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Revista Gaúcha de Enfermagem

On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.37 no.2 Porto Alegre  2016  Epub May 31, 2016 

Experience Report

Contributions of the sandwich doctoral program to methodological approaches: an experience report

Elisiane Lorenzinia 

Nelly Donszelmann Oelkeb  c 

Patricia Beryl Marckb  d 

Clarice Maria Dall’Agnola 

a Universidade Federal do Rio Grande do Sul, Escola de Enfermagem. Porto Alegre, Rio Grande do Sul, Brasil.

b University of British Columbia, School of Nursing, Okanagan Campus. Kelowna, Canada.

c University of Calgary, Department of Community Health Sciences, Cummings School of Medicine, Calgary, Canada.

d University of Victoria, Faculty of Human and Social Development. Victoria, Canada.



To share our experience on theoretical and methodological insights we have gained as researchers working together during the Sandwich Doctoral Program.


This is a descriptive experience report.


We have incorporated restoration thinking into a study on patient safety culture and will enhance knowledge translation by applying principles of deliberative dialogue to increase the uptake and implementation of research results.


Incorporating new approaches in Brazilian nursing research plays a key role in achieving international participation and visibility in different areas of nursing knowledge.

Key words: International educational exchange; Nursing; Methodology



Compartilhar experiências e insights teóricos e metodológicos que os pesquisadores obtiveram ao trabalhar juntos durante um programa de doutorado sanduíche.


Trata-se de um estudo descritivo do tipo relato de experiência.


Incorporou-se o pensamento restaurativo no estudo da cultura de segurança do paciente e espera-se implementar o plano de knowledge translation utilizando os princípios do diálogo deliberativo como uma estratégia para aumentar a aplicabilidade dos resultados da pesquisa.


A incorporação de novas metodologias nas pesquisas da enfermagem brasileira possui um papel fundamental para o alcance de visibilidade e participação internacional nas diferentes áreas de conhecimento da enfermagem.

Palavras-Chave: Intercâmbio educacional internacional; Enfermagem; Metodologia



Compartir experiencias e introspecciones teóricas y metodológicas que los investigadores obtuvieron al trabajar juntos durante un programa de doctorado sándwich.


Estudio descriptivo del tipo relato de experiencia.


Se ha incorporado el pensamiento restaurador en el estudio de la cultura de seguridad del paciente y se espera implementar el plan de traducir conocimientos usando los principios del diálogo deliberativo como una estrategia para aumentar la aplicabilidad de los resultados de la investigación.


La incorporación de nuevas metodologías en las investigaciones de enfermería brasileña tiene un rol fundamental para el alcance de visibilidad y participación internacional en las diferentes áreas de conocimiento de enfermería.

Palabras-clave: Intercambio educacional internacional; Enfermería; Metodología


Nursing science is underpinned by diverse theories and research methodologies. All professionals need to be educationally prepared to base their practice on complex nursing knowledge(1).

In Brazil, the scope of professional roles has advanced, demonstrating the wide and diffuse nature of the professional field, resulting from the increasing complexity of technical-scientific actions and procedures. In this way, the level of education has risen. Academically, it is considered to be “in consolidation” because there is still a need to achieve visibility internationally(2-3).

The internationalization of Brazilian graduate programs is defined by international cooperation directives that complement the education and formation of its professors and students. The objective is to promote the progress of science and solving specific problems in Brazil and others issues common to humanity(4). Internationalization is desirable and can be enhanced through graduate program exchanges. There are 63 graduate programs across Brazil accredited by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). To promote advances in terms of science and technology, CAPES has made several efforts inside and outside the country, such as collaborative initiatives and international academic mobility(5). For example, doctoral students with proven academic accomplishment can receive international scholarships for a Sandwich Doctoral Program(6). The Sandwich Doctoral Program provides a distinct opportunity to develop research skills, to increase their visibility within academia, and to expand work opportunities in an international context. This type of program facilitates the development of a network between nurse researchers building mutual trust and facilitating quality research through the knowledge and skills gained through the program. The exchange also contributes to new knowledge by spreading the discoveries of Brazilian scientific research in nursing.

This report describes the experience of a Doctoral student from Federal University of Rio Grande do Sul (UFRGS) - Brazil, who chose to do her Sandwich Doctoral Program at the School of Nursing - University of British Columbia – Okanagan Campus – Canada from February 2015 to August 2015. This research centre was chosen mainly, because of the international reputation of Dr. Patricia B. Marck as a research leader in using restorative ecological methodology to study safety issues in complex health care systems.

The objective of this article is to share our experience on theoretical and methodological insights we have gained as researchers working together during the Sandwich Doctoral Program.

Some aspects of theory and research methodology in our study

The impetus for this Doctoral exchange started during Dr. Marck’s graduate course offered as an International Visiting Professor at the School of Nursing of UFRGS – Brazil in 2011. Over the last 10 years, Canada has made concerted efforts to create safer health care systems. Despite significant advances, patient safety remains an issue. Recently, the National Steering Committee report identified “creating a culture of safety”(7 p.6) as the central goal for patient safety in Canada.

During the course, Dr. Marck introduced graduate students to the adaptation of principles and methods from the field of ecological restoration to safety research in complex health systems. Restorative thinking about complex systems requires communities to engage in collective repairs and improvements that develop and sustain stronger, healthier relations with each other and with the places they share(8). The main goal of restoration science and practice is to reduce and avoid ecological threats and fortify the relations between peoples and systems with resilience and integrity through projects and actions that include both cultural and ecological repairs(8-9).

One key feature of restorative methodology is the use of participatory, expert-led (practitioners or clients) photo walkabouts to encourage researchers and research participants to jointly explore and exchange knowledge about safety practices and safety issues within health care environments(10-13). In restorative work, human and natural systems are concurrently rehabilitated as interdisciplinary teams of researchers, students, practitioners, policy-makers, and community members explore the history, culture, ecology, and habits of land use, focusing on designing and implementing improvements and developing a strong understanding of a particular place.

Informed by these principles of good restoration, we will use participatory photo methods of practitioner-led unit photo walkabouts and researcher-led photo elicitation focus groups(10-17) to study patient safety culture and gain a better understanding of its elements together (researchers and the health care team). The study will be underpinned by the conviction that the best discoveries will be made when mutually identifying and working on those problems which matter most in the shared workplace. This involves the ethics, art, and science of how we work and invites participants to re-examine and self-monitor their practices in light of what they discover as they look at their workplace with the researchers.

Supported by a Canadian professor advisor, to better understand patient safety culture in Brazil, we incorporated restorative ecological thinking into our mixed method research project. Specifically, we will administer and use the findings of the Safety Attitudes Questionnaire(18) to conduct a subsequent qualitative phase where we use restorative photo methods and deliberative dialogue(19). Discussions with experts and other stakeholders in areas related to patient safety created the possibility to rethink some aspects of our research project.

The Safety Attitudes Questionnaire(18), a tool developed to elicit a snapshot of the patient safety culture through surveys of frontline worker perceptions, was administered in units across the surgical pathway at 14 hospitals in the Canadian province of British Columbia-Canada in 2012.

In a discussion with a member of the British Columbia Patient Safety & Quality Council about her experience of implementing this initiative, she realized that staff did not feel comfortable after the study. From those reflections, the following questions emerged: is it ethical to measure the perceptions of front line staff about managers of the unit and hospital and other aspects related to patient safety culture and after that not to do anything to collaborate to improve the issues found in the research? How can our data serve as a support for local change efforts?

These questions highlighted the need for Knowledge Translation (KT)(19) to be a part of the research project and process. KT is defined as:

“A dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system”(20 p.1).

KT strategies include both integrated KT and end-of-grant KT. Integrated KT refers to those activities undertaken before a study begins (e.g., discussions with decision-makers on potential research issues) and throughout the research process (e.g., refinement of research questions, advice on methods, and assistance in interpreting the data). Engagement of stakeholders is key to integrated KT(20). End-of-grant KT encompasses those activities that occur at the end of study such as infographics, Cafe Scientifique, videos and social media in addition to more traditional peer-reviewed articles and conference presentations.

The first contact with this theory occurred during a KT course by Dr. Oelke in December 2014 as an International Visiting Professor at School of Nursing of UFRGS. The Doctoral student continued to further her knowledge and skills during the Sandwich Doctoral Program in Canada. During this time, she learned how to use deliberative dialogue as a KT strategy to generate rich data and move research toward action involving stakeholders in intentional and facilitated discussions to achieve a consensus related to a vision of action(19). Deliberative dialogue uses various activities (e.g., background evidence for pre-reading, brainstorming, priority setting) to engage stakeholders in dialogue to co-create solutions for changes in health care practice(19).

Both KT and deliberative dialogue are critical because there is very limited knowledge of them in Brazil. However, in Canada, KT is a developed science that has been widely used by researchers and it is a mandatory step for grant supported research projects. This means that during the development and execution of a project the researchers will use strategies for transferring the evidence into practice to promote changes in the context of a study.

Along that line, we have decided to use the principles of deliberative dialogue as a KT strategy, where decision-makers and researchers will work together on a critical dialogue envisioning how to put research evidence into the context of the study to together develop solutions and make changes to practice.

With these new approaches and the foundation of the restorative theoretical lens, we (researchers and the health care team) will jointly learn about and propose potential workplace improvements to strengthen the patient safety culture.


Participating in a Sandwich Doctoral Program is an opportunity to expand our perspectives and open the mind to the world of science. Knowing other cultures and language, going across borders and making relationships with renowned international professors, and creating an international professional network are important attributes of this Program.

In this paper, we have shared our experience and insights about theory and research methodology gained in a Sandwich Doctoral Program. Incorporating new approaches in Brazilian nursing research plays a key role in achieving international insertion and visibility in different areas of nursing knowledge.

Our intention is to encourage professors and students to choose this international approach to improve nursing doctoral programs in Brazil. This type of exchange provides many positive outcomes and strengthens nursing knowledge. More Doctoral students across Brazil need to be encouraged to access this program that will help Brazilian nurses to understand other realities and also to contribute to the scientific world by spreading the discoveries of Brazilian scientific research in nursing.


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Received: September 09, 2015; Accepted: February 25, 2016

Corresponding author: Clarice Maria Dall’Agnol. E-mail:

Creative Commons License  This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.