Performativity, identity formation and professionalism: Ethnographic research to explore student experiences of clinical simulation training

Tanisha Jowsey; Lynne Petersen; Chris Mysko; Pauline Cooper-Ioelu; Pauline Herbst; Craig S. Webster; Andy Wearn; Dianne Marshall; Jane Torrie; Meng-Jiun Penny Lin; Peter Beaver; Johanne Egan; Kira Bacal; Anne O’Callaghan; Jennifer Weller

doi:10.1371/journal.pone.0236085

Peer Review History

Original SubmissionSeptember 26, 2019
15 Apr 2020 Decision Letter - Janhavi Ajit Vaingankar, Editor PONE-D-19-27048 Performativity, identity formation and professionalism: ethnographic research to explore student experiences of clinical simulation training PLOS ONE Dear Dr Jowsey, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. We would appreciate receiving your revised manuscript by May 30 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Janhavi Ajit Vaingankar Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. To meet our criteria on data reproducibility, please ensure that the program has been adequately described (in particular, please consider reporting in more details the scenarios included in the simulation training. 3. We note that Figures 1, 2 and 3 includes images of participants in the study. As per the PLOS ONE policy (http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research) on papers that include identifying, or potentially identifying, information, the individual(s) or parent(s)/guardian(s) must be informed of the terms of the PLOS open-access (CC-BY) license and provide specific permission for publication of these details under the terms of this license. Please download the Consent Form for Publication in a PLOS Journal (http://journals.plos.org/plosone/s/file?id=8ce6/plos-consent-form-english.pdf). The signed consent form should not be submitted with the manuscript, but should be securely filed in the individual's case notes. Please amend the methods section and ethics statement of the manuscript to explicitly state that the patient/participant has provided consent for publication: “The individual in this manuscript has given written informed consent (as outlined in PLOS consent form) to publish these case details”. If you are unable to obtain consent from the subject of the photograph, you will need to remove the figure and any other textual identifying information or case descriptions for this individual. 4. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability. Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized. Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access. We will update your Data Availability statement to reflect the information you provide in your cover letter. 5. Your ethics statement must appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please also ensure that your ethics statement is included in your manuscript, as the ethics section of your online submission will not be published alongside your manuscript. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: I have thoroughly enjoyed reading this well written manuscript. The use of focused ethnography is highly valuable in healthcare education and practice. I congratulate the authors conducting on such a fantastic piece of research. I have only four very minor points for consideration to the methods section: Line 223: Focused ethnography is a valid method. Perhaps it is worth adding how the 26-minute content was selected from the overall 100 hours. What was the focus of the editing? This would add a little more transparency. Line 228: Could you clarify which data this refers to - by hand as I initially presumed this excluded the video data? How was the video data coded? Did you use specific software, or simply make handwritten notes? Line 231: Consider clarifying what constitutes the data set? Lines 457-458: The word clearly is used twice in this sentence. Consider revision. Reviewer #2: I am not an expert in ethnography or qualitative methods generally. This created several points of confusion and doubt on my part due to that ignorance but also due to the use of technical language and jargon in reference to the methods and the theoretical framework. Please read the paper for areas you could simplify and clarify. I will point out some that I encountered. The quote by Grant on page 10 was particularly dense and confusing. Ethnography would be an appropriate methodology for this situation. The use of multiple observers seems a good choice and the brevity of the experience makes it feasible as well. I remain confused about the purpose of the filming and the ethnographic video that resulted. If this was a planned part of the study, please describe how it was intended to contribute and where the observations about the use of the film are reported and incorporated into the discussion and conclusions. Similarly, it would be useful to have more detail about the simulation itself, particularly the nature and content o the simulations. Performativity theory is appropriate for use in this study but I would like the authors to explain why they selected this framework - is it novel? Previously used by these investigators? Does it have a particular strength or nuance that helps this study? I found the sentence on page 10 lines 253-254 rather opaque - please clarify what you intend by theatirical and improvisational components. An example would be helpful. Similarly, please expand and illustrate your definition of risk. There are many ways to talk about and conceptualize risk, but I am unsure of the specifics of what you are using. Also, what do you mean by "fleeting moments of decision making (p 11 line 272)? please explain and illustrate in the context of the UIPCW. The three figures mentioned on page 13 were absent from my version of the manuscript. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Suzanne Gough Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: PONE-D-19-27048_reviewer.pdf https://doi.org/10.1371/journal.pone.0236085.r001
Revision 1
19 May 2020 Author Response Dear Editor, RE: Performativity, identity formation and professionalism: ethnographic research to explore student experiences of clinical simulation training Thank you for the opportunity to make the minor revisions requested for this manuscript. Following are our responses to the reviewer comments. COMMENTS and RESPONSES Reviewer #1: I have thoroughly enjoyed reading this well written manuscript. The use of focused ethnography is highly valuable in healthcare education and practice. I congratulate the authors conducting on such a fantastic piece of research. Thank you for the kind words I have only four very minor points for consideration to the methods section: Line 223: Focused ethnography is a valid method. Perhaps it is worth adding how the 26-minute content was selected from the overall 100 hours. What was the focus of the editing? This would add a little more transparency. Change made in text to provide this information (line 223ff): Footage was purposively selected for the film based on its relevance to the key findings and consistent with ethnographic film techniques. Editing was conducted by the first author and a professional film editor (Richard Smith of UoA Media Productions) using Adobe Premiere Pro software. Line 228: Could you clarify which data this refers to - by hand as I initially presumed this excluded the video data? How was the video data coded? Did you use specific software, or simply make handwritten notes? Change made to clarify (lines 231-239) modes of analysis for the written and film data …coded the observational written data (not including film data) by hand. … The film data was analysed by hand and film analysis/editing notes were made in Microsoft Word software. Line 231: Consider clarifying what constitutes the data set? Now clarified, as above. Lines 457-458: The word clearly is used twice in this sentence. Consider revision. Change made, second word ‘clearly’ replaced with “effectively” Many thanks to reviewer one for their time in reading and reviewing with these helpful comments. Reviewer #2: I am not an expert in ethnography or qualitative methods generally. This created several points of confusion and doubt on my part due to that ignorance but also due to the use of technical language and jargon in reference to the methods and the theoretical framework. Please read the paper for areas you could simplify and clarify. I will point out some that I encountered. The quote by Grant on page 10 was particularly dense and confusing. Change made. While Grant’s quote is dense, we see it as being useful to explaining the complexity of performance as risk. It is a complex issue. It is difficult to say it simply. We have tried to say it simply in our text surrounding Grant’s quote. After careful consideration we have decided to keep Grant’s quote and to explain it more simply as well [lines 277-280] What Grant is saying here is that the performer – the person in the moment of having to make a decision and act upon it – experiences risk in terms of that very decision they are making. Further, that decision is based on the performer’s history and experiences leading up to that moment. Ethnography would be an appropriate methodology for this situation. The use of multiple observers seems a good choice and the brevity of the experience makes it feasible as well. Thank you for your support I remain confused about the purpose of the filming and the ethnographic video that resulted. If this was a planned part of the study, please describe how it was intended to contribute and where the observations about the use of the film are reported and incorporated into the discussion and conclusions. Similarly, it would be useful to have more detail about the simulation itself, particularly the nature and content o the simulations. No change made. The reviewer is asking for a more evaluative approach to the paper than an ethnographic one. The key elements of the course needed to understand the ethnographic approach are described (box 1 and 2), and that, in fact, one of the important purposes of the film is to offer the thickest description possible (as per Clifford Geertz) and experiential summary of the course itself (which the reviewer is very welcome to watch from the link in the paper, see ref 23). Evaluative approaches to prior iterations of the UIPC course have been published elsewhere: Jowsey, T., Yu, T. C. W., Ganeshanantham, G., Torrie, J., Merry, A. F., Bagg, W., ... & Weller, J. (2018). Ward calls not so scary for medical students after interprofessional simulation course: a mixed-methods cohort evaluation study. BMJ Simulation and Technology Enhanced Learning, 4(3), 133-140. Performativity theory is appropriate for use in this study but I would like the authors to explain why they selected this framework - is it novel? Previously used by these investigators? Does it have a particular strength or nuance that helps this study? I found the sentence on page 10 lines 253-254 rather opaque - please clarify what you intend by theatirical and improvisational components. An example would be helpful. Changes made. We have completely reworked this section of the manuscript to make it easier to understand why we chose performativity theory and to make that part of the manuscript easier to understand for readers who are not performance theorists or ethnographers. [lines 254-258 and 262-267] Similarly, please expand and illustrate your definition of risk. There are many ways to talk about and conceptualize risk, but I am unsure of the specifics of what you are using. Change made to define risk [lines 283-288]: In this paper, we are conceptualising risk in terms of the way a person perceives their personal exposure or the exposure of their patient to danger, harm, or loss (including loss of face). In the case of personal risk, this may involve risk of being seen to make an error and being judged socially – by teachers and peers – on performance. Also, what do you mean by "fleeting moments of decision making (p 11 line 272)? please explain and illustrate in the context of the UIPCW. Text changed to clarify: …and often rapid moments of decision making. In the simulation setting, people are often required to quickly make decisions and act on them, where risks are either embraced, shied away from, ignored, or abandoned. The three figures mentioned on page 13 were absent from my version of the manuscript. Sorry, they are photos of students during simulations, they were uploaded with the submission. We are not sure why the reviewer couldn’t see them. We hope that if the reviewer does see them and the film they will get a richer understanding of our work. Many thanks to reviewer two for their time in reading and reviewing with these helpful comments. We really appreciate the insights from these two reviewers that have enabled us to polish the manuscript. Much appreciated. Kind wishes from the authors, https://doi.org/10.1371/journal.pone.0236085.r002
30 Jun 2020 Decision Letter - Janhavi Ajit Vaingankar, Editor Performativity, identity formation and professionalism: ethnographic research to explore student experiences of clinical simulation training PONE-D-19-27048R1 Dear Dr. Jowsey, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Janhavi Ajit Vaingankar Academic Editor PLOS ONE Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: (No Response) ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: (No Response) ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: (No Response) ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: I would like to thank the authors for addressing all of the comments raised in my initial review. The use of focused ethnography is highly valuable in healthcare education and practice. I look forward to reading the published article. Reviewer #2: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes:** Dr Suzanne Gough Reviewer #2: No https://doi.org/10.1371/journal.pone.0236085.r003
Formally Accepted
6 Jul 2020 Acceptance Letter - Janhavi Ajit Vaingankar, Editor PONE-D-19-27048R1 Performativity, identity formation and professionalism: ethnographic research to explore student experiences of clinical simulation training Dear Dr. Jowsey: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Ms Janhavi Ajit Vaingankar Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0236085.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .