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D'Angelo JD, Rivera M, Rasmussen TE, Nelson MH, Behm KT, Kelley SR, D'Angelo ALD. Assessing the stops framework for coping with intraoperative errors: Evidence of efficacy, hints of hubris, and a bridge to abridging burnout. Surgery 2024; 176:319-323. [PMID: 38763791 DOI: 10.1016/j.surg.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/21/2024] [Accepted: 04/06/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Answering calls in the literature, we developed and introduced an evidence-based tool for surgeons facing errors in the operating room: the STOPS framework (stop, talk to you team, obtain help, plan, succeed). The purpose of this research was to assess the impact of presenting this psychological tool on resident coping in the operating room and the related outcome of burnout while examining sex differences. METHODS In a natural experiment, general surgery residents were invited to attend 2 separate educational conferences regarding coping with errors in the operating room. Three months later, all residents were asked to fill out a survey assessing their coping in the operating room, level of burnout, and demographics. We assessed the impact of the educational intervention by comparing those who attended the coping conferences with those who did not attend. RESULTS Thirty-five residents responded to the survey (65% response rate, 54% female respondents, 49% junior residents). Our hypothesized moderated mediation model was supported. Sex was found to moderate the impact of the STOPS framework-female residents who attended the coping educational conference reported higher coping self-efficacy, whereas attendance had no statistically significant impact on male levels of coping self-efficacy. In turn, higher coping self-efficacy was associated with lower levels of burnout. CONCLUSION Our results suggest that there is evidence of efficacy in this instruction-female residents presented this material report higher levels of coping in the operating room compared to those who did not receive the framework. Further, increase in coping ability was associated with reduced levels of burnout for both genders.
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Affiliation(s)
| | - Mariela Rivera
- Divsion of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Kevin T Behm
- Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, MN
| | - Scott R Kelley
- Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, MN
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Talbott J, Khurana A, Wasson M. The Supply of Surgical Specialists and Subspecialists to the U.S. Medicare Population: National Trends from 2013 to 2019. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:889-896. [PMID: 38363800 DOI: 10.1097/acm.0000000000005664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
PURPOSE The U.S. population is rapidly aging. The supply of surgeons needed to meet this demand should be evaluated. This study evaluated the trends in supply of Medicare surgeons by specialty and by U.S. state and region. METHOD All surgeons associated with a National Provider Identifier for cardiothoracic surgery, colorectal surgery, general surgery, gynecologic oncology, hand surgery, neurosurgery, obstetrics-gynecology, ophthalmology, oral and maxillofacial surgery, orthopedic surgery, otolaryngology, plastic and reconstructive surgery, surgical oncology, urology, and vascular surgery from 2013 to 2019 on the Centers for Medicare & Medicaid Services website were included. The absolute number of physicians was adjusted per 100,000 Medicare beneficiaries. Annual change was calculated by linear regression model, and the compound annual growth rate (CAGR) was calculated per specialty. RESULTS The absolute number of physicians per 100,000 beneficiaries increased in 6 of 15 specialties during the study period. Vascular surgery had the largest annual increase (+0.23; CAGR, +2.75%), and obstetrics-gynecology had the largest annual decrease (-1.08; CAGR, -1.44%). Surgical oncology showed the largest positive CAGR (+4.20%). Oral and maxillofacial surgery had the largest negative CAGR (-2.86%). The Northeast was above the national average in supply for each specialty. The Midwest had the most specialties with positive CAGRs. The South did not meet the national average for physicians in any specialty. CONCLUSIONS This analysis of 15 surgical specialties provides important context to predicted physician shortages to the Medicare population. The study found geographic variation by region across specialty, which has important implications for health care planning from the level of undergraduate medical education to provision of hospital resources. Overall, the supply of surgeons across all specialties may not be sufficient to meet the demand of the rapidly aging U.S. population. Future study is needed to evaluate why surgeons are leaving the Medicare program.
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Hughes D, Hanson MN, Alseidi A, Bittner JG, Romanelli J, Vassiliou M, Feldman LS, Asbun H. The joy of surgery: how surgeons experience joy, time, and support. Surg Endosc 2024; 38:3494-3502. [PMID: 38872020 DOI: 10.1007/s00464-024-10961-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/23/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Burnout is a crisis in medicine, and especially in surgery it has serious implications not only for physician well-being but also for patient outcomes. This study builds on previous SAGES Reimagining the Practice of Surgery Task Force work to better understand how organizations might intervene to increase the "joy in surgery." METHODS This was a cross-sectional, descriptive study utilizing a REDCap survey with closed-ended questions for data collection across 5 domains: facilitators of joy, support for best work, time for work tasks, barriers to joy, and what they would do with more time. We calculated average scores and "percentage of respondents giving a high score" for each item. RESULTS There were 307 individuals who started the survey; 223 completed it and were surgeons who met the inclusion criteria. The majority (85.7%) were trained in general surgery, regardless of sub-specialty. Surgeons found joy in operating and its technical skills, curing disease, patient relationships, and working with a good team. They reported usually having what they needed to deliver care. A majority felt valued and respected. Most were dissatisfied with reimbursement, perceiving it as unfair. The most commonly worked range of hours was 51-70 per week. They reported having little time for paperwork and documentation, and if they had more time, they would spend it with friends and family. CONCLUSION Organizations should consider interventions to address the operative environment, provide appropriate staff support, and foster good teamwork. They can also consider interventions that alleviate time pressures and administrative burden while at the same time promoting sustainable workloads.
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Affiliation(s)
- Dorothy Hughes
- Departments of Population Health and Surgery, University of Kansas School of Medicine- Salina Campus, 138 N Santa Fe Ave, Salina, KS, 67401, USA.
| | - Melissa N Hanson
- Department of Surgery, Guelph General Hospital, Guelph, ON, Canada
| | - Adnan Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - James G Bittner
- Department of Surgery, Trinity Health of New England, Hartford, CT, USA
| | - John Romanelli
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate Medical Center, Springfield, MA, USA
| | - Melina Vassiliou
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Center, Montreal, QC, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Center, Montreal, QC, Canada
| | - Horacio Asbun
- Department of Hepato-Pancreato-Biliary Surgery, Miami Cancer Institute, Miami, FL, USA
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Egen L, Wessels F, Quan A, Westhoff N, Kriegmair MC, Honeck P, Michel MS, Kowalewski KF. Maximizing efficiency and ensuring safety: Exploring the outcomes of 2 consecutive open radical cystectomies by the same team within a single surgical day. Urol Oncol 2024; 42:118.e1-118.e7. [PMID: 38246807 DOI: 10.1016/j.urolonc.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/28/2023] [Accepted: 01/07/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND The purpose of this study was to evaluate the outcomes of performing 2 consecutive open radical cystectomies (RCs) within 1 day by the same surgical team. PATIENTS AND METHODS A retrospective analysis was conducted on data from patients who underwent RC at a single tertiary care center from January 2015 to February 2023. Patient characteristics, perioperative outcomes and endpoints were analyzed. Univariable and multivariable logistic regression models were created to predict major complications. RESULTS A total of 657 patients were included in the final cohort, containing 64 paired RCs (32 RC1 and 32 RC2) and 593 single RCs. Major complications occurred in 24.7% of the entire cohort, with no significant differences between single RC vs. RC1 and RC2. Paired RCs showed significantly shorter operative time (OT; p = 0.001) and length of stay (LOS; p = 0.047) compared to single RCs. There were no significant differences in transfusion rates, 30-day readmission, 30-day mortality, or histopathological results between paired and single RCs. Multivariable analysis identified patient characteristics such as age (OR = 1.67, p = 0.03), sex (OR = 0.45, p = 0.008), BMI (OR = 1.98, p = 0.007), ASA-score (OR = 1.61, p = 0.04), and OT (OR = 1.87, p = 0.008) as independent predictors of major complications. CONCLUSION Performing 2 consecutive open RCs within 1 day by the same surgical team is a safe approach in experienced hands. This strategy optimizes the utilization of surgical resources and addresses the growing demand for urologic care while maintaining high-quality patient care. Preoperative planning should consider patient-specific factors to minimize risks associated with major complications. MICRO ABSTRACT This study evaluates the outcomes of performing 2 consecutive open radical cystectomies (RC) in a single day by the same surgical team. Data from 657 patients who underwent RC at a single tertiary medical center proved that this approach is safe, with no significant differences in major complications. Preoperative planning should consider patient-specific factors for efficient utilization of surgical resources.
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Affiliation(s)
- Luisa Egen
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany; German Cancer Research Center (DKFZ) Heidelberg, Division of Intelligent Systems and Robotics in Urology (ISRU), Heidelberg, Germany; DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany.
| | - Frederik Wessels
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany
| | - Allison Quan
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany
| | - Niklas Westhoff
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany
| | | | - Patrick Honeck
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany
| | | | - Karl-Friedrich Kowalewski
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany; German Cancer Research Center (DKFZ) Heidelberg, Division of Intelligent Systems and Robotics in Urology (ISRU), Heidelberg, Germany; DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
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Houdmont J, Daliya P, Adiamah A, Theophilidou E, Hassard J, Lobo DN. Management standards and burnout among surgeons in the United Kingdom. Occup Med (Lond) 2023; 73:484-491. [PMID: 37802910 PMCID: PMC10756657 DOI: 10.1093/occmed/kqad102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Burnout arising from chronic work-related stress is endemic among surgeons in the UK. Identification of contributory and modifiable psychosocial work characteristics could inform risk reduction activities. AIMS We aimed to assess the extent to which surgeons' psychosocial working conditions met aspirational Management Standards delineated by the UK Health and Safety Executive, draw comparisons with national general workforce benchmarks and explore associations with burnout. METHODS Surgeons (N = 536) completed the Management Standards Indicator Tool and a single-item measure of burnout. Descriptive data were computed for each Standard, independent t-tests were used to examine differences between trainees and consultants, and hierarchical linear regression was applied to explore relations between psychosocial work environment quality and burnout. RESULTS Psychosocial work environment quality fell short of each Management Standard. Trainee surgeons (n = 214) reported significantly poorer psychosocial working conditions than consultant surgeons (n = 322) on the control, peer support and change Standards. When compared with UK workforce benchmarks, trainees' psychosocial working conditions fell below the 10th percentile on four Standards and below the 50th percentile on the remainder. Consultant surgeons were below the 50th percentile on five of the seven Standards. Psychosocial working conditions accounted for 35% of the variance in burnout over that accounted for by socio- and occupational-demographic characteristics. CONCLUSIONS Surgeons' psychosocial working conditions were poor in comparison with benchmark data and associated with burnout. These findings suggest that risk management activities based on the Management Standards approach involving modification of psychosocial working conditions would help to reduce burnout in this population.
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Affiliation(s)
- J Houdmont
- School of Medicine, University of Nottingham, Nottingham NG8 1BB, UK
| | - P Daliya
- East Midlands Surgical Academic Network, Queen’s Medical Centre, Nottingham NG7 2UH, UK
- Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - A Adiamah
- East Midlands Surgical Academic Network, Queen’s Medical Centre, Nottingham NG7 2UH, UK
- Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - E Theophilidou
- East Midlands Surgical Academic Network, Queen’s Medical Centre, Nottingham NG7 2UH, UK
- Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - J Hassard
- School of Medicine, University of Nottingham, Nottingham NG8 1BB, UK
- Management School, Queen’s University of Belfast, Belfast, BT9 5EE, UK
| | - D N Lobo
- School of Medicine, University of Nottingham, Nottingham NG8 1BB, UK
- East Midlands Surgical Academic Network, Queen’s Medical Centre, Nottingham NG7 2UH, UK
- Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK
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Al‐Ghunaim T, Johnson J, Biyani CS, Coleman R, Simms‐Ellis R, O'Connor DB. Evaluation of the reboot coaching workshops among urology trainees: A mixed method approach. BJUI COMPASS 2023; 4:533-542. [PMID: 37636204 PMCID: PMC10447217 DOI: 10.1002/bco2.249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/16/2023] [Accepted: 04/05/2023] [Indexed: 08/29/2023] Open
Abstract
Background Urology trainees experience high burnout, and there is an urgent need for acceptable and effective interventions. The current study evaluated Reboot coaching workshops (Reboot-C), a tailored intervention based on cognitive-behavioural principles, with urology trainees. Objective Our primary objective was to evaluate the acceptability of Reboot-C among urology trainees. In addition, this study aimed to investigate whether there were changes in confidence, resilience, depression and burnout levels. Materials and method A single-arm design was used, including pre- and post-online questionnaires and semi-structured interviews. Result Twenty-one urology trainees replied to the survey, attended both Reboot-C workshops and responded to the post-intervention questionnaire. Thirteen of 21 (61%) urology trainees participated in the interview. Participating in Reboot-C was associated with significant improvements in resilience and confidence and a significant reduction in burnout. However, there was no significant reduction in depression. Qualitative data indicated that Reboot was acceptable and helped participants develop useful skills. Conclusion These findings pave the way for more conclusive studies on the efficacy of Reboot-C for surgeons.
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Affiliation(s)
| | - Judith Johnson
- School of PsychologyUniversity of LeedsLeedsUK
- Bradford Institute for Health ResearchBradford Royal InfirmaryBradfordUK
- School of Public Health and Community MedicineUniversity of New South WalesSydneyAustralia
| | | | | | - Ruth Simms‐Ellis
- School of PsychologyUniversity of LeedsLeedsUK
- Bradford Institute for Health ResearchBradford Royal InfirmaryBradfordUK
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Li Z, Wang H, Luo X, Luo F. A commentary on 'Burnout in surgeons: A qualitative investigation into contributors and potential solutions' (Int J Surg 2022;101:106613). Int J Surg 2023; 109:2819-2820. [PMID: 37195784 PMCID: PMC10498866 DOI: 10.1097/js9.0000000000000508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/10/2023] [Indexed: 05/18/2023]
Affiliation(s)
| | | | | | - Fuchao Luo
- Department of Cardiothoracic Surgery, Chongqing University, FuLing Hospital, Chongqing, People’s Republic of China
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8
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Al-Ghunaim T, Johnson J, Biyani CS, Yiasemidou M, O'Connor DB. Burnout and patient safety perceptions among surgeons in the United Kingdom during the early phases of the coronavirus disease 2019 pandemic: A two-wave survey. Scott Med J 2023; 68:41-48. [PMID: 36946068 PMCID: PMC10067362 DOI: 10.1177/00369330231163378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Surgeons in the UK report high burnout levels. Burnout has been found to be associated with adverse patient outcomes but there are few studies that have examined this association in surgeons and even fewer which have examined this relationship over time. PURPOSE The main aim was to examine the relationships between surgeon burnout and surgeons' perceptions of patient safety cross-sectionally and longitudinally. The secondary aim was to test whether surgeons' burnout levels varied over the first six months of the coronavirus disease 2019 pandemic. METHODS This paper reports data from a two-wave survey (first wave from 5 May and 30 June 2020, the second wave 5 January to 30 February 2021). The dataset was divided into a longitudinal group (for surgeons who responded at both the time points) and two cross-sectional groups (for surgeons who responded at a one-time point, but not the other). RESULTS The first key finding was that burnout was associated with patient safety outcomes measured at the same time point (Group 1 = 108, r = 0.309, p < 0.05 and Group 2 = 84, r = 0.238, p < 0.05). Second, burnout predicted poor patients' safety perceptions over time, and poor patient safety predicted burnout over time (Group 3 = 39, p < 0.05). Third, burnout increased between the first and second surveys (t = -4.034, p < 0.05). CONCLUSION Burnout in surgeons may have serious implications for patient safety. Interventions to support surgeons should be prioritised, and healthcare organisations, surgeons and psychological specialists should collaborate on their development.
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Affiliation(s)
| | - Judith Johnson
- School of Psychology University of Leeds, Leeds, UK
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Chandra S Biyani
- Department of Urology, St James's University Hospital, Beckett Street, Leeds, West Yorkshire, UK
| | - Marina Yiasemidou
- NIHR Academic Clinical Lecturer General Surgery, University of Hull, Hull, UK
- ST8 Colorectal Surgery, Bradford Teaching Hospitals, Bradford, UK
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Al-Ghunaim T, Johnson J, Biyani CS, O'Connor DB. How UK surgeons experience burnout and the link between burnout and patient care: A qualitative investigation. Scott Med J 2022; 67:197-206. [PMID: 36069048 PMCID: PMC9643814 DOI: 10.1177/00369330221122348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background and Aims Poor well-being affects the performance of all kinds of workers, including
surgeons. This study aimed to answer two questions: (1) how does burnout
affect surgeons personally, and what is their burnout experience like? (2)
How does burnout affect the care that surgeons provide in the United Kingdom
(UK)? Method This study conducted thematic analysis of semi-structured interviews with 14
surgeons recruited from the UK National Health Service (NHS). Result The study found three themes in surgeons’ experiences of burnout: first,
burnout is common but frequently not recognised nor understood; second,
burnout is a personal crisis; and third, burnout creates vulnerability at
work. The study also revealed four themes related to burnout's effect on
patient care: first, burnout reduces the quality of surgeon-patient
relationships; second, burnout affects patient safety; third, burnout
impairs staff relationships; and fourth, burnout makes surgeons less
motivated to improve. Conclusion Burnout is common but not well recognised in surgeons. Improving
understanding and treatment of burnout could have benefits for both surgeons
themselves and the care they provide to patients.
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Affiliation(s)
| | - Judith Johnson
- School of Psychology, 4468University of Leeds, Leeds, UK.,Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
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Nash C, MacPherson AC, Collins D. Reflections on Reflection: Clarifying and Promoting Use in Experienced Coaches. Front Psychol 2022; 13:867720. [PMID: 35602681 PMCID: PMC9114759 DOI: 10.3389/fpsyg.2022.867720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background We draw on the work of established scholars in the field of reflective practice who highlight its importance as a key cognitive skill for professionals to hold. While the substantive effect of engaging in reflective practice is emphasised in the literature, apparently coaches only spend a limited time learning about and engaging with it. Objectives This study was conducted in two parts: Part 1 examined coaches' knowledge of reflective practice and ascertained their perceived lack of value and use of reflective practice within their coaching. In response to the unexpected findings in Part 1, in Part 2, we instituted an educational intervention to further these participant coaches' knowledge of Reflective Practice (RP) and facilitate its integration into their coaching practice. Design The present study utilised a mixed method design with semi-structured interviews being conducted in Part 1. A coach development reflective programme inspired by Stimulated Recall approach was implemented in Part 2. Participants Twelve high level coaches were interviewed about their reflective practices in Part 1. In Part 2, the same coaches agreed to participate in the educational intervention for the duration of the project. Results Findings from Part 1 revealed an interesting paradox: coaches demonstrated a lack of appreciation for reflective practice yet recounted the positive influence that specific events and individuals had on their practice. In Part 2, to fully develop RP with the present cohort, an educational intervention was conducted. While watching videos of their own practice, coaches initially required lots of prompts from the lead interviewer to facilitate a deep and meaningful discussion of their practice. During the latter stages of the intervention, however, participants were less dependent on questions and prompts. Conclusion In part 1, the coaches in this study did employ reflection, although they did not label it as such. The qualitative evidence we have gathered enables us to suggest that it is the combination of how to reflect, and against what criteria that makes RP a powerful tool to develop expertise which it has the potential to be. Importantly, however, additional coach education input is necessary for these benefits to be fully realised.
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Affiliation(s)
- Christine Nash
- Institute for Sport, PE and Health Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Alan C MacPherson
- Institute for Sport, PE and Health Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Dave Collins
- Institute for Sport, PE and Health Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Grey Matters Performance Ltd., Stratford-upon-Avon, United Kingdom
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