant when compared, in particular, to studies conducted within different research paradigms where “quality” can mean something very different .There is a growing body of evidence to support the assertion that healthcare professionals’ knowledge-in-practice—the knowledge that is used as they practice—is influenced by interactions with a variety of formal and informal sources of information and experience. However, as shown in this review, there has been relatively little real-time empirical study of the ways in which this happens. We think that by studying the ways in which healthcare professionals’ knowledge-in-practice is influenced by what they encounter and how they encounter it, we can begin to better understand how to work with the grain of practice to develop systematic approaches to contribute to achieving implementation science’s aspiration of promoting the uptake of research and other evidence-based findings into practice .From their ethnographic work in general medical practices, Gabbay and Le May coined the term mindlines to describe the internal, personal, tacit guidance medical practitioners used as they went about their practice. Mindlines develop as healthcare professionals interact with, and make sense of, multiple sources of information and experiences. Recognising that quantitative methods can rarely develop the rich understanding of individual practices that ethnographic methods can, we nonetheless think that the classification described here will allow for longitudinal survey tools to be developed that capture rich contextual data of how healthcare professionals develop their knowledge-in-practice in a variety of contexts.With the increasing availability and functionality of digital means to record experiences in real time , there iFurther, development of this longitudinal approach could explore whether, and how, particular facets of knowledge encounters are associated with changes in knowledge-in-practice and how these facets change, for example as healthcare professionals mature. Implementation researchers might then develop interventions that leverage off these facets to help improve uptake of evidence-based practices. For example, if knowledge encounters that share the facets of individualised codified knowledge, verbal, non-electronic, with practitioners, in social settings and occur in groups are associated with more change in knowledge-in-practice, can we adopt, adapt or design new opportunities for professionals to experience knowledge encounters with research based on these, rather than on facets not associated with changes in knowledge-in-practice?Finally, whilst classifications function as descriptive and explanatory frameworks for ideas or phenomena, they also act like theories do in providing the basis for the generation and testing of new ideas . We thinHealthcare professionals encounter information and experiences that may change their knowledge of patient care in many different ways. We have developed a classification to organise and describe the complexity of how healthcare professionals encounter information and experiences. We have identified six key classifying questions to understand the context in which information and experiences are encountered and described important facets for each of these. This novel faceted classification for knowledge encounters has been developed as a tool for future observational studies of healthcare professionals. Future research should explore how this classification of knowledge encounters can deepen our understanding of how healthcare professionals learn and develop their knowledge-in-practice. Over time, we want to be able to facilitate knowledge encounters that improve the uptake of evidence-based practices in healthcare.


Do children spontaneously represent spatial-numeric features of a task, even when it does not include printed numbers ? Sixty f Table 1). The overarching goal of the present experiment was to compare children’s performance on tasks known to tap numerical knowledge to a novel measure, the page finder task, which asked children to estimate the location of a page within a book without labeled page numbers and is hypothesized to measure magnitude estimation. If book affordances are related to the affordances of other measures, such as number lines, then the results of the page finder task should be highly related to other measures that tap children’s numerical magnitude understanding.Do children spontaneously represent spatial-numeric features of a task, even when it does not include printed numbers ? PreviouNumber sense refers to representing and processing numbers and includes several underlying processes, such as the ability to subitize a small number of items exactly, count, and compare approximate values . ChildreNumbers are represented both as approximate magnitudes and as exact categories such as “five” . CompariApproximate number magnitudes are represented in a left-to-right ascending order along a mental number line in which small numbers are oriented on the left and large numbers are oriented on the right . EvidencAs further evidence of the spatial-numeric association in children, even young preschoolers show an advantage on numerical tasks that have an orientation that is consistent with the left-to-right directionality of writing in their cultures. For instance, United States children played a spatial search match-to-sample game in which they were shown two boxes with seven compartments each. The compartments in the sample and matching box were verbally labeled in an increasing numeric order from left-to-right or right-to-left. In the game, children were shown an object hidden in one of the compartments in the sample box, and they were asked to find another object that was hidden in the same numbered compartment in the matching box. Children were faster and more accurate at finding the hidden object in the matching box if both boxes were verbally numbered from left-to-right as compared to right-to-left . Furtherconfident in their small-scale as opposed to large-scale estimates , the number line estimation task has emerged as a robust e.g., , 2016 anstimates . As chilstimates , 2016, hstimates . It shoustimates  suggest stimates , 2016 suThe number line task has both spatial and numeric components. There are numerically labeled end-points on the number line as well as a to-be-estimated number that appears above the number line. To estimate the magnitudes appropriately, the child needs to map the to-be-estimated number to the correct spatial location . Improving children’s estimates on the number line task appears to improve the precision of children’s mental number line, because improvements transfer to other types of tasks. In interventions aimed at improving children’s number line estimates , 2016, cIn addition to intervening more directly by providing one-on-one feedback on children’s estimates on the number line task, a variety of interventions have aimed to improve children’s number sense in more ecologically natural contexts . There has been increasing interest in improving mathematics performance in early school years by improving children’s number sense, through formal and informal instruction . These iInterventions using board games have demonstrated learning benefits for children . Board gEvidence from these board game experiments suggests that three affordances appear to be most important for materials that support learning number magnitudes: (1) left-to-right orientations, (2) promoting equal spacing between values, and (3) providing an explicit means for mapping numbers to relative magnitudes .Reading books to children is an important aspect of promoting children’s developing literacy. Sharing reading with young children promotes an understanding of reading conventions . Recall that the left-to-right orientation of number lines and linear board games was related to greater increases in learning. Books are oriented left-to-right in a similar fashion with smaller page numbers on the left and increasingly larger page numbers on the right. Number lines promote equal spacing between values because the distance between end markers can be evenly divided by equally spaced hatch marks  in much the same way that they previously interacted with large-scale objects  . FurtherOur sixty first grade participants completed five tasks in a counterbalanced order: number line estimation , magnitude comparison , numeral identification , counting on , and a page finder magnitude estimation task . We hypothesized that: (1) Magnitude comparison, numeral identification, and counting on performance would be correlated with number line performance because all of these tasks tap numerical knowledge, and (2) To the extent that the page finder magnitude estimation task also taps magnitude understanding, number line estimation performance will predict page finder performance, even after controlling for age and accuracy on the magnitude comparison, numeral identification, and counting on tasks.M age = 6.68, SD = 0.89) in four classrooms in two public school districts in northeast Ohio. Approximately 39% of children who attended these schools were eligible for free or reduced price lunches. Gender was balanced in the sample: 50% of children were identified as female. Parents provided written informed consent for their children to participate, and children provided verbal assent. Each child received a sticker at the end of the experimental session. The Kent State University IRB approved this study.Participants were 60 first grade students  Task order was counterbalanced, and the problems were presented in a random order within each task. All children were tested individually in a quiet location in their school by a female research assistant.2RLin represents the percent of variance in each child’s estimates accounted for by the best fitting linear model for that child. The slopes (jb) of the best fitting linear model for each child indexes how close that child’s estimates are to the ideal slope that relates estimates to the given numbers (1.00). It should be noted that we chose to characterize children’s estimates with a linear function to maintain consistency with prior research on informal tasks , and Page 2 is on this side (researcher flipped the page and pointed to it). If Page 3 is on this side (researcher pointed to it), which page is on this side (researcher flipped the page and pointed to it)? When children answered correctly, they were told, “Good!” When children answered incorrectly, they were told, “It would be Page 4, right?”The researcher continued with the instructions, “If this is Page 5 (researcher pointed to page) which page is on this side (researcher flipped the page and pointed to it)?” Again, children were given corrective feedback on this practice trial . Then, the child was told, “The book keeps going until we get to page 100 (researcher flipped to page 100).” Then, the child was asked to find page 1 and page 100, and they were given corrective feedback if they did not correctly identify these practice pages.1 After the child flipped to the intended page, he was asked to find a hidden picture on the page. The researcher closed the book before the child searched for the location of the next page. Some children used the strategy of lifting a large chunk of pages to get to the back of the book if asked to find a large number page. We did not systematically code children’s flipping strategies for later analysis.Children did not receive any corrective feedback on the remaining test trials. They were told, “If I say the number ‘20,’ I want you to quickly flip the pages until you believe that you’ve gotten to page 20. See you can quickly flip through the pages like this.” The researcher demonstrated how to quickly fan through the pages. Children were reminded how to properly flip through the book if they attempted to count the pages. This most frequently happened when they were asked to find a small number page. It should be noted that some children chose to flip from the back of the book or lift a chunk of pages when the book was closed to get closer to the intended location of a large-numbered page in the book. According to our research assistant, flipping from the back of the book was rare, though admissible in our protocol.∗100, linearity (2RLin), and slopes of the best fitting linear models.If children forgot the number of the page that they were looking for, the researcher could verbally remind them by saying, “Where is page N?” Children were asked to search for the following pages: 4, 8, 17, 23, 29, 33, 48, 57, 61, 72, 84, and 90. In line with the number line estimation task, we calculated percent absolute error, PAE =  Table 2. As shown in Table 2, children had high accuracy on the numeral identification, magnitude comparison, and counting on tasks, indicating knowledge of numerical symbols. Furthermore, on average, children’s number line estimates were moderately good, with an average PAE of 14%. However, there was substantial variability in the accuracy and precision of children’s number line estimates.First, we examined children’s average performance on each task, see Table 2, children’s accuracy on numeral identification and magnitude comparison was consistent with prior research with first graders and kindergartners (2Lin), and slopes on the number line task were also consistent with prior research  of their magnitude estimates and the slope of the best fitting lines were also similar across tasks. Both 2RLin, r = 0.46, p < 0.001, and slope, r = 0.42, p < 0.001, were correlated across tasks . This is further evidence that children who made highly linear estimates on the number line were also likely to make highly linear estimates when seeking page numbers in a book.Given that the precision of children’s magnitude estimates during the number line task was highly correlated with the precision of children’s magnitude estimates during the page finder estimation task, we assessed whether the p < 0.01, p = 0.41, p = 0.20, p = 0.21, Finally, we examined whether children’s magnitude estimation performance on the page finder task was related to their magnitude estimation performance on the number line estimation task, over and above the other facets of children’s numerical knowledge. Although all of the tasks assess children’s number knowledge, we hypothesized that the number line estimation task and the page finder magnitude estimation task would both specifically assess magnitude understanding, and therefore would be significantly related even after accounting for other aspects of children’s number knowledge. Thus, we regressed children’s PAE on the page finder task on children’s PAE on the number line task, controlling for accuracy on numeral identification, counting on, and magnitude comparison as well as age. In this model, children’s number line estimation PAE did predict their page finder PAE, β = 0.48, 2RLin, and slope) were related to the same dependent variables in the novel, page finder magnitude estimation task in which children were asked to find the location of a page number in a book. Interestingly, page finder PAE did not correlate with children’s accuracy on identifying numerals and counting on from a given number—tasks that seem to rely less on magnitude knowledge and more on symbolic numerical knowledge—and this may be related to the non-symbolic nature of the page finder book because it contained no printed page numbers. Children’s performance on the number line estimation task predicted their page finder PAE, even after controlling for overall age and performance on all other tasks tapping numerical knowledge. Overall, these findings suggest that children may be relying on similar mental representations to guide their estimates on both the highly symbolic number line estimation task and our novel page finder magnitude estimation task that contained no printed numbers.Our results provided evidence for a novel measure of spatial-numerical association, the page finder task. We found that for sixty first grade students, their performance on a number line estimation task in the 0–100 range was correlated with their performance on other numerical tasks, such as magnitude comparison, numeral identification, and counting on from a given number. Importantly, all three dependent variables that characterized performance in the number line estimation task  at finding page numbers in a book without printed page numbers as placing numbers on number lines. The number line estimation task can test for spatial-numeric associations because this task inherently involves spatial  as well as numeric components . Children’s accuracy on the page finder task was all the more impressive because the number line was 23 cm wide, yet the book used in the page finder task was only about 1 cm wide. We interpret children’s similar level of accuracy on these tasks as indicating that the number line estimation task and the page finder task tap a common underlying numerical representation. In this way, PAE on each task might indicate the level of precision in the underlying numerical representation: if participants’ numerical representations are precise enough to be accurate on one task, they are equally precise and accurate on the other. Was children’s performance so accurate on the page finder task because we oriented them to the size of one unit–a procedure similar to that used when children make estimates on “unbounded” number line tasks –by orienIn our regression analysis, we were able to predict page finder PAE from number line estimation PAE after controlling for age and performance on other numerical tasks, and we take this as evidence in support of the hypothesis that the page finder task and the number line estimation task tap a common underlying numerical representation. It is important to note that we are not able to make any causal claim about the direction of this relationship. In this analysis, we operationalized children’s underlying numerical representation by measuring their percent absolute error on the number line estimation task. Thus, we argue that our findings demonstrate that finding a page number in a book taps children’s underlying magnitude representation. If this is the case, it may be possible that finding page numbers in books is one way in which parents can help children improve their understanding of relative numerical magnitudes. Parents and teachers already encourage children’s literacy development through reading, and reading books is a familiar activity for many children. Our findings suggest that while reading books, caregivers can help children identify page numbers in the books in an effort to promote their understanding of numerical magnitudes. Like board game interventions, books may have the potential to provide an easy and cost-effective means for caregivers to integrate numerical experience into children’s everyday lives. In this way, books can promote the development of literacy as well as numeracy skills.Number sense is inherently spatial and numeric . We inveThis study was carried out in accordance with the recommendations of the Kent State University IRB with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Kent State University IRB.CT and BM conceptualized the study. CT and BM oversaw the data collection with undergraduate research assistants. CT and PS analyzed the data. CT, BM, and PS wrote and revised the paper.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.