"I can do better": exploring purposeful improvement in daily clinical work.

Clinicians' purposeful improvement of practice is vital to maintaining excellence in patient care. This activity is understood as a core competency of adaptive expertise. As part of a broader program of research exploring adaptive expertise in healthcare, this study explored purposeful improvement in paediatric minimally invasive surgery. A cognitive ethnography was conducted, with the aim of identifying and elaborating distributed cognitive processes that occur when an individual enacts purposeful improvements in a clinical context. A saturation sample of data from weekly pre-operative meetings, 13 observed minimally invasive procedures and 12 semi-structured interviews was collected over 6 months. A concurrent analysis of field notes and transcribed interviews was done inductively to uncover emergent themes. An audit trail was maintained throughout the research. We analyzed the interview and observation data with particular attention to the ways in which the activity of purposeful improvement is distributed socially (e.g. patient families, health care team) and materially (e.g. procedure, patient position, instruments, OR equipment) as well as over time (i.e. before, during and after). These results made visible the distributed nature of purposeful improvement, building on our understanding of this important adaptive expert activity in clinical settings and suggesting implications for more effective training of future adaptive experts. In particular, our results inform how purposeful improvement can occur during daily work and highlight two related forms of integration that occur during this activity: integration of individual competencies and integration of individuals and their social and material context.