Questioning the "big assumptions". Part II: recognizing organizational contradictions that impede institutional change

Big Assumptions in Online and Blended Continuing Professional Development: Finding Our Way Forward Together

ABSTRACT

Continuing professional development (CPD) providers and faculty face a practice gap between our knowledge of effective practices in CPD and our implementation of them, particularly in online environments. Developmental psychologists Bob Kegan and Lisa Lahey have attributed such knowledge-implementation gaps to an "Immunity to Change" rooted in tacit "Big Assumptions." These Big Assumptions produce fears or worries, reveal competing commitments, and result in actions or inactions that hinder intended change. We sought to understand the barriers to change in online and blended CPD, to support CPD leaders in pursuing their goals for optimal use of technology in CPD. This inquiry arose from the 13th National Continuing Professional Development Accreditation Conference of the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada, a virtual conference held in October 2022. After introducing the Immunity to Change framework and best practices in online and blended learning, we invited audience members to list Big Assumptions in CPD through chat and polling software. These responses were analyzed and grouped into five interrelated Big Assumptions that suggest a number of key barriers to optimal implementation of online CPD. We present data that counter each Big Assumption along with practical approaches to facilitate desired change for CPD.

Development and Evaluation of a Faculty-Based Accredited Continuing Professional Development Route for Teaching and Learning

This article characterizes and evaluates the development of an accredited, in-house, faculty-based teaching recognition scheme aimed at supporting clinicians and academics to achieve Advance HE Fellowship recognition. The scheme takes 6 to 24 months to complete and forms part of an institution-wide scheme. The evaluation covered 44 months, collecting data on participation rates across the school and 21 semi-structured interviews across 16 staff participants. We describe the outcomes measured alongside key perceived benefits and challenges to support the implementation of similar schemes elsewhere. Across 130 academic staff, there was 61% engagement. In interviews, 11 participants characterized benefits in terms of changes to their teaching, such as adopting new strategies for differing class sizes, and highlighted the benefit of accessible and context-specific development opportunities designed specifically for STEMM (science, technology, engineering, mathematics, and medicine) practitioners and clinicians. Motivations for participating were mainly intrinsic (69%), with international professional recognition also featured (61%, n = 10). Of the 23 participants who withdrew, the largest subgroup (39%) withdrew because they had left the institution, and 35% withdrew because of a lack of time, which encompassed a range of issues. We outline recommendations for implementing similar schemes including protected time, accessible development opportunities, and support for mentors.

Sensor, Wearable, and Remote Patient Monitoring Competencies for Clinical Care and Training: Scoping Review

Sensor, wearable, and remote patient monitoring technologies are typically used in conjunction with video and/or in-person care for a variety of interventions and care outcomes. This scoping review identifies clinical skills (i.e., competencies) needed to ensure quality care and approaches for organizations to implement and evaluate these technologies. The literature search focused on four concept areas: (1) competencies; (2) sensors, wearables, and remote patient monitoring; (3) mobile, asynchronous, and synchronous technologies; and (4) behavioral health. From 2846 potential references, two authors assessed abstracts for 2828 and, full text for 521, with 111 papers directly relevant to the concept areas. These new technologies integrate health, lifestyle, and clinical care, and they contextually change the culture of care and training-with more time for engagement, continuity of experience, and dynamic data for decision-making for both patients and clinicians. This poses challenges for users (e.g., keeping up, education/training, skills) and healthcare organizations. Based on the clinical studies and informed by clinical informatics, video, social media, and mobile health, a framework of competencies is proposed with three learner levels (novice/advanced beginner, competent/proficient, advanced/expert). Examples are provided to apply the competencies to care, and suggestions are offered on curricular methodologies, faculty development, and institutional practices (e-culture, professionalism, change). Some academic health centers and health systems may naturally assume that clinicians and systems are adapting, but clinical, technological, and administrative workflow-much less skill development-lags. Competencies need to be discrete, measurable, implemented, and evaluated to ensure the quality of care and integrate missions.

A Framework for Competencies for the Use of Mobile Technologies in Psychiatry and Medicine: Scoping Review

BACKGROUND

To ensure quality care, clinicians need skills, knowledge, and attitudes related to technology that can be measured.

OBJECTIVE

This paper sought out competencies for mobile technologies and/or an approach to define them.

METHODS

A scoping review was conducted to answer the following research question, "What skills are needed for clinicians and trainees to provide quality care via mHealth, have they been published, and how can they be made measurable and reproducible to teach and assess them?" The review was conducted in accordance with the 6-stage scoping review process starting with a keyword search in PubMed/Medical Literature Analysis and Retrieval System Online, APA PsycNET, Cochrane, EMBASE, PsycINFO, Web of Science, and Scopus. The literature search focused on keywords in 4 concept areas: (1) competencies, (2) mobile technologies, (3) telemedicine mode, and (4) health. Moreover, 2 authors independently, in parallel, screened the search results for potentially relevant studies based on titles and abstracts. The authors reviewed the full-text articles for final inclusion based on inclusion/exclusion criteria. Inclusion criteria were keywords used from concept area 1 (competencies) and 2 (mobile technologies) and either 3 (telemedicine mode) or 4 (health). Exclusion criteria included, but were not limited to, keywords used from a concept area in isolation, discussion of skills abstractly, outline or listing of what clinicians need without detail, and listing immeasurable behaviors.

RESULTS

From a total of 1232 results, the authors found 78 papers eligible for a full-text review and found 14 papers directly relevant to the 4 key concepts. Although few studies specifically discussed skills, the majority were clinical studies, and the literature included no lists of measurable behaviors or competency sets for mobile technology. Therefore, a framework for mobile technology competencies was built according to the review, expert consensus, and recommendations of the Institute of Medicine's Health Professions Education Summit and Accreditation Council of Graduate Medical Education framework. This framework borrows from existing competency framework domains in telepsychiatry and social media (patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication) and added domains of mHealth clinical decision support, device/technology assessment/selection, and information flow management across an electronic health record platform. mHealth Asynchronous components require additional traditional learning, teaching, supervisory and evaluation practices. Interactive curricula with case-, problem-, and system-based teaching may help faculty focus on decision making and shape skills and attitudes to complement clinical exposure.

CONCLUSIONS

Research is needed on how to customize implementation and evaluation of mHealth competencies and to ensure skill development is linked to the quality of care. This will require the management of organizational change with technology and the creation of a positive electronic culture in a complex policy and regulatory environment.

Mobile Health, Smartphone/Device, and Apps for Psychiatry and Medicine: Competencies, Training, and Faculty Development Issues

Faculty and trainees need clinical skills, knowledge, and attitudes to ensure quality care using technology. Clinical faculty teach, supervise, and role model skills for trainees and interprofessional team members. Mobile health, smartphone/device, and app competencies may be situated within the graduate medical education milestone domains. This article outlines these competencies and aligns them with clinical care, teaching methods, and evaluation. These competencies have similarities and differences from in-person and telepsychiatric care and additional dimensions like clinical decision support, technology selection, and information flow management across an e-platform. Health systems must integrate in-person and technology-based care, while maintaining the therapeutic relationship.

Continuing professional development to foster behaviour change: From principles to practice in health professions education

Healthcare professionals need to continuously improve their knowledge, skills and performance to effectively function in an ever-changing healthcare environment. They depend on continuing professional development programs (CPD), either within or outside their institutions, to reflect on and update their clinical practice. Professional growth requires more than knowledge transfer; it requires curiosity, humility, self-awareness and a motivation for mastery. Educators can build on these factors and create effective learning experiences to develop complex skills including communication, interprofessional collaboration, teamwork, leadership and reflective practice. CPD program leaders should adopt an evolved approach to program design that leverages adult learning principles, active learning and longitudinal curricula, while identifying and overcoming system barriers to change, and targeting meaningful behaviour and health outcomes. In this article, we describe principles and strategies that CPD leaders can apply to their own programs, categorized under three steps: (1) Program design, (2) Program implementation and (3) Program evaluation. Under each step, we provide theoretical principles as well as practical tips, focusing on strategies that can motivate and facilitate change.

PET-Saúde/GraduaSUS na visão de atores do serviço e do ensino: contribuições, limites e sugestões

RESUMO Este manuscrito apresenta os resultados de um survey on-line conduzido com os coordenadores de projetos e de grupos da última edição do Programa de Educação pelo Trabalho para a Saúde (PET-Saúde/GraduaSUS), que buscou identificar os resultados alcançados e apontar os limites e as contribuições dessa edição na produção de mudanças. O survey foi realizado em março e abril de 2018, com 445 coordenadores, cujos dados quantitativos foram tratados estatisticamente; e os qualitativos, por análise de conteúdo, dando origem a quatro categorias: As repercussões positivas do PET-Saúde/GraduaSUS; Os aspectos negativos do PET-Saúde/GraduaSUS; A coordenação dos projetos pelo serviço de saúde: ponto controverso; e Sugestões de mudanças. Constatou-se que o PET-Saúde/GraduaSUS contribuiu para o desenvolvimento profissional, ampliação e diversificação dos cenários de aprendizagem, fortalecimento da atenção primária e da educação interprofissional nos currículos e beneficiou a comunidade local. Os principais aspectos positivos da edição foram a coordenação de projeto pelo serviço de saúde e os relatos de experiências na Comunidade de Práticas; já a composição numérica e uniprofissional dos grupos foi apontada como aspecto negativo.

A framework for telepsychiatric training and e-health: Competency-based education, evaluation and implications

Telepsychiatry (TP; video; synchronous) is effective, well received and a standard way to practice. Best practices in TP education, but not its desired outcomes, have been published. This paper proposes competencies for trainees and clinicians, with TP situated within the broader landscape of e-mental health (e-MH) care. TP competencies are organized using the US Accreditation Council of Graduate Medical Education framework, with input from the CanMEDS framework. Teaching and assessment methods are aligned with target competencies, learning contexts, and evaluation options. Case examples help to apply concepts to clinical and institutional contexts. Competencies can be identified, measured and evaluated. Novice or advanced beginner, competent/proficient, and expert levels were outlined. Andragogical (i.e. pedagogical) methods are used in clinical care, seminar, and other educational contexts. Cross-sectional and longitudinal evaluation using quantitative and qualitative measures promotes skills development via iterative feedback from patients, trainees, and faculty staff. TP and e-MH care significantly overlap, such that institutional leaders may use a common approach for change management and an e-platform to prioritize resources. TP training and assessment methods need to be implemented and evaluated. Institutional approaches to patient care, education, faculty development, and funding also need to be studied.

Immunity-to-change: are hidden motives underlying patient nonadherence to chronic disease medications?

New approaches to understanding patient nonadherence to chronic disease medications are urgently needed. To explore whether patient hidden motives and their underlying assumptions contribute to nonadherence, we examined an innovative application to health care of a transformative learning process successfully used in work settings, immunity-to-change. Eligible participants taking at least 2 chronic disease medications, filling prescriptions at U.S. chain drugstores, wanting to continue to take medications and reporting adherence problems underwent a psychological interview focused on their medication-taking behavior as part of a market survey. Participants (n = 46) were interviewed as a construction sample to create a preliminary set of motive clusters. To test the completeness of the cluster categories, 17 additional eligible persons were interviewed. An established psychological interviewing method was used to identify hidden motives and unrecognized assumptions underlying nonadherent behavior. Hidden motives (n = 167) for nonadherence were identified and categorized into 6 clusters based on their commonality (n, %): (1) to avoid interference with other priorities (40, 24%), (2) to avoid losing control (35, 21%), (3) to avoid a negative identity (28, 17%), (4) to be one's own doctor (28, 16%), (5) to keep an arm's length relationship to one's medications or to the medical establishment (27, 16%) and (6) to avoid unpleasantness (10, 6%). Within each cluster, a set of previously unrecognized assumptions inhibiting adherence was identified. In conclusion, hidden motives, and their underlying assumptions, contributing to chronic disease medication nonadherence were identified using a transformative learning process. Research is needed to test this approach in larger general population samples.

'Discovery learning': an account of rapid curriculum change in response to accreditation

BACKGROUND/AIMS

The purpose of this study was to explore the attitudes and experiences of leaders responsible for making rapid changes to a medical school curriculum in response to an adverse accreditation report. The new curriculum was based on the principles of problem-based learning ('Discovery Learning'), with changes to the way that students were assessed.

METHODS

We conducted semi-structured interviews with leaders responsible for education at the school two and a half years after the adoption of the new curriculum. We coded the resulting transcripts to identify major and minor themes expressed by participants.

RESULTS

Thirty-five senior leaders, administrators and course directors were invited for the interview; 14 (40%) were interviewed. Five main themes were noted in the data: (1) organization and control of the curriculum; (2) changes in the practices of teaching and learning; (3) effects on faculty members; (4) sources of resistance and (5) attitudes to curriculum change in general.

CONCLUSION

This study demonstrates that major curriculum change can be achieved successfully in a short period of time. This study also illustrates some of the problems associated with making rapid changes to the medical school curriculum, and highlights the importance of attitudes to change amongst the leadership of a medical school.

Faculty development in veterinary education: are we doing enough (or publishing enough about it), and do we value it?

In this discussion article, I aim to promote international discourse about faculty development in veterinary education, to highlight both the paucity of literature available in this field and the variation in terminology used in publications, to draw from existing evidence in medical education literature, and to identify what we know already and where we are now and where we should be in the next 10 years.

Medical faculty and curriculum design - 'No, no, it's like this: You give your lectures ...'

BACKGROUND AND AIMS

The purpose of this study was to understand more completely the (tacit) curriculum design models of medical faculty. We report on two research questions: (1) Can medical faculty give an account of their curriculum design assumptions? and (2) What are their assumptions concerning curriculum design?

METHOD

We conducted an explorative, qualitative case study. We interviewed educational decision makers at the three Danish medical schools and associate professors from different courses concerning curriculum design. We carried out four individual, in-depth interviews and four focus groups with 20 participants in all.

RESULTS AND CONCLUSIONS

Only one decision maker had an explicit curriculum design model. However, all participants had assumptions concerning curriculum design. We displayed their assumptions as five essentially different and increasingly complex models: the method-driven, pragmatically driven content-driven, outcome-driven and vision-driven curriculum design models. In the five models, the role of learning outcomes differs. The differences range from a belief that learning outcomes are essential, to a belief that learning outcomes are unimportant, to a belief that learning outcomes are incompatible with higher education. Finally, we found that teachers do not necessarily play a clear, central role in curriculum design.

Survey of attitudes towards curriculum reforms among medical teachers in different socio-economic and cultural environments

BACKGROUND

Curriculum reforms in medical schools require cultural and conceptual changes from the faculty.

AIMS AND METHODS

We assessed attitudes towards curriculum reforms in different academic, economic, and social environments among 776 teachers from 2 Western European medical schools (Belgium and Denmark) and 7 medical schools in 3 countries in post-communist transition (Croatia, Slovenia, Bosnia and Herzegovina). The survey included a 5-point Likert-type scale on attitudes towards reforms in general and towards reforms of medical curriculum (10 items each).

RESULTS

Teaching staff from medical schools in Bosnia and Herzegovina had a more positive attitude towards reforms of medical curriculum (mean score 36.8 out of maximum 50 [95% CI 36.1 to 37.3]) than those from medical schools in Croatia or Slovenia (30.7 [29.8 to 31.6]) or Western Europe (27.7 [27.1 to 28.3]) (P < 0.001, ANOVA). Significant predictors of positive attitudes towards medical curriculum reform in post-communist transition countries, but not in Western European schools, was younger age, as well as female gender in Bosnia and Herzegovina.

CONCLUSIONS

Factors influencing faculty attitudes may not be easy to identify and may be specific for different settings. Their identification and management is necessary for producing sustainable curriculum reform.

Change in higher education: understanding and responding to individual and organizational resistance

In many fields, the ability of educators and practitioners to cope with rapid change is essential to sustained success. In veterinary medical education, as in other scientific disciplines, meaningful change is challenging to achieve and subject to resistance from many individual and organizational norms. Individual concerns often relate to fears of instability or uncertainty, loss of current status, or effects on individual time and workload. Sources of organizational resistance may include a conservative culture, fierce protection of current practices, and prevalence of disciplinary or territorial viewpoints. In academia, especially in scientific or medical fields, individuals appear to be strongly independent and conservative in nature, and generally skeptical of educational change. In this environment, a highly participatory process, with regular communication strategies and demonstrations or evidence that supports proposed changes, can be useful in facilitating change. An understanding of the nature of complex change, as well as of the reasons underlying resistance to change, and some methods to overcome these barriers are highly valuable tools for educational leaders.

Questioning the "big assumptions". Part I: addressing personal contradictions that impede professional development

BACKGROUND

The ultimate success of recent medical curriculum reforms is, in large part, dependent upon the faculty's ability to adopt and sustain new attitudes and behaviors. However, like many New Year's resolutions, sincere intent to change may be short lived and followed by a discouraging return to old behaviors. Failure to sustain the initial resolve to change can be misinterpreted as a lack of commitment to one's original goals and eventually lead to greater effort expended in rationalizing the status quo rather than changing it.

OBJECTIVE

The present article outlines how a transformative process that has proven to be effective in managing personal change, Questioning the Big Assumptions, was successfully used in an international faculty development program for medical educators to enhance individual personal satisfaction and professional effectiveness. This process systematically encouraged participants to explore and proactively address currently operative mechanisms that could stall their attempts to change at the professional level.

CONCLUSIONS

The applications of the Big Assumptions process in faculty development helped individuals to recognize and subsequently utilize unchallenged and deep rooted personal beliefs to overcome unconscious resistance to change. This approach systematically led participants away from circular griping about what was not right in their current situation to identifying the actions that they needed to take to realize their individual goals. By thoughtful testing of personal Big Assumptions, participants designed behavioral changes that could be broadly supported and, most importantly, sustained.