Growth, Engagement, and Belonging in the Clinical Learning Environment: the Role of Psychological Safety and the Work Ahead

You Get What You Reward: A Qualitative Study Exploring Medical Student Engagement in 2 Different Assessment Systems

PURPOSE

Educational impact is dependent on student engagement. Assessment design can provide a scaffold for student engagement to determine the focus of student efforts. Little is known about how medical students engage with assessment. Therefore, we asked the following research question: How do medical students engage with the process of assessment and their assessment data in 2 clinical assessment systems?

METHOD

This multi-institutional, cross-sectional constructivist grounded theory study of fourth-year undergraduate medical students at the University of Washington and Cleveland Clinic Lerner College of Medicine assessed 2 different assessment systems: traditional tiered grading, in which clerkship grades were summative, and programmatic assessment, in which students received low-stake, narrative feedback across clerkships with progress based on aggregated performance data in student portfolios. All fourth-year students were invited to participate in one-on-one semistructured interviews guided by student engagement theory between September 2022 and January 2023. Verbatim transcripts underwent iterative, qualitative analysis.

RESULTS

Twenty-two medical students were interviewed, 13 from a traditional grading assessment system and 9 from a programmatic assessment system. Three major ways in which assessment systems affected how students engaged with their assessments were categorized into the affective, cognitive, and behavioral domains of engagement: as a sociocultural statement of value, as the cognitive load associated with the assessment system and practices themselves, and as the locus of power and control in learning and authentic practice.

CONCLUSIONS

Medical students' beliefs about assessment goals, cognitive burden of assessment, and relationships with others significantly affected their engagement with their assessments. In assessment systems that reward grading and an archetypal way of being, students report engaging by prioritizing image over learning. In programmatic assessment systems, students describe more fully and authentically engaging in their assessment for and as learning. Systems of assessment communicate what is rewarded, and you get what you reward.

Psychological Safety in Medical Education, Another Challenge to Tackle?

Psychological safety is the feeling that one can take interpersonal risks without fear of negative consequences including retaliation, intimidation, or rejection. The literature base on psychological safety in medical education is increasing. Despite increasing recognition in the medical literature, many medical practitioners and educators are uncertain about the background and effects of psychological safety on medical education. For learners (students and residents), having an environment with high psychological safety means being able to admit knowledge gaps and skill deficits. Psychological safety is recognized as an essential attribute for a positive learning environment and is associated with several positive behaviors. To benefit medical educators, we contextualize the benefits of improved psychological safety in medical education and highlight the limited data substantiating what interventions are known to enhance psychological safety in graduate medical education. While it is recognized that higher psychological safety is important, creating better psychological safety is a complex challenge analogous to patient safety, well-being, and healthcare disparity. The challenges for environments with lower psychological safety are understanding what to fix and how to fix it, and recognition that quick fixes are elusive. Moving forward, medical educators must have a better understanding of how to enhance psychological safety.

Check, Please! Supervisor-Learner Dyads Using "Checking" for Clinical Support During Indirect Supervision

BACKGROUND

Indirect supervision is essential for granting autonomy to learners. Sometimes referred to as leaving the learner "unsupervised," there is growing recognition that learners and supervisors engage in clinical support through ongoing interactions, albeit at a distance.

OBJECTIVE

To understand how the complementary activities of asking for and providing clinical support at a distance come together as indirect supervision by identifying the natural language used between learners and supervisors.

DESIGN

A collective case study of 15 attending physician-senior medical resident dyads from 2018 to 2023. Each case consisted of 2 full days of ethnographic observation of the resident on an internal medicine clinical teaching unit in one of three metropolitan hospitals; 2 end of day interviews with each dyad member; and a third interview with the attending after the 2-week rotation.

PARTICIPANTS

Fifteen internal medicine residents (PGY-2 and PGY-3) who were scheduled to work for the first time with 15 attending physicians.

APPROACH

Data collection was iterative with deductive and inductive analysis to identify patterns of communication.

KEY RESULTS

The language of "checking," such as checkpoints, checking on, and checking in, was central to communications within dyads. Indirect supervision included attendings using scheduled checkpoints and backstage oversight activities to check on the senior resident's patient care while expecting residents to access their support, as needed, by checking-in with them. Residents checked in with their attending to relay patient information updates, ask questions, and hint at needing their plans doublechecked; these communications had similar formats making them difficult to distinguish but functioned to preserve resident independence while accessing clinical support.

CONCLUSIONS

Indirect supervision creates clinical support through ongoing communication between learners and supervisors at a distance. It is a collaborative process for mutual reassurance that safe patient care is being provided and that support is available when needed.

Psychological Safety Competency Training During the Clinical Internship From the Perspective of Health Care Trainee Mentors in 11 Pan-European Countries: Mixed Methods Observational Study

BACKGROUND

In the field of research, psychological safety has been widely recognized as a contributing factor to improving the quality of care and patient safety. However, its consideration in the curricula and traineeship pathways of residents and health care students is scarce.

OBJECTIVE

This study aims to determine the extent to which health care trainees acquire psychological safety competencies during their internships in clinical settings and identify what measures can be taken to promote their learning.

METHODS

A mixed methods observational study based on a consensus conference and an open-ended survey among a sample of health care trainee mentors from health care institutions in a pan-European context was conducted. First, we administered an ad hoc questionnaire to assess the perceived degree of acquisition or implementation and significance of competencies (knowledge, attitudes, and skills) and institutional interventions in psychological safety. Second, we asked mentors to propose measures to foster among trainees those competencies that, in the first phase of the study, obtained an average acquisition score of <3.4 (scale of 1-5). A content analysis of the information collected was carried out, and the spontaneity of each category and theme was determined.

RESULTS

In total, 173 mentors from 11 pan-European countries completed the first questionnaire (response rate: 173/256, 67.6%), of which 63 (36.4%) participated in the second consultation. The competencies with the lowest acquisition level were related to warning a professional that their behavior posed a risk to the patient, managing their possible bad reaction, and offering support to a colleague who becomes a second victim. The mentors' proposals for improvement of this competency gap referred to training in communication skills and patient safety, safety culture, work climate, individual attitudes, a reference person for trainees, formal incorporation into the curricula of health care degrees and specialization pathways, specific systems and mechanisms to give trainees a voice, institutional risk management, regulations, guidelines and standards, supervision, and resources to support trainees. In terms of teaching methodology, the mentors recommended innovative strategies, many of them based on technological tools or solutions, including videos, seminars, lectures, workshops, simulation learning or role-playing with or without professional actors, case studies, videos with practical demonstrations or model situations, panel discussions, clinical sessions for joint analysis of patient safety incidents, and debriefings to set and discuss lessons learned.

CONCLUSIONS

This study sought to promote psychological safety competencies as a formal part of the training of future health care professionals, facilitating the translation of international guidelines into practice and clinical settings in the pan-European context.

Veterinary Nursing Students' Experience in the Clinical Learning Environment and Factors Affecting Their Perception

Student veterinary nurses (SVNs) spend a significant proportion of their training time within the clinical learning environment (CLE) of a veterinary practice. These clinical experiences are vital for building practical and professional skills. To evaluate the current satisfaction of SVNs in the CLE, a cross-sectional survey design was used incorporating a previously validated instrument. To provide understanding of factors that may affect the SVN satisfaction, additional validated tools were added across factors, including resilience, well-being, personality, and workplace belonging. A total of 171 SVNs completed the survey. In addition, two open questions were included to provide greater depth of understanding of the SVN experiences. Results showed that 70.76% of respondents were satisfied/very satisfied with the CLE. Significant factors that affected the satisfaction scores included, depression, anxiety, and stress (p ≤ .001), psychological sense of organizational membership (p ≤ .001), agreeableness (p = .022), and emotional stability (p = .012). The qualitative data demonstrated shared SVN factors that are considered to contribute to clinical learning and those that detract from clinical learning. Educational facilities and training veterinary practices can support the SVN within the CLE by creating a greater sense of belonging, considering the SVN individual personality and well-being, and including the SVN in discussions around learning support needs.

Twelve tips for medical school faculty to support students with disabilities

As medical schools embrace diversity, it is increasingly acknowledged that medical students with disabilities must be welcome and supported in becoming physicians. Students should be able to ask for and receive reasonable accommodations to support their education. However, a practical shared approach to supporting medical students with disabilities is needed. The 12 tips in this article use sense-making theory as a framework to guide medical school faculty in supporting medical students with disabilities. The tips center on perceiving cues, creating interpretations, taking action, and communicating with students. The 12 tips can be utilized by faculty members across universities to take a proactive role in implementing support for medical students with disabilities and, in turn, nurturing an inclusive educational environment.

Enhancing ESG learning outcomes through gamification: An experimental study

This study investigates the effectiveness of gamification in enhancing learning outcomes in Environmental, Social, and Governance (ESG) education. Employing a cluster randomized experiment, the research involved 22 classes from four universities, divided into gamified and traditional teaching groups. The gamified group engaged with ESG concepts through interactive, game-like elements, while the control group followed standard educational practices. The study aimed to determine whether gamification could improve ESG course effectiveness and enhance Psychological Ownership and Perceived Importance, thereby influencing learning outcomes. Data collected through post-experiment surveys were analyzed using multiple linear regression and Structural Equation Modeling (SEM). Results indicated that students in the gamified group performed significantly better in ESG exams compared to the control group, demonstrating the effectiveness of gamification in enhancing academic achievement. The SEM analysis further revealed that gamification positively impacted Psychological Ownership and Perceived Importance, which in turn significantly improved academic performance. These findings suggest that incorporating gamification in ESG education can effectively engage students and deepen their understanding of complex sustainability issues. This study contributes to the field by highlighting the potential of gamification as a transformative tool in higher education, particularly in teaching abstract and multifaceted subjects like ESG.

Organizational Climate for Inclusion Among Nurses: A Mixed-Methods Analysis

OBJECTIVE

The aim of this study was to answer the research question: What factors predict sense of belonging among nurses?The connection between inclusion (an element of diversity and equity) and a nurse's sense of belonging is poorly understood.

METHODS

In this mixed-methods research, regression analysis of Climate for Inclusion Scale subscales and Sense of Belonging score plus thematic content analysis of questions assessing sense of belonging were conducted. Nurses (n = 131) attending a research conference in June to July 2022 were invited to participate; 131 (72%) participated.

RESULTS

Climate for Inclusion Scale was positively associated with and predictive of sense of belonging (F3,113 = 71.7, P < 0.001). Themes reflecting actions to enhance sense of belonging were as follows: authentic leadership, embracing social justice, team unification, feeling heard, being seen, professional development, developing a healthier work environment, and integration of differences.

CONCLUSIONS

Leaders can promote a sense of belonging among nurses by focusing on actions reflected in the themes.

Psychological Safety and Hierarchy in Operating Room Debriefing: Reflexive Thematic Analysis

INTRODUCTION

Debriefing is a team discussion in a constructive, supportive environment. Barriers exist to consistent, effective team debriefing in the clinical setting, especially in operating theaters. The purpose of this study was to gain insights from frontline workers on how to set up an effective debriefing policy for our operating room.

METHODS

This was a qualitative study in which we interviewed operating room workers in a tertiary children's hospital. Interviews were audio-recorded, transcribed, and coded. Data were analysed using the reflexive thematic analysis technique within a critical realism paradigm.

RESULTS

Interviews were analysed from 40 operating room staff: 14 nurses, seven anesthetic technicians, seven anaesthetists, and 12 surgeons; 25 (65%) were female. The three key themes were (1) "commitment to learning"-healthcare workers are committed to teamwork and quality improvement; (2) "it is a safe space"-psychological safety is a prerequisite for, and is enhanced by, debriefing; and (3) "natural leader"-the value of leadership, but also constructs around leadership that maintain hierarchies.

CONCLUSIONS

Psychological safety is both a prerequisite for and a product of debriefing. Leadership, if viewed as a collective responsibility, could help break down power structures. Given the results of this study and evidence in the literature, it is likely that routine debriefing, if well done, will improve psychological safety, facilitate team learning, reduce errors, and improve patient safety.

Development of a Competency Framework Defining Effective Surgical Educators

OBJECTIVE

The objective of this study is to develop a practical framework of competencies and behaviors which define an effective surgical educator.

DESIGN

A modified Delphi approach was used. A literature review and series of discussions with surgical education experts led to creation of a survey instrument which was sent to surgical faculty and trainees from a single academic institution. The results from this initial survey informed the creation of the subsequent survey instrument which was also sent to surgical faculty and trainees. Focus groups with surgical faculty and residents were conducted separately, transcribed, deidentified, and then evaluated for recurring themes. A competency framework was developed.

SETTING

The surveys were administered and focus groups were conducted at the University Hospitals Cleveland Medical Center, a tertiary care academic institution.

PARTICIPANTS

Residents, fellows, and faculty surgeons from the fields of general surgery, plastic surgery, vascular surgery, orthopedic surgery, otolaryngology, neurosurgery, and urology.

RESULTS

There were 115 responses (31.3%) from 367 faculty surgeons, residents, and fellows invited to complete the initial survey examining 50 competencies. Eighteen competencies received a mean Likert score of at least 4 by both faculty and residents and were included in the subsequent survey instrument which was completed by 72 participants (19.6%). Focus groups were held separately with 6 faculty surgeons and 6 residents. Analysis of the survey results and focus group discussions identified several themes which informed the development of a competency framework consisting of 5 overarching competencies as well as 16 specific behaviors.

CONCLUSIONS

A practical framework was developed consisting of 5 competencies and 16 behaviors which define an effective surgical educator. The 5 competencies are: 1) fosters psychological safety, 2) displays exemplary medical knowledge and patient care, 3) diagnoses the learner and adjusts teaching, 4) communicates thought process to trainee, and 5) displays learner-centeredness. Based on the competency framework, residency leadership may specifically tailor faculty development initiatives to improve surgical education programming.

Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs

BACKGROUND

Safe and effective physician-to-physician patient handoffs are integral to patient safety. Unfortunately, poor handoffs continue to be a major cause of medical errors. Developing a better understanding of challenges faced by health care providers is critical to address this continued patient safety threat. This study addresses the gap in the literature exploring broad, cross-specialty trainee perspectives around handoffs and provides a set of trainee-informed recommendations for both training programs and institutions.

METHODS

Using a constructivist paradigm, the authors conducted a concurrent/embedded mixed method study to investigate trainees' experiences with patient handoffs across Stanford University Hospital, a large academic medical center. The authors designed and administered a survey instrument including Likert-style and open-ended questions to solicit information about trainee experiences from multiple specialties. The authors performed a thematic analysis of open-ended responses.

RESULTS

687/1138 (60.4%) of residents and fellows responded to the survey, representing 46 training programs and over 30 specialties. There was wide variability in handoff content and process, most notably code status not being consistently mentioned a third of the time for patients who were not full code. Supervision and feedback about handoffs were inconsistently provided. Trainees identified multiple health-systems level issues that complicated handoffs and suggested solutions to these threats. Our thematic analysis identified five important aspects of handoffs: (1) handoff elements, (2) health-systems-level factors, (3) impact of the handoff, (4) agency (duty), and (5) blame and shame.

CONCLUSIONS

Health systems, interpersonal, and intrapersonal issues affect handoff communication. The authors propose an expanded theoretical framework for effective patient handoffs and provide a set of trainee-informed recommendations for training programs and sponsoring institutions. Cultural and health-systems issues must be prioritized and addressed, as an undercurrent of blame and shame permeates the clinical environment.