Educator as Diagnostician, Judge and Confidant: a positioning analysis of medical student support encounters

It's very difficult to set the boundaries, it's human nature to want to respond: exploring health professions educators' responses to student mental health difficulties through a positioning theory lens

By virtue of their teaching role and contact with students, health professions (HP) educators are often the first point of connection for students who are experiencing mental health difficulties. Educators are increasingly expected to include some form of pastoral care in their role. Mental health-related interactions with students may have a negative emotional impact on educators, particularly when roles and expectations are not clearly defined and where boundaries are not managed effectively. Using positioning theory as a lens, this study explored how educators experienced such interactions and how this manifested in positions, storylines, and speech acts. Interviews were conducted with 27 HP educators at a faculty of medicine and health sciences. Reflexive thematic analysis using inductive coding identified themes corresponding to the nearing, weighted, ambivalent, and distancing positions participants adopted in relation to students with mental health difficulties. There was fluidity in and between positions, and more than one position could be occupied simultaneously; participants each moved through different positions in response to different relational situations. Multiple storylines informed these positions, representing how moral- and care-informed responsibility intersected with responsiveness to make certain actions possible or impossible. Normative and personal value narratives were evident in storylines, in many cases underscored by care or justice ethics. The value of positioning theory in facilitating reflective faculty development initiatives for educators engaged in these interactions is discussed.

Teacher, Gatekeeper, or Team Member: supervisor positioning in programmatic assessment

Competency-based assessment is undergoing an evolution with the popularisation of programmatic assessment. Fundamental to programmatic assessment are the attributes and buy-in of the people participating in the system. Our previous research revealed unspoken, yet influential, cultural and relationship dynamics that interact with programmatic assessment to influence success. Pulling at this thread, we conducted secondary analysis of focus groups and interviews (n = 44 supervisors) using the critical lens of Positioning Theory to explore how workplace supervisors experienced and perceived their positioning within programmatic assessment. We found that supervisors positioned themselves in two of three ways. First, supervisors universally positioned themselves as a Teacher, describing an inherent duty to educate students. Enactment of this position was dichotomous, with some supervisors ascribing a passive and disempowered position onto students while others empowered students by cultivating an egalitarian teaching relationship. Second, two mutually exclusive positions were described-either Gatekeeper or Team Member. Supervisors positioning themselves as Gatekeepers had a duty to protect the community and were vigilant to the detection of inadequate student performance. Programmatic assessment challenged this positioning by reorientating supervisor rights and duties which diminished their perceived authority and led to frustration and resistance. In contrast, Team Members enacted a right to make a valuable contribution to programmatic assessment and felt liberated from the burden of assessment, enabling them to assent power shifts towards students and the university. Identifying supervisor positions revealed how programmatic assessment challenged traditional structures and ideologies, impeding success, and provides insights into supporting supervisors in programmatic assessment.

Supporting medical students to support peers: a qualitative interview study

BACKGROUND

Students may be the first to recognise and respond to psychological distress in other students. Peer support could overcome medical student reluctance to seek help despite their high rates of mental ill-health. Yet, despite the adoption of peer support programs, there is little evidence of impact on students. Peer support programs may assume that medical students accept and view peer support positively. We explored these assumptions by asking students about their experiences and views on peer support.

METHODS

Qualitative semi-structured interviews exploring peer support experiences and views on peer support were conducted with ten medical students at two contrasting medical schools. Informed by a constructivist stance, interview transcripts underwent thematic analysis.

RESULTS

Three groups of themes were identified: participants' experiences of peer support encounters, concerns about providing support, and views on students' roles in peer support. Participants readily recalled signs of peer distress. Encounters were ad hoc, informal, and occurred within relationships based on friendship or by being co-located in the same classes or placements. Concerns about initiating and offering support included lack of expertise, maintaining confidentiality, stigma from a mental health diagnosis, and unclear role boundaries, with implications for acceptance of student roles in peer support.

CONCLUSIONS

Our study emphasised the centrality of social relationships in enabling or discouraging peer support. Relationships developed during medical studies may anticipate the collegial relationships between medical professionals. Nevertheless, only some students are willing to undertake peer support roles. We suggest different strategies for promoting informal peer support that can be offered by any student, to those promoting formal support roles for selected students. Future research focusing on the impact for both the students who receive, and on the students who provide peer support is called for.

Educator, judge, public defender: Conflicting roles for remediators of practising physicians

CONTEXT

Practising physicians who remediate their peers face unique challenges. Recent research suggests that leaders of regulatory and educational institutions (ie, those who might be seen as responsible for overseeing remediation programmes for practising physicians) view remediation as a duality: education and regulation. Research has yet to study the perspectives of remediators; therefore, to address that gap we asked: What is the nature of remediation as experienced by remediators?

METHODS

We used a theory-informing inductive data analysis study design with positioning theory as a sensitising concept. We interviewed nine remediators from five Canadian provinces, asking them to narrate particularly memorable remediation experiences, then exploring the stories in more depth by asking probing questions around topics related to the research question. We used a hermeneutic analytic approach to explore the meanings that participants gave to their remediation work by iteratively reading their stories, examining the sense making that participants achieved through these narratives, and identifying the positions and responsibilities they described.

RESULTS

In their remediation narratives, participants variably position themselves in three different ways: (a) educator; (b) judge, and (c) public defender. For each position, remediators in turn framed the remediatee in a particular way. Participants shifted between educator, judge and public defender in response to evolving experiences with the remediatee, but they expressed preference for the educator position. However, they sometimes encountered serious obstacles to enacting that educator position. Those obstacles were imposed both by regulators and by remediatees.

CONCLUSIONS

This study suggests that the duality of remediation as both education and regulation may be contributing to the challenges faced by those working one to one with remediatees. Understanding the dual nature of remediation and equipping remediators with the tools to manage this duality might contribute to improving the experience for both remediators and remediatees, and ultimately to a greater number of successful remediation outcomes.

Medical student perceptions of curricular influences on their wellbeing: a qualitative study

BACKGROUND

Medical student mental health and wellbeing is highly topical and the subject of much research. While theoretically informed definitions of wellbeing abound, how do medical students themselves understand and perceive wellbeing? What aspects of the curriculum do they regard as affecting their wellbeing and mental health? This study explored these questions, and aimed to identify factors associated with student acceptability of wellbeing programs and interventions.

METHODS

All students at an Australian undergraduate medical school (n = 619) were invited to complete a qualitative online questionnaire between 2017 and 2018 following the introduction of several wellbeing initiatives, including "Wellbeing Days" (WBD). WBD allow students to take single absence days for self-care. Open-ended questions were asked about perceptions and experience of mental health and wellbeing, and views on interventions to improve wellbeing such as WBD. Thematic analysis was conducted across all responses. Three authors developed preliminary themes, which were then refined and confirmed by all researchers. Thematic saturation was achieved within data from the 68 respondents, which included participants from all cohorts.

RESULTS

Participants described wellbeing as positively experienced work/life balance, impacted by four factors; contact hours, peer relationships, staff relationships, and trust in how wellbeing initiatives were used. Long contact hours were deemed incompatible with self-care activities, maintaining employment, and seeking professional medical/psychological help. Peers could promote wellbeing by offering social and academic support, but also undermine wellbeing by being competitors. Degree of trust, engagement and communication with staff influenced acceptability of interventions. Participants viewed initiatives such as WBD favourably, but distrust of peers, and of staff, led to perceptions that WBD could be prone to misuse, or used for surveillance rather than support.

CONCLUSION

Our findings suggest that wellbeing days which allow self-care, reduction in contact hours, and peer support may promote student wellbeing, but the acceptability of any interventions is influenced by relationships between staff and students, and in particular, trust in these relationships. We suggest strategies to strengthen trust and further research to investigate the relationship between trust and perceptions of wellbeing in self and peers.

Health Professions Educators' System-Oriented Roles as Educational Advocate, Quality Improver, and Broker

INTRODUCTION

Health professionals have many facets to their educational role. Although the teaching and student support dimensions of health professionals' educational role are highly visible in the literature, other nontraditional elements are not. This study presents a broader conceptualization of health professionals' educational role, with a focus on the strategic dimensions of their role.

METHODS

Participants were health professionals from different clinical backgrounds and teaching settings, with a formal role in education. Data were collected using a survey (n = 41) and interviews (n = 9), and this article focuses on reporting the qualitative findings of this study. Thematic analysis was used for data interpretation.

RESULTS

Health professionals have three strategic dimensions to their educational role. The first strategic dimension is educational advocacy, which is aimed at championing education at different levels and parts of the educational system and building educational capacity. The second strategic dimension is educational quality improvement which is focused on shifting narratives around education and educational change in health service settings and leveraging educational evidence. The final strategic dimension is educational brokerage which is oriented at connecting clinical and educational communities and building trust and consensus.

DISCUSSION

Beyond the microlevel of learning and teaching, health professionals engage in strategic work that is focused on the broader educational mission within health. Continuing professional development initiatives can empower health professionals to optimize these strategic and system-focused educational roles and responsibilities.